Glasgow Royal Infirmary patients left on chairs and trolleys

The system, first adopted by NHS Greater Glasgow and Clyde (NHS GGC) in December 2022, means that a certain number of patients requiring admission to hospital are transferred at regular intervals out of the emergency department or assessment units onto a ward, even if there is no bed available.

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They can be moved to any ward - not necessarily one specialising in their particular condition.

As a concept, continuous flow originated in the United States but is better known in the UK as the 'North Bristol' model after the NHS England trust which piloted it in mid-2022 as a potential solution to worsening A&E bottlenecks.

The idea is that it "spreads the risk" of overcrowding throughout a hospital, helping to relieve pressure on emergency departments.

The introduction of the continuous flow model by NHS GGC is understood to have reduced 12-hour waits and the overall length of stay for patients in A&E - something that is in itself associated with an increased mortality. 

However, it tends to be unpopular with staff in other departments who have to care for more patients than their ward was designed to accommodate.

In its inspection report, Healthcare Improvement Scotland states that some patients moved to wards in this way "complained to inspectors that they were uncomfortable whilst waiting for their bed to become available".

It added: "Staff in multiple ward areas raised concerns regarding the suitability of some patients who were selected to be moved into wards under the model, citing issues such as a lack of available space to provide personal care and patients waiting a prolonged period of time in chairs.

"Inspectors were also told that in some wards, the only suitable place to place a continuous flow patient who required to stay on a trolley until a bed was available was in the thoroughfare in the middle of the ward."

Continuous flow models are intended to relieve pressure on the 'front door' of hospitals by getting people out of A&E faster (Image: PA)

Inspectors found that staff had escalated concerns to hospital management in relation to "patients who had waited a prolonged period in wards under the continuous flow model".

Parts of Glasgow Royal Infirmary date back to the 1790s, and senior managers who spoke to inspectors admitted that "the older part of the hospital estate did pose challenges in regard to having space to accommodate additional patients in wards who were waiting for a bed".

The unannounced visit followed a previous inspection of the A&E at Glasgow Royal Infirmary in April, when HIS found that the emergency department was "often operating at over 250% capacity".

Inspectors raised "significant patient safety concerns" at the time, after finding evidence of patients falling from trolleys or becoming "critically unwell" while waiting in corridors, and of patients being misidentified or discovered in A&E hours after they were thought to have left.

On both the April and June visits, inspectors found that the hospital as a whole was operating with a 96% bed occupancy rate - well above the 85% maximum recommended as a safe level for patient care.

Inspectors found that changes introduced in A&E since the April inspection mean that no more than six patients are allowed to wait in the ambulance corridor and seven patients on trolleys in the main department.

The GRI has limited the number of people who can wait on trolleys in A&E and in the ambulance corridor to 13 - but it means ambulances waiting longer outside A&E to offload patients (Image: Getty)

These trolley spaces "are now individually numbered enabling patients to be easily identified", said inspectors, with the electronic patient system updated to identify the patients "who are being cared for in non-cubicle areas".

In addition, a designated registered nurse and two healthcare support workers are allocated "to provide ongoing care and treatment for patients waiting in corridors or around the nursing station".

Inspectors said that a review of shift reports since the April inspection "observed no instances" where the maximum threshold of 13 patients being cared for on trolleys and in the ambulance corridor had been exceeded.

They noted that the new rule means paramedics are now more likely to face delays in handing patients over to the A&E department, because patients remain in the back of ambulances for longer instead.

However, inspectors did not observe any cases of patients becoming sicker as a result.

The report states: "In evidence provided we observed that ambulances were waiting up to two hours to transfer patients into the emergency department.

"We did not observe any patient safety incidents relating to patients deteriorating whilst awaiting transfer into the emergency department within provided incident reports."

In a statement, NHS GGC noted that inspectors had praised five areas of good practice including "well organised mealtimes, good staff health and wellbeing support, and specifically in our emergency department an electronic logbook which allows real time oversight of the department".

It added: "We were also pleased to note that the inspectors found the ward areas calm and well led, with good teamwork and senior team visibility and support.

"We recognise some aspects of care and standards weren’t what they should have been, and we have taken the report findings very seriously.

"Immediate improvements were made following the inspection, and we can confirm that nine out of the 11 requirements published in the report have been completed, with the remaining two on track to be complete by the end of December 2024.

"Immediate actions included points related to Continuous Flow, such as taking the opportunity to revisit its principles with ward and operational teams, and to work together to ensure all patients arriving to a ward are given a bed space at the earliest opportunity, monitoring this closely with clear escalation if there is not a delay."