Sarah Markham: The success of the high intensity user programme should see it rolled out across the NHS

It all starts with a phone call and a simple opener: “Hi. My name’s Rhian. I work on behalf of the emergency department and I’m really worried about you. I notice that you have been to the hospital lately and I was wondering what’s happening in your life and whether you can be better supported. Is it a good time to talk?’”

Just two years after NHS RightCare invested in their High Intensity User (HIU) programme initiated by NHS Blackpool clinical commissioning group (CCG), the service has been successfully replicated in more than 60 CCGs, with more in the pipeline.

The programme works by identifying high intensity service users and giving them a phone call to offer support and find out the underlying reasons behind their frequent trips to A&E. The HIU programme helps some of the most vulnerable people in our society, while saving NHS resources through reductions in A&E attendances, 999 calls, and non-elective admissions.

These live programmes are yielding positive and meaningful outcomes for clients and their families, including the opportunity to regain friends and purpose, prevent crises, address loneliness or social isolation, and return to employment, as well as a reduction in or prevention of self-harm and a reduction in dependency on family and friends.

This HIU model was originally developed by Rhian Monteith, NHS RightCare’s national HIU clinical lead, while she was working as an advanced paramedic. For many years, Rhian experienced firsthand the challenge of frequent attenders in A&E. She thought that there must be a better way to meet the needs of this vulnerable group. She developed a person centred, one-to-one coaching approach.

The results of this new model of care are substantial and have proven sustainable during Rhian’s initial piloting of the model. When I spoke to Rhian, she told me that “this is about finding better ways to help people by discovering issues at the individual client level; finding out what was wrong in their lives and how to fix it. Often this involves simply linking people up to community resources which are already in existence, but not necessarily used.

“The people concerned were mainly young, who may have experienced some form of crisis in their lives. They needed to be able to express their problems and support in getting them fixed, often with a healthy dose of TLC thrown in for good measure. Never underestimate the value of time to talk, especially in the context of discussing and deciding on practical support of the kind the individual wants.” 

The programme is broken down into three principles—diagnose, develop, deliver—as follows:

Diagnosis: Every area of the country has a rapidly growing challenge of individuals (high intensity service users) presenting frequently to medical services with needs that are not being met by clinical intervention.

Develop: A high intensity worker makes contact with the “top 50” attendees in A&E and uses a health coaching approach to find out what’s going on in their lives and offer support. Drawing on the support of partner organisations, including drug and alcohol services, housing, social services, police, and third sector groups, as required, helps provide a personalised response to each individual’s circumstances.

Deliver: Independent evaluation of the HIU programme operating in four CCG areas has found evidence of reductions in activity across A&E, non-elective admissions, and 999 calls in all cohorts. Data from active HIU sites have shown that there is a return on initial investment within three to five months. The central powerful premise of the model is that by doing the right thing for each individual, the results will follow. The core principles to “demedicalise, decriminalise, and humanise” have provided the opportunity for a powerful shift in perception about this vulnerable client group; creating a compelling, compassionate case for change.

This programme and its success have special meaning to me because of my involvement, both as a researcher and a person with lived experience, in research into the use of S136 in Sussex. Led by Gillian Bendelow of the University of Brighton, our research explored some of the complexity that can underlie high rates of detention under S136 of the Mental Health Act, and how this can be reduced through effective joint agency interventions. We found evidence of repeated sections of a small number of highly vulnerable and socially marginalised individuals, which echoes the need for a HIU programme to be implemented in mental healthcare and other parts of the NHS.

Sarah Markham is an academic mathematician and patient representative currently pursuing a second PhD in theoretical computer science. She is a member of the BMJ Patient Advisory Panel. Twitter: @DrSMarkham

Competing interests: None declared.