Author: Shirley James
Company: Audit Scotland

Key messages
Accident and Emergency
Performance update

Prepared by Audit Scotland
May 2014

Key facts
1.57 million
Patients attended A&E departments & MIU in 2008/09 
1.62 million
Patients attended A&E departments & MIU in 2012/13

38 per cent
Patient delays in A&E were reported as 'wait for a bed' in 2012/13
21 per cent 
Patient delays in A&E were reported as 'wait for first full clinical assessment' in 2012/13

334,879
Patients were admitted to hospital from A&E in 2008/09
361,121
Patients were admitted to hospital from A&E in 2012/13

3,659 (2.8 per cent)
Patients waited longer than four hours in December 2009
8,300 (6.5 per cent)
Patients waited longer than four hours in December 2013

97.2 per cent
Patients were seen within four hours in December 2009
93.5 per cent
Patients were seen within four hours in December 2013

What’s this report about?
Typically, Accident and Emergency (A&E) departments assess and treat patients with serious or life-threatening injuries or illnesses. There are 31 A&E departments in Scotland. Around 1.35 million patients attended these departments in 2012/13, at a cost of around £163 million. To ensure patients are being treated quickly, NHS boards have a standard to treat and discharge or admit 98 per cent of patients within four hours of arriving at A&E.^1 The four-hour standard also applies to minor injury units (MIUs) where patients are treated for less serious, but urgent, injuries. There are 64 MIUs in Scotland that provide treatment to over 260,000 patients a year at a cost of around £25 million.
We published a report on A&E departments in August 2010.^2 We reported at that time that NHS boards had improved the way they tackled longer A&E waiting times, but faced challenges in maintaining the four-hour standard. Since then, A&E departments’ performance against the standard has deteriorated. In April 2013, the Scottish Government introduced a new interim target of 95 per cent of patients being treated within four hours by the year ending September 2014.
We focused on reviewing A&E departments’ performance against the four-hour waiting time standard since our previous audit. We used information that NHS boards routinely submit to Information Statistics Division (ISD) Scotland.
Our objectives were to provide an update on:
•	how NHS boards are performing against the A&E waiting times standard and the main reasons for delays in A&E treatment
•	what the Scottish Government has done to help improve the way A&E departments perform.
Key messages
1.	The NHS in Scotland’s performance against the four-hour A&E waiting time standard has deteriorated since our last report. The percentage of patients seen within four hours fell from 97.2 per cent in December 2009 to 93.5 per cent in December 2013, although there was improvement during 2013. Performance varies considerably between A&E departments, and many face challenges in meeting the interim target of 95 per cent by the year ending September 2014. 
2.	A&E departments are part of a complex health and social care system. Problems across the whole system can delay the flow of patients out of A&E. Around a third of patients who are delayed in A&E are waiting because hospital beds are not available at the time they need them. This can be for a variety of reasons, including the time of day that patients are discharged from hospital. Since our last report, more patients are being admitted to hospital from A&E. Challenges around staffing can also affect how long patients wait in A&E. Although A&E consultant numbers have increased, there are still pressures around medical staffing.
3.	The Scottish Government launched the National Unscheduled Care Action Plan in February 2013 in response to the deterioration in performance against the four-hour standard. Supported by planned funding of £50 million over three years, the Action Plan aims to address the challenges that NHS boards are facing in delivering emergency and urgent care, including reducing A&E waiting times. It is too early to comment on the impact of the Action Plan as significant changes to services will take time to deliver, but the Scottish Government and NHS boards are taking steps to address some of the causes of delays.
Recommendations 
The Scottish Government should share good practice on:
•	GPs referring appropriate patients directly to hospital without first attending the A&E department
•	protocols that allow senior A&E staff to admit patients directly to hospital themselves
•	effective models of A&E services and use of assessment units
•	effective hospital discharge processes which support early planning of patient discharge.
The Scottish Government should:
•	ensure that NHS boards have access to benchmarking information on staffing levels and skill-mix in A&E departments.
What happens now?
The full report can be accessed on our website www.audit-scotland.gov.uk . We will present our report to the Scottish Parliament’s Public Audit Committee. The Committee can call relevant people at the Scottish Government and other public bodies to discuss the issues our audit has raised.
We will also monitor progress against our recommendations through our audit work.

1	The Scottish Executive established the target in 2004 that, by the end of 2007, 98 per cent of A&E patients should wait no longer than four hours from arrival to admission, transfer or discharge. This applies to A&E departments and to minor injury units. The target became a standard in March 2008. Standards are used for targets that are past the target date, but are maintained to monitor progress or for other purposes such as benchmarking.
2	Emergency departments. Audit Scotland, August 2010. Data in this report was for 2008/09.