Reducing health inequalities in urgent and emergency care settings, November 2023

Health Inequalities peer learning event, held on 27 November 2023.

This interactive online peer learning event explored:

the role of High Intensity Use services in reducing demand in urgent and emergency care settings and tackling health inequalities
the current approaches trusts have taken in targeting interventions at frequent attenders in A&E
the barriers that have prevented trusts from implementing or growing existing High Intensity Use services and how these challenges could be overcome.

About the event

Services are experiencing an unprecedented level of operational pressures in the run up to winter. Trusts are working to reduce elective care backlogs, in the face of ongoing workforce pressures. It is more important than ever to ensure effective winter planning to manage and minimise the expected increase in demand over this period. A&E is the front door to hospitals and often sees the biggest rise in patient numbers during winter.

Trusts can act now to reduce attendance in emergency and urgent care settings by providing targeted approaches to reduce the number of frequent attenders in A&E settings. Often, individuals frequently attending are likely to present from more deprived backgrounds and with complex health and wellbeing needs. High Intensity Use (HIU) services identify the top attenders in A&E and make contact with these individuals to find out how the local health and care system can better meet their needs. This often involves working in partnership with voluntary and community sector (VCSE) organisations to provide non-medical assistance, such as for housing, loneliness, social isolation and wellbeing.

Although the majority of acute NHS trusts have access to an HIU service, there is variation nationally in how services operate and the level of support they are able to provide for patients. Implementation of HIU services is a key priority for NHS England (NHSE), with references in the Delivery Plan for Recovering Urgent and Emergency Care Services (2023), the 2023/24 operational planning guidance, and the 2023/24 business plan.

Key themes from the event

This peer learning event was aimed at trust board members and those who contribute to or lead work on health inequalities in their trust. It provided a safe space to discuss how trusts can meet the dual goals of tackling health inequalities and reducing demand in A&E services through the use of HIU services.

In facilitated breakout discussions, delegates were asked to discuss their current approaches to HIU services, the barriers that have prevented them from implementing services and the opportunities services could provide in reducing health inequalities and alleviating pressure in urgent and emergency care.

Themes from the breakouts are outlined below:

Current approaches

Among attendees there was a mix of trusts who do and do not have access to HIU services.
There was variation between trusts with a specific HIU service and those with a more general approach to reducing frequent attenders. This included using data to identify patient groups, collaborative working between professionals and targeted outreach programmes for specific groups (eg homeless communities).
HIU approaches can complement other approaches aimed at reducing hospital attendance.

Barriers

Many of the barriers raised reflect broader challenges trusts face when implementing health inequalities initiatives.
Awareness of HIU services: more awareness of what HIU services are and how to establish them locally would be useful, alongside education for staff to ensure they are embedded effectively.
Workforce: operational pressures within emergency departments and lack of dedicated staff job roles are key barriers to implementation. The non-medical approach requires training and time to embed among staff groups, specifically to overcome any stigma or cultural bias relating to patients attending frequently.
Funding: short-term and sporadic funding for HIU services can prohibit the development of long-term services and will not adequately meet the needs of patients. Funding for HIU services should be seen as business as usual.
System working: there is a need to join up the different frequent attender programmes and services taking place at different levels across the system. This includes improving communication and data sharing.
Data: data analysis should be harnessed to increase awareness and understanding of the level of demand for HIU services. Dedicated data analyst resource and skills dedicated to reviewing the data to help shape the design and delivery of HIU services is critical.
Accountability: meeting the needs of frequent attenders was not always seen as an organisational priority alongside other competing pressures. Greater advocacy may be needed nationally to make the case for HIU services.
Availability of HIU providers: a lack of local HIU service providers (often VCSE) is a barrier to setting up services, which may be compounded by lack of out-of-hours provision.

Opportunities

Evidence of the impact of HIU services: HIU services have had an impact on reducing emergency attendance within trusts. The British Red Cross' report Nowhere else to turn provides an overview of HIU services and the impact they have had on patients and services.
Collaboration with system partners: trusts reported positive working relationships with Local Authorities and VCSEs that can be built upon to develop HIU services. There is an opportunity to share learning and resource across the system to provide holistic support for patients.
Personalisation of care: by taking a non-medical approach, HIU services provide an opportunity to deliver personalised care pathways for patients that address their needs – incorporating social care, physical health and mental health needs.
Linking HIU services to the broader health inequalities agenda: a key opportunity is connecting the need for HIU services to broader health inequality work within the trust, to help prioritise and raise the profile of the issue.
Sharing learning on HIU services: trusts would welcome more opportunities for peer learning on HIU services, to share what is working well and how trusts have overcome challenges in implementation, such as a repository of case studies.

Download the full notes

Additional resources

Chair:
Dr Sohail Munshi – chief medical officer, Manchester Local Care Organisation

Speakers:

Rhian Monteith – specialist advisor in High Intensity Use Services, NHS England

Prof Bola Owolabi – director, national health inequalities improvement programme, NHS England