Supporting people who frequently use emergency services
A pilot project led by Trent Primary Care Network (PCN), set out to tackle one of the biggest pressures on the health system - people who frequently rely on emergency services.
Using Population Health Management (PHM) Pathfinder Analytics, analysts identified patients who had visited Accident and Emergency (A&E) or other urgent services multiple times over the past year. The focus was on those facing complex challenges such as poverty, poor health, substance misuse, homelessness, mental health struggles, and social isolation.
Reaching out, not waiting for crisis
Rather than waiting for people to reach crisis point, Link Workers contacted those identified and listened to their stories. Together, they explored what might be driving their repeated visits, which were often issues like housing insecurity, loneliness, or lack of support.
When appropriate, people were connected with a range of services, from mental health and addiction support to social prescribing and community-based activities, helping them get the right support, at the right time, in the right place.
Target group
Adults over 18 who had attended A&E seven or more times in 12 months (and were not on an end-of-life pathway).
The power of personal connection
The High Intensity Use (HIU) service, costing just £70,000 a year, employs two dedicated HIU leads who provide flexible, non-clinical support.
They meet people where they are - in their homes, communities, or trusted local spaces - to understand the whole picture of their lives.
Working with GPs, social prescribers, local councils, and voluntary sector partners, they co-create personalised care plans that build on each person’s strengths and goals.
This relationship-based approach goes beyond treating symptoms; it helps people regain stability, confidence, and control over their lives.
Real results, real value
A robust evaluation showed that investing in proactive, person-centred support delivers measurable impact, fast.
In just six months, the £80,000 pilot achieved a nearly 3:1 return on investment, saving an estimated £230,000 in avoided emergency admissions compared with a control group.
Benefits after six months:
- Emergency admissions down by 58%
- A&E attendances down by 41%
- GP encounters down by 4%
- Mental health activity down by 37%
A smarter, kinder way to care
The Trent High Intensity Use Pilot shows that proactive, personalised care pays off, not just in financial terms, but in human ones.
By investing in relationships and understanding people’s real needs, we can reduce pressure on services, improve lives, and create a more sustainable health and care system for everyone.
