We need to look beyond the statistics to help reduce repeat A&E visits among vulnerable patients
Emergency departments are again feeling the pressure. The public see the messages: call 111 first. Don’t come unless you need to. Consider alternatives. But for a small but significant number of people, A&E feels like their best or only option.
Less than one per cent of people coming to A&E meet the definition of “high intensity use” (attending five or more times in a year). The group is small but its members account for more than 16 per cent of A&E attendances, 29 per cent of ambulance journeys, and 26 per cent of hospital admissions. That last figure is important – they do require admission, they are ill, but why are they repeatedly reaching crisis point?
Previous research has been patchy. It often doesn’t include the voices and experience of the people who are making repeat visits. We spoke to them, and to healthcare staff, as well as looking at the data for our report. So, while we can now put some numbers to the issue, we can also see beyond the statistics to the people and the complex reasons that bring them to A&E.
People’s reasons for coming to A&E are as nuanced as they are
Let’s look at Brian (pseudonym) as an example. Brian, when you look at the numbers, was a worry. He was visitng A&E over 300 times a year. He was always calm, polite, he would come in for tests and then go home. He was presenting with urine retention, but the nurses were sure there was more to it. Someone needed to get beyond the number of visits and the most obvious symptoms. One of the nurses thought he might be hungry, but it was hard to get him to open up and talk about it.
Every day, for a week, one of our high intensity use staff dropped off a sticky bun and a note on Brian’s doorstep. He eventually let them in, and they were able to build a relationship of trust. Brian had no hot water, heating, food, or family to support him. We got his benefits sorted, the boiler fixed, and he now has links to a local church where he can come for company on his terms. He’s also just received, in his 70s, an autism diagnosis. In the last six months of working with Brian, he only went to A&E once.
The numbers help us prove high intensity use services work – we’ve seen attendances fall by as much as 84 per cent amongst this cohort. But the numbers are a by-product of focusing on people, sparing time to listen, and find out what they need to be well.
People’s reasons for coming to A&E are as nuanced as they are. Grief, loneliness, homelessness, mental health issues, past trauma – these are all common factors, combined with sudden life changes that can bring someone to crisis point. From the data we also see a clear link between deprivation and repeat attendance at A&E – lay one data map over another, and you are basically looking at the same map.
There isn’t a magic wand to fix all the myriad causes behind someone’s repeat visits. And we know A&E staff don’t have the time to uncover issues that may be deep-rooted or deliver buns to people’s doorsteps. But there are things we can do.
We can expand the number of high-intensity use services - every hospital must be able to refer people who need this dedicated one-to-one support. We can look for and address any barriers to community services so people can get help earlier, and nearer to home. And we can continue to make changes and call for further action from government to address health inequalities.
But mostly, all of us can learn from the basic approach of high intensity use teams: we can listen, be non-judgemental, and see beyond the numbers or the symptoms to the whole person.
Mike Adamson is the Chief Executive of the British Red Cross.
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