The truth about the Scotland-England A&E comparisons

This is not an unusual level of demand; in fact, it was four per cent lower than the five-year average for the same week pre-pandemic.

The same week in October 2019 - a particularly busy winter - saw more than 28,300 people turn up.

And yet waiting times continue to spiral: in the latest week 3,553 people spent over eight hours in emergency departments waiting to be seen, treated and moved on or discharged, including 1,506 waiting over 12 hours.

The equivalent figures for that same week in October 2019 were 483, and 75.

The reasons for these extraordinary and dangerous bottlenecks are well-rehearsed, from acute bed shortages in the hospital to disintegrating social care services in the community.

READ MORE: Investigation into deaths of two patients who suffered cardiac arrests while waiting to be seen at Glasgow A&E 

Yet time and again, the Scottish Government has sought to deflect at least some of the heat by noting that - however bad things are - at least they are not as bad as England.

But are such comparisons fair?

Firstly, it is worth noting what is meant by “A&E” when Scotland and England are compared in this way.

Scotland has 91 A&E services in total, including minor injury units, but the weekly statistics published by Public Health Scotland cover only the 30 larger A&Es - emergency departments (EDs) - which typically provide a 24-hour consultant-led service.

Percentage of patients seen, treated and discharged/transferred/admitted within four-hour target across Scotland's Emergency Departments, weekly statistics (Source: Public Health Scotland) (Image: PHS)

These vary widely, however, from Scotland’s busiest ED at Edinburgh Royal Infirmary (roughly 2,300 attendances per week) to remote EDs such as Western Isles hospital or Balfour hospital on Orkney, which each see around 100 patients a week.

When the Scottish Government compares waiting times at these 30 EDs, it does so against England’s 170 Type 1 “major” A&Es, which have full resuscitation and hospital services in addition to being 24-hour consultant-led departments.

These are quite different from the EDs at the likes of Caithness General, Gilbert Bain hospital on Shetland, the Belford in Fort William, or Lorn & Islands hospital in Oban (705 A&E attendances combined in the most recent week).

Dr Neil Nichol (Image: Tayside)

As one retired emergency medicine consultant, Dr Neil Nichol - formerly of Ninewells hospital in Dundee - put it: “None of these are comparable sites to those in England. If I were being difficult, I would also point out that neither Perth Royal Infirmary nor Inverclyde Hospital take major trauma so, again, are not comparable.”

Furthermore, if total monthly attendances were divided equally between each of these departments in England versus Scotland, patient turnover would also be twice as high: around 7000-8000 per Type 1 A&E in England against 3000-3,500 per ED in Scotland.

So when the Scottish Government notes that Scotland’s EDs are outperforming England’s on the key four-hour target, it is a bit like comparing apples and oranges.

But, in fact, there is even more sleight of hand at play.

Percentage of people seen, treated and discharged/transferred/admitted across ALL of Scotland's A&E services, monthly data and (dotted line) rolling average (Source: PHS) (Image: PHS)

While Scotland’s weekly A&E statistics cover EDs only, the monthly report issued by Public Health Scotland covers “all A&E sites”, including small community hospital casualties and minor injury units.

Yet when Nicola Sturgeon told MSPs in September that Scotland had outperformed England on the four-hour target in July, by 66.5% to 57%, this was based on a monthly total solely relating to the EDs versus England’s Type 1 A&Es.

The four-hour target stipulates that 95% of people attending A&E should be seen, treated, and subsequently discharged, transferred or admitted within four hours, so both nations are falling well short - and have been for years.

READ MORE: More than half of excess deaths caused by non-Covid illnesses - amid fears over impact of A&E delays

But if that same July comparison is applied to all A&E services, then England slightly outperforms Scotland: 71% of patients were dealt with within four hours, versus 69.9% in Scotland.

This wasn’t an aberration. In August, England hit 71.4% to 69.7% in Scotland; in June, 72.1% to 71.3% in Scotland.

What’s more, the “clock” doesn't necessarily start when patients actually arrive in A&E.

Performance against the four hour target can include hours spent by a patient waiting in ambulances outside A&E before the handover even takes place - something increasingly common UK-wide.

For patients though, all this is pretty meaningless. Whichever side of the border you find yourself, the situation is abysmal and likely to deteriorate in winter.

England has also seen its A&E performance deteriorate significantly - particularly over the past year (data illustrated up to end of March 2022, Source: Nuffield Health think tank) (Image: Nuffield)

More intriguing country comparisons might be gleaned from the likes of Ireland and Norway, which spend less than the UK on healthcare as a percentage of GDP yet boast better life expectancy and significantly more doctors, nurses, beds and MRI scanners per head.

Perhaps an independent Scotland should seek to emulate their models, or at least consider it? Yet this appears taboo. At its party conference the SNP pledged to safeguard the NHS formally as part of the constitution of an independent Scotland.

True, many of its current woes stem from Tory austerity which dictates how much money overall the devolved governments have to spend on public services; but how much more an independent Scotland would, or could, invest in the NHS is debatable.

READ MORE: Will cutting Covid testing in hospitals increase the number of beds available this winter?

In the meantime, 'whataboutery' based on misleading statistics is an insult to exhausted medics struggling to do their best on either side of the border.

“It never occurred to me to think in terms of 'us' and 'them' in relation to the NHS in Scotland and England," said Dr Nichol.

"We’re all just in the NHS and value the mutual support in terms of, for example, paediatric referrals from Scotland to super-specialist units in England. It was never a competition."