Deterioration in emergency NHS care in Wales, says auditor general
Unscheduled care services - such as accident and emergency units - are deteriorating across Wales, according to the auditor general.
A report blames confusion over when people should go to A&E, staff shortages and problems with the flow of patients through hospitals.
It says that too many patients, in particular older people, spend longer than 12 hours in emergency units.
The Welsh government will consider the recommendations made.
The auditor general, who has looked into the progress made in the Welsh NHS since a previous report on the issue in 2009, said A&E waiting times have generally increased in recent years.
Huw Vaughan Thomas also said some of the key challenges raised in the previous report about unscheduled care - described as any urgent, unplanned treatment in a hospital emergency unit or at home - remained.
The report highlighted problems including:
- Patients face a "complex and confusing" range of options when in an emergency situation, such as whether to call 999 and when to go to A&E. This needs to be simplified.
- The need for older patients to be admitted quickly to wards is hindered by problems with bed availability and the speed at which specialty doctors can come to A&E to assess patients.
- At times of peak demand, problems with patient flow through the hospital result in significant pressure being placed on A&E departments, which become over-crowded, with patients facing long waits and ambulances needing to queue outside A&E departments to hand over people needing treatment.
- The time it takes for ambulances to hand over patients to hospitals has got worse since 2009.
- Problems recruiting doctors in Wales has made the pressure on emergency units worse. No A&E departments in Wales are able to meet the College of Emergency Medicine standards for consultant presence on the "shop floor".
- There can also be problems with the recruitment and retention of doctors to work in GP out-of-hours services.
The report said to help improve the situation, access to urgent same-day GP appointments during the working day should be increased.
The skills of ambulance staff also needed to be improved to allow them to treat more patients at the scene or refer them to non-emergency services.
The planned development of community-based services offering alternatives to hospitals should be sped up, the report said.
And it added that the launch of a 111 telephone service in 2015 will also help patients get the right treatment as quickly as possible and reduce demand in other emergency services.
Dave Thomas, director of health and social care at the Wales Audit Office, said the NHS faced a "struggle".
"A&E is actual front door of hospital but it'll actually be a symptom of many of the causes elsewhere," he told BBC Radio Wales.
"You'll find that if there are problems with patients flow through the hospital they then be manifest with back pressures in the A&E department.
"We are concerned that the problems are enduring.
"I think there's a clear focus by the Welsh government and the NHS. It's not from want of trying. I think the issues are complex.
"All the pressures are coming at a pace which is greater than the pace of changes made by the service."
Dr Tony Bleetman, an A&E consultant, said increased demand for emergency care in recent years was a huge problem.
He said because of targets to see patients within four hours, people often went to A&E knowing they would get the help they needed.
"We need to look at what we do at the front door of the hospital," he said.
"We need to filter off people who don't need to be there."
The Welsh government said the report "makes some sensible recommendations".
A spokesperson said: "The report articulates the complexity of the unscheduled care system, and resolving the challenges described will require all key partners in hospitals, primary care, and local authorities to work creatively and robustly at a local and national level to ensure that we see sustainable improvement.
The spokesperson added that ministers would work with NHS Wales and social care to build on early improvements and respond to the report's recommendations.