The trained “casualty watchers,” who collect the data, are local people appointed to the statutory community health councils to monitor local health services and are committed to improving the quality of emergency services in their area. Many have personal experiences of receiving treatment in the department they are monitoring and see Casualty Watch as a way of improving services for the whole community.

The casualty watchers simultaneously arrive at their local emergency department at 4 30 pm on a prearranged date and meet with a senior nurse, who provides anonymised data on all patients currently in the department—no direct contact is made with patients. The data are collected manually and then immediately faxed to the data collection point. Emergency departments are informed of data collection dates well in advance.

The collection and rapid turn around of “hot” data by Casualty Watch set it apart from most other systems of NHS monitoring. Long trolley and bed waits identified by the casualty watchers are used by the local community health council to focus the minds of NHS chief executives and clinicians, leading to both short term and long term change. The focus of Casualty Watch is on patients' clinical needs and distress rather than the institutional and statistical focus, which usually predominates in discussions about emergency services. Rapid access to data on trolley and bed waits enables local community health councils to work with hospital managers to find solutions to long waiting times in a way that brings patients' concerns to the heart of decision making in the local NHS.

The simplicity of the Casualty Watch model correlates closely with its effectiveness. It relies on the community health councils' statutory right of access to hospitals to collect the data, the legal duty on NHS bodies to provide data required by the councils to monitor the NHS, the dedication of the casualty watchers, and a good fax machine. Monthly collection of Casualty Watch data over 13 years, together with annual data collected by the Association of Community Health Councils for England and Wales (ACHCEW), has created a unique opportunity for communities to exert a powerful influence on the local NHS and on central government.

Casualty Watch first hit the headlines when the Labour party was in opposition, and their shadow health spokesman, Robin Cook, read out details of the Casualty Watch data in parliament during prime minister's question time. The data, which were only a day old, pressurised the secretary of state for health to make an announcement the same evening on television that the government would take action over the conditions in King's College Hospital emergency department. This was the start of many such engagements between local people and health ministers, often mediated through local MPs and the media. The response from ministers to the sometimes outrageous waits that casualty watchers discovered was overwhelmingly positive as they recognised the power of the data and the potential political embarrassment lurking in emergency departments. For what had up to then been hidden—except from the distressed patients, their relatives, and the harassed staff on the front line—became a matter of public record. The national disgrace of seriously ill people, often in their 70s and 80s, waiting for over 20 hours in emergency departments was revealed and forced the government to take action.

The persistence of Casualty Watch kept up the pressure on government and exposed the lack of priority previously given to emergency services. It became clear that large scale bed closures in some areas had led to some emergency departments becoming “warehouses” for seriously ill patients, where they were treated without the specialised nurses, doctors, and equipment required for proper care. Winter was shown to be a particularly dangerous time for patients in some emergency departments.

Once out in the public domain, the data on waiting times had an important effect on local practice and central government policy. The monthly delivery of Casualty Watch data ensured that ministers could not dismiss results as a one-off blip, while the national data collection by ACHCEW showed the extent of the problem. Also revealed was the unique opportunity afforded by public involvement in the community health councils to allow patients and carers to influence the political process.

Emergency services are now high on the government's health priorities, leading to major redevelopments in many departments, improvements in the quality of emergency care, much shorter waits, and a substantial change in the monitoring of waiting times (these had been calculated by emergency departments from the time of decision to admit but now follow the Casualty Watch model to reflect patients' perspective—that is, the total wait in the department).

Casualty Watch will end in July 2003 when community health councils and ACHCEW are abolished by the government and replaced by patients' forums. Appeals to health ministers to stop the loss of Casualty Watch have fallen on deaf ears and led to doubts about the government's continuing commitment to public involvement and influence in NHS policy.