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

However you measure it, 12-hour waits in Scotland's A&E departments reached a record high in January of this year.

Despite concerted efforts by health boards to reduce demand at the front door by diverting people onto other parts of the health service or to get patients moving through and out of hospitals faster, the numbers paint a grim picture of a system in gridlock.

So how bad was it, why does it matter, and exactly how does Scotland compare to other parts of the UK?


According to the statistics published on Tuesday, a total of 125,244 people attended emergency departments, casualties, and minor injury units across Scotland in the first month of 2024.

This is not unusually high. A decade ago, in January 2014, nearly 29,000 turned up at A&E.

Yet the percentage of people being seen, treated and subsequently admitted, discharged or transferred to another hospital within the target time of four hours has plunged from 92.2% to 65.5% over the same period.

In January of this year a record number of people – 8,857, or 7.2% of all attendees – spent over 12 hours in A&E. That exceeds the previous record of 8,821 (7%) recorded in December 2022.

For comparison, in January 2014 the figures were 146 and 0.1% respectively.

The 12-hour measure tells us how busy hospitals are because most of those spending over 12 hours in A&E are stuck there because they need a bed to become available on a ward.

Exactly why January was so bad is not immediately obvious. Flu rates were higher last winter, and levels of delayed discharge (beds occupied by patients well enough to leave) have been higher at other points over the past 18 months.

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Excess deaths

Whatever the reason, prolonged stays in A&E are a problem. If an emergency department is at capacity, ambulances end up stranded outside unable to hand over patients and get back on the road.

That is bad news for 999 callers as well as the one in 10 patients who are currently spending over one hour 40 minutes stuck in the back of an ambulance when they should be inside A&E already.

More worrying is the clear evidence that patients who spend too long in A&E have much worse outcomes in the long-run.

This can be due to a range of factors: they are more likely to contract infections, suffer falls, develop delirium if elderly, or have simply waited too long for the kind of specialist care only available on a ward.

The best study of its kind to date – an analysis of five million patients treated in NHS England between 2016 and 2018 – found that there was one excess death within 30 days for every 82 patients who spent six to eight hours in A&E prior to being transferred into an inpatient bed. 

In January alone, that would translate into well over 200 potentially avoidable deaths.

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UK performance

Scotland is definitely not alone in its deteriorating A&E situation.

On February 28, the Office for National Statistics published its first report tracking changing A&E trends in Scotland, England and Wales from January 2013 to September 2023.

For the purposes of national comparisons, the ONS restricted itself to Type One A&E departments in England, Emergency Departments in Scotland, and major EDs in Wales, all of which are "24-hour consultant-led departments equipped for the treatment of serious and life-threatening injuries".

All three nations have seen steep increases in the percentage of patients breaching the four-target threshold, but as of September 2023 this was highest (at 42.4%) in England. Wales was just over 40% and Scotland stood at 33.5%.

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In Scotland and Wales, the "clock" starts whenever the ambulance pulls up outside A&E or "as soon as is practically possible after". In England, it is counted from the point of ambulance handover or 15 minutes after ambulance arrival – "whichever is sooner".

As accolades go, then, Scotland can consider itself 'less bad' than England and Wales – at least on the four-hour measure.

Across the board, however, patients are facing worsening delays with potentially fatal consequences and little sign of a return to even pre-pandemic levels of performance.