Exclusive: ‘Uncomfortable’ A&E model could be rolled out nationally

The Royal College of Emergency Medicine has said it would be “unethical” for leaders not to at least consider implementing some form of “continuous flow” model for emergency patients.

The approach has been been trialled recently by North Bristol Trust and at several London trusts. HSJ understands NHS England is considering the wider implementation of the continuous flow model, although no final decision has yet been made.

The calls come despite patient safety concerns about the model being raised by the Nuffield Trust think tank, who said the evidence for the model is “poor” and could spread risk to other parts of the hospital.

The call from the RCEM comes at a time of record levels of long waits in emergency departments across the country.

The model involves moving accident and emergency patients to wards at regular intervals in a bid to clear the emergency departments for new arrivals and reduce long ambulance handover delays.

Adrian Boyle, president of the Royal College of Emergency Medicine, said in some places the model is “absolutely the right thing to do” in order to stop concentrating risk in emergency departments.

He told HSJ: “The continuous flow model will feel uncomfortable for the inpatient wards. But we cannot carry on with this level of risk being concentrated in ambulances and emergency departments.

“People will feel uncomfortable about [the model] but it would be unethical for people not to at least consider and do at least some version of this.

“What’s happening with handover delays and long waits in emergency departments should be an absolute call to action.”

Dr Boyle said the model should be discussed rather than imposed on local leaders, and said the model would work best where executive teams are good at collaborating with ambulance services.

He added that leaders “have to justify why they are not doing this. They have got to consider it and come up with a reasonable argument that stacks up to scrutiny on why they are not doing it.

“This is the only intervention we think we’ve got in the short term about the admissions pathway,” he said.

While Dr Boyle admitted evidence for the new model is “weak,” he said the NHS “is not good at getting evidence to support changing the way it does business”.

The Nuffield Trust said it would be a “massive problem” if continuous flow models were imposed on local trusts.

In a recently published piece, the health think tank drew attention to two studies – in Australian and American hospitals – which showed hospitals which overcrowd their wards, known as ‘boarding’, were associated with increased mortality.

Louella Vaughan, senior clinical fellow at the Nuffield Trust, said the NHS lacks the necessary staff or real time bed management in order to enact the continuous flow models.

She told HSJ: “If NHS England say ‘this is the solution and everyone has to enact this’, that would be a massive problem. Overall the evidence for continuous flow is poor.

“What these models are talking about is pushing patients to the wards even if there is no bed space available. I’ve spoken to some hospitals where that means an extra six to eight patients on a ward. We’re coming into winter, covid may come back – if we have an overstuffed ward and we get an outbreak what are we going to do?

“I don’t have a problem with trusts trialling it, my concern is what happens at the policy level.”

Dr Vaughan added that enacting the model could have a detrimental effect on staff morale, including that of nurses. “One of the main reasons nurses leave is because they are overstretched, and staffing levels on downstream wards tends to be poor anyway,” she said. “Nurses are already leaving the NHS in record numbers.”

An NHS England spokeswoman added: “The NHS continually monitors a variety of measures being used by trusts across the country to improve flow and reduce delays for patients, so we can identify safe and effective solutions that can be shared across hospitals.

“Earlier this week, further guidance was issued to systems on how they can best prepare for winter with plans for 24/7 control centres, falls response services, additional beds and more call handlers – all aimed at increasing capacity and reducing pressure on hospitals.”