Background: The COVID-19 pandemic, declared in March 2020, is suspected to have greatly impacted Scotland's accident and emergency (A&E) services. Stringent public health measures, including lockdowns, heightened pressures on A&E departments, but their long-term effects remain understudied. This study examines how the pandemic influenced A&E attendances over a broader time-frame. Methods: Secondary data from Public Health Scotland (2018-2022) on monthly A&E attendances was analysed, standardised per 1,000 population using census data. Choropleth maps visualised A&E attendances and wait times across health boards during key pandemic periods. A Poisson generalised linear model (GLM) assessed the influence of COVID restrictions, demographics, and service factors on attendance rates. Results: A&E attendances dropped from 2018 to 2022, with NHS Lanarkshire (-32.7%) and NHS Borders (-27.9%) seeing the largest declines. Despite reduced attendances, the percentage of patients seen within four hours also dropped (-29.4% in NHS Lanarkshire). The Poisson GLM confirmed that COVID-19 restrictions influenced attendance rates with a lower incident rate (IRR: 0.89, 95% CI: 0.88-0.90) during lockdowns and an increased incident rate (IRR: 1.04, 95% CI: 1.03-1.05) during easing periods. Health board-level effects varied substantially. Discussion: COVID-19 disrupted A&E services, causing fluctuating attendances and worsening wait times. Large health board-level variations suggest local policies, behaviours, and existing pressures significantly influenced outcomes. These findings highlight the need to address systemic issues alongside localised strategies for future resilience.

The authors have declared no competing interest.

CAO was supported by the EPSRC Centre for Doctoral Training in Mathematical Modelling, Analysis and Computation (MAC-MIGS) funded by the UK Engineering and Physical Sciences Research Council (grant EP/S023291/1), Heriot-Watt University and The University of Edinburgh.

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