The NHS has recorded its worst A&E waiting times in England since current targets began in 2004.
The latest figures show that 83.6% of patients were seen within 4 hours in October.
That compares to 85.2% in September, and 89.1% in October 2018.
However, attendances rose to 2,170,510 in October, 4.4% up on the same month last year.
There were also 563,079 emergency admissions, a rise of 3.1%.
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In addition, there were more than 6,000 extra category 1 ambulance callouts – a rise of 11.2%.
The rate of growth for those over 65 is double that of those under 65, according to data from a sample of trusts.
Older people also tend to spend longer in A&E, NHS England said.
The 95% target in A&E was last met in July 2015.
Patients are being asked to go to their local casualty department only in a genuine emergency.
An NHS spokesperson said: “These figures show that while NHS staff are looking after a markedly higher number of older and sicker patients, a higher number of patients are being seen quickly than a year ago.
“While hospitals will be opening more beds over the coming weeks, the public also have a role to play going into winter, and can help doctors, nurses and other staff by getting their flu jab, and by using the NHS 111 phone or online service as a first port of call for non-emergencies.”
Responding to the latest fugures, the Nuffield Trust said the next government could be faced with “one of the bleakest winters in the NHS’s history”.
The health think tank added that there were “many months to go until seasonal pressures really hit the NHS”.
Analysing the figures, it said: “The health service is seeing far more patients, yet one in six is now waiting more than four hours in A&E. If the usual trends continue after Christmas, that would head towards one in five.”
Labour’s shadow health secretary, Jonathan Ashworth, said the NHS was “in crisis” and a “winter of abject misery for patients” was in prospect.
He added: “Our A&Es are overwhelmed, more so than ever. In every community there’s an ever growing queue of people waiting for treatment.”
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