Title: Frequent Users of the Emergency Department: Improving and Standardising Services-a mixed methods study
Funder: Department of Health and Social Care

Abstract: A small number of people account for a large number of attendances at urgent and emergency care including emergency departments, NHS 111 and 999. These people, who are referred to as 'frequent users', have a range of physical and mental health and social problems. The highest frequent users are especially likely to have mental health issues and often suffer stigmatisation. Recently, across England, emergency departments have been encouraged to set up services for frequent users, and there are now 80 services. Most are staffed by mental health teams. There are 4 broad types of service which offer interventions to different types of frequent user: three types are based in emergency departments but all has different staffing models and one type is located in the community. These services may be effective, but at the moment we do not know how well they work for patients or how many people they see would have stopped attending anyway, without any kind of help from services._x000D_ AIMS_x000D_ We aim to improve services for frequent users by understanding which activities are carried out by emergency services for them, how the services bring about change and what difference they make. This will enable us to develop ideas (programme theories) about change which includes which aspects of services are important, how they work and which patients they help most. We can then develop guidance in the form of a framework to help new services get started and current services focus on activities likely to bring benefit. _x000D_ RESEARCH_x000D_ There are 4 work streams. Work stream 1 will map what frequent user services are currently available across England and then interview staff from 20 services (5 from each of the 4 service types) to understand what they actually do to help frequent users. Work stream 2 will use routinely collected healthcare data to understand more about how and when people use services frequently, especially those who keep attending over many months and those who attend lots of different EDs. We will use two sets of data: one is the most detailed in the UK and covers 18 EDs in Yorkshire; the other covers all of England but in less detail. These two datasets complement one other. We will assess the impact of current services for frequent users on attendances at ED, and estimate costs and savings, by using national data to compare the 80 EDs which have services with the 90 without. We will also be able to assess the impact of COVID-19 on ED attendance patterns. Work stream 3 will bring together the findings of Work stream 1 & 2, along with other research to construct theories about how different interventions bring about change for different groups of frequent users and then test these theories by in-depth study of 4 different services (one from each type), interviewing staff and patients and holding focus groups. Work stream 4 will develop a framework to help improve services for frequent users._x000D_ PATIENT AND PUBLIC INVOLVEMENT AND ENGAGEMENT _x000D_ Two of our co-applicants are experts by experience. One is Chair of the Crisis Care Group in Sheffield and one is a service champion for people with mental health problems. We will form a patient reference group who will be involved in all aspects of the study. _x000D_ TEAM_x000D_ We are a team of researchers, with expertise from emergency medicine, liaison psychiatry, primary care, social science, patient expertise, statistics, data analysis, and health economics._x000D_ DISSEMINATION_x000D_ We will work closely with NHS England, relevant Royal Colleges and patient forums/networks to fast track our results into clinical practice, and cascade the clinical framework to relevant services via a series of webinars.

Lay abstract: BACKGROUND: Approximately 2.5% Emergency Department (ED) users account for 10% of total attendances. Many frequent users suffer from mental health and social problems. Services for frequent users have developed recently in a piecemeal fashion and evidence of efficacy of interventions is weak. In previous work we found 80/170 Emergency Departments with frequent user services with 4 different service types. These are: frequent user services based in ED and run by ED staff: frequent user services based in ED and run by mental health staff (liaison mental health teams); frequent user services with in-reach to ED from mental health services; and community based services for frequent users based outside the ED. _x000D_ _x000D_ AIMS: Our aims are to: a) describe current patterns and costs of frequent use of urgent and emergency care (UEC); b) describe the services for frequent users; c) identify predictors of high-cost patterns of attendance, and the impact of frequent user services on attendance; d) identify which interventions appear to work for which types of frequent users and why, and test these findings by in-depth case-studies of 4 different service types; and e) disseminate an implementation framework for frequent user services to improve planning and optimise care._x000D_ _x000D_ METHODS: _x000D_ Workstream 1: This is a cross-sectional mapping of the current extent of services for frequent users of urgent and emergency care networks in England, and a mixed methods study to characterise 20 