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The number of patients forced to wait too long in accident and emergency (A&E) departments has almost trebled in five years, according to a study across the NHS in Scotland.
About 104,000 people waited beyond the standard four-hour target in 2012-13, compared with about 36,000 in 2008-9, Audit Scotland found in a new report.
The proportion of people being seen within the four-hour target fell from 97.2% at the end of 2009 to 93.5% by December last year, it revealed.
The health service has rarely achieved the Scottish Government's 98% standard four-hour target over the study period, although there are signs of improvements.
Caroline Gardner, auditor general for Scotland, said: "A&E departments provide a really important service in assessing and treating patients with serious injury and illness.
"Maintaining good performance in A&E was one of the Scottish Government's key objectives in 2013-14.
"Delays in A&E can be a sign of pressure across health and social care. While there has been improvement in performance, such as the progress made in tackling the longest waits in A&E, performance against the target still remains lower than it was when we last reported.
"It is important that the Scottish Government and NHS boards build on their whole system work and continue to reduce delays for A&E patients.''
The study also discovered a spike in admissions during the last 10 minutes of the four-hour period.
More than 18% of admissions from A&E at the Royal Infirmary of Edinburgh were recorded just before the time limit passed.
Scotland has 31 A&E departments which saw about 1.35 million patients in 2012-13 at a cost of about £163 million, Audit Scotland said.
The report shows variation in demand at A&E across the country.
The Royal Sick Children's Hospital in Edinburgh recorded an increase of about 15% over the five years while, at the other end of the scale, demand fell by about 13% at Gilbert Bain Hospital in Lerwick, Shetland.
Gilbert Bain and the Royal Aberdeen Children's Hospital were the only two to meet the 98% target in each month of the financial year 2012-13. Most other hospitals failed in every month.
The report notes that action is being taken by the Scottish Government and that the situation has improved in recent months.
The Government announced a national plan in February last year to improve emergency care.
The NHS plans to invest about £50 million in unscheduled care between 2013-14 and 2015-16.
Health Secretary Alex Neil said there has been an 87% reduction in patients waiting over 12 hours.
Hospitals are also under more pressure because of increased demand, he said. "We have already invested heavily, both in service improvements and more staff. That includes the 18 new consultants now appointed across NHS Scotland,'' he said.
"This builds on the increase under this government, which has seen the number of A&E consultants more than double, from 75.8 to 162.3 since 2006.
"We're also working with health boards to ensure they can achieve our interim 95% target by September this year, as an important step towards sustainably delivering 98% by the end of the £50 million three-year action plan.
"But we know that we need to look at health and social services, both within and outwith the hospital setting, to improve these lifeline services, and that is exactly what we will do in years two and three of the national programme.
"For example, our new non-emergency care direction guidance will make sure that patients are getting the right treatment, in the right place and by the right clinicians.
"However, I am under no illusion that we have more to do and I am clear that health boards must continue to prioritise this vital work to ensure that we can build on the progress made.''
Opposition politicians said the report is a warning to the SNP administration. Hugh Henry, convener of Holyrood's Public Audit Committee, said: "This is extremely worrying. We all know the complexity of A&E services but by now we should have been seeing signs of progress.
"The fact that things are getting worse should give cause for concern, not just for the Scottish Parliament but for the wider public.''
"Clearly, the Scottish Government knows there is a problem here, evidenced by the planned funding it has put in place, but the issue is whether it can reverse the longer-term trend in A&E performance.''
Scottish Labour MSP Neil Findlay said: "This report shows that, as it stands, our NHS isn't prepared for the future.
"The SNP believe that sticking-plaster solutions are enough - Scottish Labour doesn't.
"Health sector workers agree with us. We need a full-scale review of how our health and social care services will cope in the years to come.
It's time for the SNP to accept that reality.''
Scottish Conservative health spokesman Jackson Carlaw said: "This report makes it perfectly clear that a lack of staff is one of the reasons departments struggle, and it's notable that the Scottish Government began slashing numbers about the same time casualty performance began to decrease.
"While the SNP's stewardship of the NHS has to improve considerably, there has to be an element of personal responsibility too.
"The majority of patients are sent home without being admitted, so people need to stop and think if A&E is the best place for them to go.
"It seems minor injury units perform far better, and for thousands would blatantly be a more suitable and convenient point of contact.''