Managing vulnerable frequent service users

In early 2017 we collaborated with the Academic Health Science Network North East and North Cumbria (AHSN) and the North of England Mental Health Development Unit (NEMHDU) on a project to identify and analyse vulnerable people who were frequent users of urgent and emergency care services in the region. This work became known locally as the Cohort 30 work stream as each organisation worked with their 30 most frequent users of services.

The project involved senior representatives from mental health crisis and liaison services, North East Ambulance Service, emergency departments, police, local authorities and CCGs attending accelerated learning events facilitated by NEMHDU to understand the patterns of behaviour of the frequent service users in their area and develop potential responses to better support those people and reduce demand on services.  The Durham and Darlington, Northumberland, and North Tyneside crisis care concordat groups took part in this project which is based on work previously done in Teesside.

Focused both on reducing demand on A&E, ambulance, police and mental health crisis services, as well as providing more proactive planned interventions for vulnerable people, the project made recommendations which included developing a proactive well-being and intervention service to reduce demand on emergency services, and better co-ordinating the responses from different services to manage people with complex needs.

The recommendations from each of the learning events shared some common themes, including developing multi-agency processes which would enable individual organisations to identify when a person was becoming a frequent user and initiate a multi-agency case planning meeting.

Throughout the process participants demonstrated a shared willingness and desire to provide a more connected and proactive service for vulnerable frequent users of their services and which could make a significant contribution to both the quality and safety of care received by the individual as well as a reduction in the inappropriate use of urgent and emergency care services.

Final Network project report

North Tyneside project report

Durham and Darlington project report

Northumberland project report