representative frequent user services (5 each from 4 different types). From this we will develop early ideas about how interventions may work for different subgroups of frequent users (i.e. safely reduce urgent and emergency care use if appropriate plus/minus provision of additional help and support). _x000D_ _x000D_ Workstream 2: This is a large data study (years 2016/17 to 2020/21) using two complementary datasets. The CUREd dataset links the urgent and emergency care network (ED, 111 and 999) data for Yorkshire and Humber Region. Hospital Episode Statistics data will be linked to ED attendance for the whole of England. The data from CUREd are more finely grained than HES data, whereas HES data provide a national perspective as opposed to a regional perspective capture by CUREd. Together they complement each other. _x000D_ _x000D_ We will: a) identify patterns of frequent use and sub-groups of frequent users; b) examine how frequent users access the whole urgent and emergency care network including attendance at multiple sites; c) study healthcare costs of frequent users to understand where costs are generated and the potential for reduction d) conduct an interrupted time series analysis of the impact on ED frequent users of the introduction of frequent user services. We will also examine the impact of the COVID-19 pandemic on frequent use of the ED._x000D_ _x000D_ Workstream 3: This involves a realist synthesis to identify and test programme theories about how interventions for subgroups of frequent users produce outcomes. The synthesis will include a realist literature review, and will incorporate the early ideas from workstream 1, 4 in-depth exemplar case studies (one each from the different types of frequent user service) and data emerging from Workstream 2. The synthesis will run iteratively throughout the project to ensure that work across the project is informed by and understood within a testable explanatory framework of cause and effect. Conceptually, it will draw on relevant theoretical models and take a whole systems approach across the urgent and emergency care network at micro, meso and macro levels._x000D_ _x000D_ Workstream 4: We will develop an implementation framework of 'ideal' models of service delivery tailored for the 4 different types of frequent user service, with a focus on specific interventions for particular subgroups of frequent use._x000D_ _x000D_ TIMELINE: 0-18months: We will employ staff, set up our programme oversight committee, set-up our PPI reference group, obtain relevant ethics and research governance permissions, begin the analyses using the CUREd dataset, obtain the relevant HES data from NHS digital, start the realist review, conduct the mapping project followed by 20 structured interviews involving frequent user services (5 each from each of the 4 different types). 18-30months: We will carry out 4 in-depth case-site studies, carry out and complete the analyses using the HES data, conduct the main health economic analyses, complete the analyses using the CUREd data, complete the realist synthesis. 31-36months: We will develop the implementation framework with case-site involvement and PPI, disseminate our findings to clinical services via a cascading series of webinars and write up the main results of the programme. _x000D_ _x000D_ DISSEMINATION We will use several different routes to disseminate our findings to relevant stakeholders including top down via NHS England and the medical and nursing Royal Colleges and bottom up via cascading webinars for clinical services plus patient groups._x000D_ _x000D_ ANTICIPATED IMPACT: We intend to improve outcomes for frequent users of urgent and emergency care networks by optimising services for frequent users, so they provide a safe and appropriate therapeutic response whilst helping to reduce urgent and emergency care use. We will: provide an up-to-date mapping of current services across England and detailed characterisation of four different service types; a characterisation of the different patterns of frequent use of urgent and emergency care and their associated factors; detailed costs related to the pattern and use of urgent and emergency care services by frequent users; an in-depth understanding of why people use urgent and emergency services frequently; a robust evaluation of the impact of frequent user services including likely cost-effectiveness; identification of specific interventions for certain sub-groups of frequent users; understanding of the impact of COVID-19 on frequent use of urgent and emergency care networks; we will develop a framework for frequent user services which will include ‘ideal models’ for each of the different service types; we will distribute the framework to all current frequent user services via a series of cascading webinars; and conduct additional multilevel knowledge transfer at a multinational, national, service and patient/ service user level. Our findings will enable urgent and emergency care networks to make informed planning choices about services for frequent users. We will provide best evidence on how interventions work (or fail) in order to guide on-the-ground delivery. By incorporating PPI in the research we will increase awareness of constructive approaches to this important issue and aim to improve care for people who use emergency care on a frequent basis.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE