Ward staff ‘must accept extra workload to help A&E’

In a recent interview with HSJ, North Bristol Trust chief executive officer Maria Kane praised her trust’s risk-sharing approach to emergency care, which involves moving patients each hour from accident and emergency to the most appropriate ward for their needs and where a discharge is expected, even if it is full.

Commenting on the article, Royal College of Emergency Medicine president Adrian Boyle said: “The NBT trust leadership deserve significant credit for maintaining this. All too often there is an acceptance of unacceptable delays (and risk) in ambulance handovers and long ED stays.

“Where this fails, it is usually because inpatient teams (both nursing and medical) have objected to the extra workload, without appreciating the real harm elsewhere. The more interesting question is why isn’t this being done more widely?”

Responding to HSJ’s request to expand on his comments, Dr Boyle said introducing such flow models requires a “real test of leadership and it’s actually about getting people to think systemwide and recognise they’re working in a partnership”.

He added: “When people get busy and overworked they just try to get through the shift, and the idea that someone is going to make that hard for them is going to be really difficult – I absolutely get that.

“People find all sorts of reasons why they don’t want to do this… but people need to find a solution as part of the system – this is our societal responsibility to try to help ambulances offload and make sure people get treatment in ED as quickly and safely as possible.”

However, the North Bristol model has prompted concern from the Nuffield Trust, which highlighted two studies from Australia and the US about increased risks of overcrowding across hospitals.

But Dr Boyle said it was more dangerous to “concentrate the risk in ED because you then run into ambulances being delayed, the nurses being stretched” and “huge amounts of safety incident reports” are sparked by long A&E stays. 

He said the North Bristol model prevented big surges in demand on hospitals because wards have to prepare for taking patients based on the predicted number of patients attending A&E, adding: “It’s still the same number of people being admitted [to hospital], it’s still the same equilibrium, but it’s reduced the crowding in ED.”

However, Dr Boyle also said: “This is not something that’s going to work in every place all the time. It’s not one size fits all, but it’s a least worst option.”

Several other trusts have reportedly implemented similar continuous flow models as North Bristol, but Dr Boyle believes not enough providers have done so, adding it was hard to know how many places have because “people are very cagey about sharing this information, because it’s seen as potentially divisive”.

Freedom of Information figures obtained by RCEM and published last month showed nearly 400,000 people had spent 24 hours or more in A&E between March 2022 and March 2023.