As the National Medical Director’s Clinical Fellow in the Healthcare Inequalities Improvement team at NHS England, I’ve had the privilege of contributing to national strategy and policy – challenging at times, but always revelatory [LW].
Of the many inspiring initiatives I’ve encountered, the High Intensity Use (HIU) Programme stands out [LW]. Our team enjoyed visiting Cambridgeshire and Peterborough’s HIU crew to learn more about this integrated, person-centred service which directly addresses health inequalities.
HIU services exemplify the best of integrated neighbourhood working, as outlined in NHS England’s ICB Blueprint, and deliver on the three shifts underpinning the 10 Year Plan. They also directly target Core20PLUS5 populations, with particular focus on inclusion groups.
What are High Intensity Use (HIU) Services?
HIU services are most often non-clinical and typically support individuals aged 18+ who frequently attend Emergency Departments (EDs). While local criteria might vary, Cambridgeshire & Peterborough’s (C&P’s) HIU service uses a threshold of over 10 ED visits in 12 months. Though fewer than 1% of England’s population attends A&E frequently*, they account for over 16% of A&E attendances, 29% of ambulance journeys, and 26% of hospital admissions (1).
The goal isn’t simply to reduce demand on emergency services. HIU services aim to restore trust, build connection, and offer integrated, person-centred support to individuals often labelled as “frequent flyers” – a term we avoid now, given the links between frequent ED attendance and deep-rooted inequalities such as housing insecurity, trauma and social isolation.
There are different models for delivering HIU, including some services led by community trusts, acute trusts or the voluntary, community and social enterprise sector. What sets the C&P HIU service apart is that it is a partnership between the Local Authority, Cambridgeshire County Council (CCC), and the Integrated Care Board (ICB). Funded by the ICB, the service uses CCC’s advantageous position to bring together health, care, and community partners to support C&P residents who frequently use emergency or crisis services.
This brings distinct advantages: well-established relationships with key partners, deep insight into referral pathways, and the ability to streamline referral processes.
The Role of Link Workers
At the heart of HIU services are link workers – often the only consistent presence in a client’s life. They advocate for individuals in need, navigate complex systems, and build therapeutic relationships grounded in respect and trust.
The C&P HIU service assesses clients using a locally adapted ‘Chaos Score’, which helps the team to manage client caseload by complexity. This tool collects data on a broad set of factors (e.g. connection with services, risk to/from others, emotional regulation, etc.) and is helpful for demonstrating client progress.
Shared case ownership allows link workers to draw on each other’s strengths and collective expertise – offering support that ranges from attending court hearings to arranging school assessments, or simply providing a compassionate check-in.
It is striking the degree to which the link workers’ own lived experience enables them to build client connections that can, at times, seem aspirational to time-constrained clinicians.
HIUs Embody the Power of Consistent, Non-Judgemental Human Relationships
Dave was referred to the C&P HIU service after 10 ED visits in a year – six of them in just three months. He had severe alcohol-related issues, was homeless, unemployed, and without family support. He experienced withdrawals and was often a victim of assault, presenting to ED in distress or unconscious. Since he had separated from his wife, his housing situation was uncertain. Dave did not meet the threshold for a diagnosable mental illness. Fortunately, Liaison Psychiatry referred him to the C&P HIU service.
A link worker became a consistent, non-judgemental presence and worked closely with partners: the Homelessness Lead, Peterborough City Council, Change Grow Live (drug and alcohol services), and the Department for Work and Pensions. They started by meeting Dave’s immediate needs – warm clothes, a mobile phone – and built from there.
Within months, Dave moved into safe accommodation and secured full-time work. As of May 2025, he had been sober for ten weeks and had not returned to ED in five months.
“You made a difference as you didn’t judge me for my drinking. We did it together.” – Dave
Dave’s story shows that coordinated, multi-agency care isn’t just effective – it’s essential.
A Programme Informed by Trauma, Equity, and Affirmation
Many HIU clients have experienced trauma, including domestic abuse, addiction, and homelessness. The C&P HIU service ensures access to culturally competent, psychologically safe support through services like the Light Project Peterborough, talking therapies, and translation services. Recognising the emotional toll of this work, staff receive monthly clinical psychological supervision.
One link worker described telling a client: “You’ve survived a lot. You deserve peace.” Words have power. These words reflect a consistent ethos within HIU services: healing begins with being seen.
Strategic Partnerships, Clarity in Impact
HIU services also show creativity in funding. Support comes from the health and social care sector – and sometimes surprising partners like Newmarket Horse Racing. The ICB’s strategic collaboration with the Health Innovation Network and AstraZeneca has led to the development of a health economics team to evaluate the impact of C&P’s HIU service.
The impact is clear. Nationally, HIU programmes deliver a financial return on investment of 250–400% (2), but the more meaningful return is human in nature. These programmes don’t just save money, they restore social connection and save lives.
Looking Ahead
C&P’s HIU service shows what is possible when we reframe frequent use of EDs as a signal, not a failure. It reminds us that many of the solutions we need already exist in our communities.
Formal evaluation of C&P’s HIU service is planned for October 2025. This will provide insight into its impact and identify opportunities for development, including expansion into children’s services. As a consistent presence, HIU teams are particularly well placed to provide guidance, a voice and empowerment for people facing exclusion, adversity or trauma.
If our ambition is an NHS rooted in equity, especially the most marginalised, then we must back HIU services with long-term investment. Because transformation doesn’t begin with a policy. It begins with a person.
*Defined as attending ED more than five times in a year
References:
- British Red Cross (2021) Nowhere else to turn. Retrieved from: http://redcross.org.uk/about-us/what-we-do/we-speak-up-for-change/ exploring-the-high-intensity-use-of-accident-and-emergency-services
- British Red Cross (2024) Seen and heard. Retrieved from: Seen and heard | British Red Cross
Authors:
Lauren Watts
Lauren Watts is the National Medical Director’s Clinical Fellow in the Healthcare Inequalities Improvement Team at NHS England. As a senior oncology registrar, Lauren has broad interests in improving earlier cancer diagnosis, access to integrative oncology, and equality, diversity and inclusion of clinical trials.
Carissa Gilbert
Carissa Gilbert has led national policy work at NHS England, most recently shaping the High Intensity Use programme to reduce emergency care pressures and support complex patient needs. She brings over a decade of experience in healthcare strategy, delivery and system transformation across the UK and internationally.
Hannah Baird
Hannah Baird is an Emergency Medicine Consultant alongside a senior clinical fellow role at NHSE Health Inequalities Improvement Programme. She is passionate about the developing HIU services to both support individuals and reduce demand on urgent and emergency care systems.
Jack Spencer
Jack Spencer is a Policy Manager in the Out of Hospital Urgent Care Policy Team at NHS England. With experience developing national urgent and emergency care strategy, Jack now plays a key role in the National HIU Programme. He is passionate about tackling health inequalities and reducing low acuity activity being delivered in Emergency Departments.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.