Frequent A&E visits: the personalised service for chronic conditions

The high intensity users’ service, which started at Charing Cross Hospital and has expanded to St Mary’s, exists to support patients who have complex health and social care needs. The team behind it focus not only on physical health, but on a patient’s life and wellbeing more generally, working with partners across the sector to join up their care.

Here, Emma Schofield, an emergency registrar and one half of the core team, explains how she and social prescription lead Gemma Harper are helping turn patients’ lives around. 

As the ‘front door’ of the NHS, it’s well known that accident and emergency departments across the country are very busy, particularly during the winter. Imperial College Healthcare NHS Trust is no exception. In February this year, across our hospitals, doctors and nurses in our accident and emergency and urgent care services saw more than 30 patients every hour, on average.

For many of those patients, going into A&E is likely to be a rarity – caused by a one-off accident or illness. But some patients attend more frequently, perhaps due to persistent or chronic conditions. We understand that no one wants to spend more time in hospital than is necessary, and so, since April 2017, I’ve been part of a team working specifically with patients who come to A&E more than six to 10 times a year.

Our aim? To understand what’s behind a patient’s frequent visits to emergency departments, and to see if there’s a better way that we, as an acute hospital trust working with partners across the sector, can help them.

Bespoke care plans

Phillip Pizey is one of our patients. He is type one diabetic, and has complex health needs. When we first got to know Phillip, shortly after we launched our service, he was falling very ill, very often – with symptoms including vomiting and severe dehydration – and was coming into Charing Cross as often as every other day. It was clearly a frustrating experience for him.

“I would have to go through the whole rigmarole of A&E staff asking me about my condition,” Phillip explains. “Am I a diabetic, what type of diabetes, and so on. And often I would be really out of it at that point, explaining my condition again to someone I’d never met.”

“Emma came to see me and asked if she could get involved. I was unsure and reluctant at the beginning. But they’ve stood by me. They’ve done well. Now I deal with people I know.”

Working with my colleague Gemma Harper, our social prescription lead whose background is in mental health, we’ve devised a bespoke care plan with Phillip’s specialty team. 

Firstly, we arranged for Phillip to have a permanent feeding tube, preventing him from becoming dehydrated when he is unwell. That means he doesn’t need to come into A&E anywhere near as often – he didn’t come in at all during January and February, which would have been unheard of a year ago.

When he does come in, doctors now follow a pre-determined plan. Phillip now quickly goes to only one of two wards, with diagnostic tests and questions kept to the essentials, based on what we know about his condition. We’ve also arranged a permanent catheter to assist emergency department staff in giving Phillip fluids, when previously they were struggling to find a vein.

“Without what I call my ‘attachments’,” guesses Phillip, “I probably wouldn’t be here now. The teams in the A&E now know what to do. It will never be a perfect process, but now they’ve got my plan, there’s no need for them to start poking and prodding me as much.”

Visiting patients at home

But our work with Phillip, and other patients like him, extends beyond the hospital. Gemma visits patients at home, aiming to understand what else in their life might be driving them to A&E. 

“You don’t learn everything about someone in A&E,” explains Gemma. “You’re seeing their immediate medical needs, but you’re not seeing what’s going on around that person at home.”

In Phillip’s case, we found that severe challenges relating to his housing and financial situation were preventing him from managing his condition properly. Working collaboratively with Phillip and the local authority, Gemma has helped Phillip ensure he’s receiving the right benefits, and, most recently, secured him a move into much better suited accommodation.

“If it wasn’t for Gemma, I would still be moving,” explains Phillip, “but probably to a B&B or a hostel. I’m going to miss my home, but this is a fresh start, it’s near my family, and it’s on the ground floor.”  

“We’ve got a good relationship,” he adds. “She has done wonders for me.”

Health and social care working together

A key feature of the recently published long term plan for the NHS is the emphasis on joined-up care, in which partners including hospitals, GPs, community health teams and local authorities work better together. 

That’s exactly what our work is about. As an acute hospital trust, we start with a patient’s physical health. But we know that’s just one part of their life – and that the best care needs to be more rounded. And so whether it’s helping with housing, sorting out a broken boiler, or getting people out dog walking, we’re thinking differently about how best to care for patients.

We’re now working with a core group of around 80 patients across St Mary’s and Charing Cross hospitals, and are supporting upwards of 200 by advising our colleagues. Right now this is seen as an innovative approach, but over time it needs to be viewed as a fundamental part of how we work with our community.

As for Phillip, we were overjoyed to see him move into his new flat a couple of weeks ago. And pleased to hear that he’d recommend us to others. “I’d say to people in my position, give them a chance,” he says. While Phillip will always have a complex health condition, he’s now coming to hospital much less frequently. Better still, his care is better managed when he is here, so he is discharged feeling much better each time.

“They’re here to help you. They’ve done a wonderful job, and they are there for a good reason – there are people out there that need their help.”

For more information on the high intensity users’ service contact: