High-Intensity Use of A&E

It is no secret that our hospitals are strained; national data estimates that around 15,000 patients every day are delayed in hospital in England when they are medically fit for discharge. In June 2024, only 60.5% of those who attended major A&E departments (type 1 attendances) were seen within 4 hours, and discharge delays are only one of several contributory factors - what if increased community support could lead to fewer people attending A&E in the first place? Diving deeper into A&E visitor data, we can see that 16% of all A&E attendances are by individuals who attend A&E 5 or more times in a given year, known as high-intensity use of A&E. Moreover, these individuals make up 29% of ambulance journeys and 26% of all hospital admissions, and yet represent just 0.67% of the English population. At a system level, high-intensity use of A&E is estimated to cost the NHS £2.5 bn a year, and as a group, frequent attenders have a higher mortality rate than those who are not, particularly amongst younger individuals in this cohort. 

To better meet the needs of individuals who frequently attend A&E, the British Red Cross provides HIU services, based on the NHS RightCare model (now Getting It Right First Time), which deliver support across all 7 of the NHS England regions. Practitioners identify individuals who attend A&E frequently, who are then asked by these HIU services whether they want support. If they do, they are taken onto a person-centred programme in the community. 

Unlike the proposed NHCs, British Red Cross’ HIU services themselves aren’t clinical. However, they are proactive, holistic and long-term with the aim of identifying and addressing unmet social needs that may be exacerbating physical or mental health conditions, and also join the dots between clinical services for people who often fall through the gaps, such as those with dual diagnoses - something that NHCs should do. 

So, what can we learn from our HIU A&E research that we could apply to shape thinking about NHCs?

1.    NHCs need to provide joined-up, community support for individuals with multimorbidities
30% of individuals who attend A&E frequently have 3 or more diagnosed conditions, known as multimorbidity, while over 50% of all A&E visits involve at least one long-term physical condition, including arthritis, back pain, COPD, diabetes and angina. The provision of linked community clinical services in the form of NHCs could support better management of these long-term conditions, and the management of several conditions, reducing the need for A&E visits. Indeed, one study in Spain found that for patients with multimorbidity, a case management intervention in the community (managed by a Primary Care Health Team) reduced the relative risk for unplanned admission to hospital by 58.4%, and for A&E visits by 73.5%. 

2.    NHCs need to tailor services to the needs of the local population
Evidence from our HIU 'Nowhere else to turn' report shows that individuals who frequently visit A&E are most likely to reside in areas near hospitals, which are often urban and socioeconomically deprived - indeed, 20% of these individuals live in the most deprived areas (IMD 1). In our qualitative sample, 13 out of 14 participants were unemployed or retired, with many reporting financial difficulties and reliance on state benefits. Anecdotally, this seems to differ from another cohort of older, wealthier individuals living in the countryside, whose high A&E usage is driven by different factors, such as a lack of local services, rather than the physical and psychological challenges of urban poverty. 

A&E complaints also differ amongst age groups. For example, our HIU report found that among 20-29-year-olds frequent attenders of A&E, the top diagnoses made were no diagnosis, gastro issues, soft tissue injuries, respiratory problems, and overdose on prescription drugs. Meanwhile, for frequent attenders aged 70 and above, the most common issues were cardiac and vascular problems, respiratory issues, no diagnosis, gastro issues, and alcohol abuse or dependency. By understanding the demographics of the local community and the associated health and care needs, neighbourhood health centres can tailor the services that they offer to provide more targeted and effective care for their communities. 

3.    NHCs should co-locate and integrate physical and mental health support 
Individuals with pre-existing mental health diagnoses are disproportionately frequent visitors to A&E; in North West London, frequent A&E attendees are 11 times more likely to have a mental health diagnosis, a figure that rises to 26 times for those visiting over 16 times a year. According to the King’s Fund, frequent A&E visits by those with mental health issues are often driven by physical health complaints, rather than mental health. By combining physical and mental health services, NHCs can help individuals understand and manage the connection between their mental and physical well-being. Many of the frequent A&E attenders that we interviewed in our research suffered from personality disorders, and tended to receive short bursts of treatment (e.g. CBT) rather than the sustained holistic support that was required. Similarly, mental health services often struggle to support people with substance abuse problems. This lack of appropriate care in the community leads to A&E being “the one place that can’t say no,” as one HIU service lead commented. By offering a variety of community services, NHCs can offer more sustained and holistic care, reducing this dependency on A&E. 

People living with severe mental illness (SMI) die on average 15-20 years earlier than the general population; they have double the risk of obesity and diabetes, and three times the risk of hypertension. In 2016, NHS England made commitments to reduce the health inequalities faced by the SMI population, including the introduction of an annual physical health check (PHC). In March 2024, only 68% of those eligible on the SMI register had received a PHC in the preceding year. Using NHCs to integrate PHCs with community mental health care could be a way to increase the provision and uptake of these services, and hence improve health outcomes. 

4.    NHCs should provide proactive & preventative community programmes/ support
NHCs are about joining up health and care across a community, which includes providing wellbeing and healthy living campaigns, and preventative programmes - for example, ‘Change4Life’, a programme encouraging physical activity and healthy eating, or Cancer Screening Programmes. A focus on proactive and preventative care improves quality of life and reduces health inequalities across different socio-economic groups. Additionally, the successes of British Red Cross’s HIU services are a testament to the importance of providing non-clinical support; service users reported service leads supporting them with interventions such as setting up a mobile phone, reducing feelings of loneliness and increasing digital inclusion, finding a new GP, buying home equipment to support day-to-day living.

In Canada, Community Health Centres (CHCs) are multi-sector, not-for-profit organisations that offer high-quality primary care through a collaborative team approach. Social workers, family physicians, nurse practitioners, nurses, dietitians, chiropodists, dental hygienists, therapists and other clinicians provide services in a team environment, based on patient needs. CHCs also integrate team-based primary care with health promotion programs, illness prevention programs, community health initiatives and social services focused on housing, food security and other inputs for health. One such CHC - Gateway CHC in Ontario - avoided 6,225 A&E visits in 2018 through their comprehensive approach, including extended hours, home and on-call visits, walk-in services, and same-day urgent care access, resulting in a saving of $3.7m to the system. 

In summary, as with all innovations, Neighbourhood Health Centres must have patients and the needs of the community at the core of all the services that they offer. 

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