This article appears as part of the Inside the NHS newsletter.

As we head into winter, attention turns once again to the situation in Scotland's A&E departments.

Responding to the latest statistics for waiting times on Tuesday, the chair of the Royal College of Emergency Medicine (RCEM) in Scotland, Dr John-Paul Loughrey, warned that the NHS could be headed for another "devastating winter".

So what are the figures telling us, and how could we reverse the crisis in emergency care?

The statistics

In the four weeks to October 29, a total of 5,038 people spent over 12 hours in Scotland’s emergency departments (EDs). This compares to nearly 5,800 over the equivalent four week period in 2022, so there are signs of a modest year-on-year improvement when it comes to extreme delays.

The number of attendances was similar (around 99,600 in October this year compared to 101,000 in October 2022) which suggests that the improvement owes more to patient flow out of EDs than a reduction in demand at the front door.

Nonetheless, the situation is considerably worse than it used to be. Back in October 2019, Scotland's EDs had over 110,000 patient attendances but only 528 people spent more than 12 hours in them. In October 2015, it was just 45 out of 98,500 attendances.

Despite the focus on NHS initiatives such as flow navigation centres designed to re-direct patients away from A&E, the years since Covid have not actually resulted in an increase in people turning up at emergency departments.

Nor is there much evidence to suggest that more people arriving at A&E now are being assessed as requiring a hospital admission. In September this year, roughly 29% of people seen in emergency departments were either admitted to an acute bed within the same hospital or transferred to another hospital. In September 2018, the figure was 30%.

The Herald:

Exit block and winter planning

The problem that Scotland's NHS will face this winter is the same one it faced last winter, and one that was already worsening in the years prior to Covid: "exit block". This refers to a lack of available beds within the hospital system versus the number of people who need to be moved out of A&E and onto a specialist ward.

A number of factors have squeezed this capacity, including an actual cut in the number of acute beds within NHS Scotland (down by around 2.4% between 2017 and 2022) as well as an additional number of beds unavailable due to staff shortages or because wards have to be temporarily closed for infection control. Before the pandemic this used to be mainly caused by norovirus and flu; now the most common cause is Covid, which means that many more beds overall are being lost in this way.

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In addition, there is the percentage of beds "blocked" by patients who are well enough to leave, but unable to get out of hospital because they are waiting for a social care package or care home placement.

Since July 2022, roughly 1,800 beds have been occupied at any one time by a patient ready for discharge – equivalent to nearly one in eight. That compares to one in 12 back in 2018/19, a huge shift.

It is a mantra that has been repeated over and over again, that the gridlock in A&E will never be fixed unless social care is fixed. The sector has been left underwhelmed by the Scottish Government's Winter Plan. In a joint statement, Dr Donald Macaskill of Scottish Care and Rachel Cackett of Coalition of Care and Support Providers in Scotland (CCPS) described it as "wholly insufficient" to address the "deep crisis" in the care sector, with no additional funding included for social care.

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Care workers in Scotland are due to see their hourly rate rise to a minimum of £12-an-hour from April 2024, but it remains to be seen whether this will incentivise enough to stay on over the winter when many are being lured into less stressful and often better-paid jobs in sectors such as retail.

In July, Scottish Care warned that care homes were closing at an unprecedented rate of one per week amid staff shortages and spiralling bills – something that could well come back to bite the NHS this winter.