Lack of hospital beds causes emergency departments to miss targets

BMJ 2007; 334 doi: (Published 18 January 2007) Cite this as: BMJ 2007;334:111
  1. Susan Mayor
  1. 1London

    More than a third of accident and emergency departments in hospitals in England said they were not reaching the government's target of dealing with patients within four hours. The main reason for this finding, from a survey published this week, was a shortage of available hospital beds, making it difficult for patients to be admitted.

    Only 49% of the nearly 500 members of the British Association of Emergency Medicine—all consultants and middle grade doctors—responding to the survey reported that their departments met the emergency access target for 98% of all patients to be seen, treated, admitted, or discharged within four hours.

    Although only 49% considered that their department actually met the emergency access target, 67% said that the figures reported by their department indicated that the target had been met. Respondents' comments on what had happened in their departments included, “Middle managers revising figures before being submitted,” “Minor injury unit figures used to help achieve department's 96.9% target,” and “Patients often ‘moved' on the computer tracking but still kept in department to meet targets.”

    Forty one per cent said that their department did not reach the intended target. “Not enough available in-patient beds” was the main reason given for departments not meeting the emergency access target, and 88% of respondents reported it as a major contributory factor.

    Don MacKechnie, chairman of the BMA's emergency subcommittee and a consultant in emergency medicine at Pennine Acute Hospitals NHS Trust, said that financial problems in the NHS had meant that the availability of hospital beds for patients needing admission from accident and emergency departments was an important problem. He said, “In certain trusts, financial recovery measures have included closing beds previously used as ‘safety valves' before, such as beds in rehabilitation wards. This has a knock-on effect to A&E [accident and emergency departments], with recovering patients that might have previously been moved remaining in acute beds.”

    Mr MacKechnie said it was important that emergency access targets were seen as having broader application than simply affecting accident and emergency departments. “Sometimes, other specialties forget that this is not just an A&E target. It is an emergency access target, with a responsibility from all specialties in an acute trust to ensure that the four hour target can be met.” He said this meant ensuring that sufficient beds were available to admit patients from emergency departments and ensuring that doctors on call in each specialty are free to see patients in accident and emergency departments within the target of one hour after being referred.

    The survey showed that patients referring themselves inappropriately was another major factor contributing to departments not reaching targets. The report on the survey noted: “There was a perception amongst emergency medicine doctors that many primary care organisations had not provided adequate out-of-hours cover for their local communities.”

    Areas of concern were also shown in accident and departments that had achieved the four hour target. Nearly half (46%) of respondents reported that their department received additional funding to meet the emergency access target, 49% reported that agency staff on short term contracts were used to meet the target, and 31% reported that data were manipulated as an additional measure to meet the target.

    Mr MacKechnie concluded, “The four hour target has been excellent news for patients, with the long waits that used to occur largely a thing of the past. But this is something that has to be adequately resourced.”

    The survey questionnaire, by the BMA and the British Association for Emergency Medicine, was mailed to 1538 members of the British Association for Emergency Medicine in 2006; 503 responses were returned (a response rate of 33%), mainly from doctors working in England.


    • Emergency Medicine: Report of a National Survey of Emergency Medicine is available at