Leading article: Paint isn't enough to make A&E wards efficient

If you are even an occasional visitor to your local A&E department - and 13 million of us make the trip each year - you may have noticed a few improvements in recent years. A lick of paint, some new furniture, upgraded washrooms - these may not improve the care but they certainly improve the morale of the sick, the injured, and the distressed as they wait their turn for treatment.

NHS trusts have finally woken up to the fact that the A&E department is the hospital's shop window - the place where first impressions of the NHS are formed and public support for it won or lost. But while appearances do matter, most important is the time patients spend waiting. Some are in pain, many are anxious and all are eager to be treated and discharged as soon as possible.

The Healthcare Commission's survey of A&E departments, published today, shows how much progress has been made. Between 2000, when it started monitoring A&E departments, and 2002, waiting times were lengthening. Since 2002, they have shortened and are now better than they were in 2000, despite rising numbers of patients treated.

Around 98 per cent of patients are now seen and treated within the Government's target of four hours. This is disappointingly short of the 100 per cent required, but a huge improvement. Staff numbers have also increased, with 20 per cent more nurses, 27 per cent more doctors and 37 per cent more consultants than in 2000. These gains are reflected in the rising level of satisfaction recorded in the commission's patient survey, which shows that 71 per cent of the public are happy with the treatment they received in A&E.

Welcome as these improvements are, measurements of A&E performance have up to now omitted a crucial factor - the quality of the care delivered. It is hardly surprising if patients judge an A&E department by the state of its paintwork and the length of its waiting times because these are the only measures that most lay people feel competent to judge.

In its first attempt to measure quality of care, based on the handling of three common conditions - children with broken arms, elderly people with hip fractures and people with paracetamol overdoses - the commission has turned up worryingly wide variations. This is exactly what a watchdog worth the name should be doing - checking on performance that the public cannot assess for themselves.

But what happens next? The commission makes a series of recommendations but there is no obvious mechanism to ensure they are acted on. The onus is now on NHS trusts to show they can improve standards without the pressure of centrally imposed targets that have achieved so much on waiting times.