The commission's report shows 18% more people are waiting over an hour to be seen by a doctor than two years ago, despite an 85% increase in the number of doctors being employed in casualty units.

Its report also states that only 25% of heart attack patients get potentially life-saving anti blood clotting drugs within half an hour of arrival at A&E - the government's target time.

The commission says that many hospitals have responded to its 1996 recommendations for improving care, but there are still wide variations between similar casualty departments.

This shows the poorer performing hospitals have some lessons to learn from the best, it states.

Measuring performance

It calls for more effective use of staff and more use of specially trained nurses to relieve pressure on junior doctors.

It also wants hospitals to measure their performance better and says hospitals with poorer performances should develop action plans.

The Audit Commission recommends poorer hospitals develop action plans

Dr Jonathan Boyce, Director of Health and Social Services at the Audit Commission, said: "Staff could be deployed better within departments. There are variations between trusts, and it is a question of using staff more efficiently and monitoring performances and setting targets."

However, it notes that many have increased the number of staff in casualty units - responding to a criticism about understaffing in the 1996 report.

And many now employ specialist doctors and nurses to help with children or other target groups.

Almost all now use CT x-ray scans.

Day surgery

The commission is also releasing details of a study on day surgery.

It notes a big increase in the use of day surgery since 1991 with the number of hospitals which have special day surgery units increasing from 75% to 93%.

Up to eight times as many patients are now being treated in day surgery units for operations such as cataract removals rather than having to stay in hospital overnight.

The audit commission, which recommends an increased use of day surgery, says efficiency has improved with more patients being seen per month than in 1991.

However, it identifies ways for improving and expanding the service, saying day surgery rates for specific operations still vary greatly between hospitals.

Unacceptable waiting times

The Department of Health said it recognised that more needed to be done to improve waiting lists in A&E.

It is spending an extra �250m this winter to reduce waiting times. A further �30m will go into streamlining A&E services.

The department said it was continuing to look at ways to bring down "unacceptable" waiting times.

It also said it was trying to improve day case facilities in some hospitals and to convince doctors of the benefits of day surgery for patients.

Shadow Health Secretary Ann Widdecombe said: "This is proof positive that the real waiting lists are getting longer and longer.

"The report also demonstrates that official figures are being fiddled on a massive scale.

"Much more quick, simple day surgery is being pushed through at the expense of more complex and often more serious treatments

"Clinical priorities are being distorted. Patients are no longer being treated on the basis of clinical need alone.