Bridging the Gap – a truly integrated approach to Frequent Flyers within Unscheduled Care Services


A collaboration between health, third sector, local authority and other agencies has been set up to reduce demand on emergency services by frequent flyers. It bases itself completely within the prudent healthcare premise, working with the patient at every step of the way. It reduces unnecessary investigations, streamlines resources, protects the emergency stream and reintegrates patients into local community support. It enables working without walls, bringing unique solutions to entrenched problems, whilst ensuring that an extremely vulnerable cohort of patients is supported through changes to their multi layers of need.

The aim

Cardiff and Vale University Health Board and the Welsh Ambulance Service NHS Trust (WAST) provide care to segments of the population that access unscheduled health care services frequently and proportionally more than the rest of the local community. This percentage of service users requires a significant amount of resources and time, often disproportionate to their actual emergency needs. There is a recognition however, that they are in need of input from the health and social care agencies, and so independently, areas of the health board, namely the Emergency Department (ED) and GP Out of Hours (OOHs) and the local Frequent Caller Officer of WAST started streams of work concentrating on their own Frequent Flyers (FF).

These independent steams of work co-existed for a number of years, and successfully began to reduce the demand these patients had on services. It became obvious however, that there was an overlap of work, with ED, OOHs and WAST sharing on average 45% of all FFs, and a further 25% of FFs are known to 2 of the 3 agencies.

An audit of the shared data showed that for 1 month, there were 371 contacts made by 40 FFs to the three agencies, costing £171,000.00

A project was commenced to integrate the health agencies work, and to bring in key partners from the local authority, third sector agencies, homeless services, criminal justice system, GPs and others to provide a comprehensive and collaborated response to the needs of the FFs in the Cardiff and Vale area.

This group has been a key innovation in the project for its wide reaching abilities to help solve real time problems for the patients. It is unique in its membership, with 28 agencies represented at meetings, spanning from the Health Board right out into the depth of community projects like community gardens and cafes. The panel then feed into a further layer of support agencies. It puts the patient directly in the centre of care, and promotes independence and reintegration into their local community.


There are 4 areas within the FF service that are measured and audited, although each agency (WAST, OOHs, ED) have their own unique slant dependent on their service needs. These areas are:
  • the amount of times the FF contacts each agency
  • the amount of time given per contact
  • the price on resources used per contact
  • the patient satisfaction/outcome. 
The baseline was set at 4 contacts a month/12 in 3 months, as per the Royal College of Emergency Medicine (RCEM) guidelines, and the National Ambulance Caller Network.

Before the project was implemented, each agency was working within its own remits, independent from any other. This meant that vast amounts of resources and energy were being spent by different services, all dealing with the same patient/patient groups. Information was not shared, meetings were held without key stakeholders, and crucially, the patient was left dealing with expectations from all avenues of health, some of which varied widely in its implementation.

The collaboration and integration of the health agencies work into the FF project has been vital in streamlining the response to the FFs needs, and ensuring that the patient remained the centre focus to the work. The Project understands that accessing the right care at the right time and from the right service is a confusing path to navigate for any patient, and especially so for the swathe of population that feeds into the FF network. It enables all agencies involved in the patients care to bring their combined expertise and strengths to formulating a patient specific plan, one that assists the FF to choose well, to access services at the best point of entry and to be supported by the right agency. These plans have been critical in managing demand on unscheduled services across ED, OOHs and WAST, ensuring that from the point of 999 call, arrival at OOHs or ED, the person assessing the FF for an emergency response has the full gamut of information needed to make that call.

The clinical management plans bring together pertinent information about the needs of the FF, including social, emotional, medical and psychosocial needs, and what each agency is undertaking to support. It is written with the full knowledge and involvement of the patient, and in doing so, fosters an appreciation of, and openness to, discussions surrounding needs and appropriate response, and a commitment from both sides to help the FF reduce unnecessary demand on emergency care and subsequent integration into local community support.

This in turn ensures that an appropriate response is actioned, and in doing so, drives down attendances at ED, the time spent by each agency with the FF, and the resources used by each agency per contact.

The outcome for the FF is to feel that they are being supported through their time of need, that although any unnecessary emergency response is reduced, they are in fact being supported to reach the best possible solution to their needs, in conjunction with community projects and services

Changes made as a result of  the  improvement

The initial changes were ones of communication and information sharing. The projects exit strategy for all FFs was for them to be integrated into local community support, and so it was crucial that third sector, local authority, GPs, criminal justice system and other support agencies were on board from the beginning. This meant the writing of an Information Sharing Policy to ensure compliance with all data protection legalities and confidentiality clauses. The tri-partite cornerstone of ED, OOHs and WAST brought with them 3 years of independent FF work, which helped to build a knowledge base of what worked. 7 patients were put into a pilot study and the findings were then extrapolated.

Case studies were used to show all agencies the benefit of changes, using the premise of the empirical/rational change management strategy that if the change can be shown as desirable, and with an equal emphasis on their gain, the agencies would be more likely to join the collaboration. It was noted that each agency was investing a lot of resource and energy into a small number of patients, and that with the combined knowledge and backing of the project, this could be reduced with minimal effort from any one individual, with the gain that the patient would be cared for via the correct pathway and the agencies financial and time resources would be reduced.

It was recognised however, that although there was a need for structural process change and implementation, the project was dealing with a cohort of emotionally and physically vulnerable patients and this had to be taken into account when enacting any service change.


Data has been collected in terms of number of contacts by FA (frequent attenders) per month, hours in ED & Cost. It shows a 95% decrease in costs, an 84% decrease in contacts, and a 91% decrease in amount of hours the patients spent in the ED. This data has been replicated across the tri-partite agencies, showing a reduction in contacts, time with the FF and resources engaged.





  • Public and professionals are equal partners through co-production – the patients are involved in their care planning and anticipated outcome from the beginning
  • Care for those with the greatest health need first – in reducing unnecessary demand on emergency services, it protects the unscheduled care stream for members of the community to access it in times of need, by freeing up ambulances, ED space and GP OOHs contact time.
  • Do only what is needed and do no harm – before the implementation of the management plans, FFs were regularly having “just in case” investigations, referrals and treatments. The plans have triggered a consistent clinical response to need based on all the relevant information
  • Reduce inappropriate variation through evidence-based approaches – having a wealth of experience and knowledge around the table to care plan and think outside the box means that the patient gets the best care based on a full disclosure of information. Evidence is showing that having a collaborative and consistent approach to care planning gives the best outcome for the patient and the service alike.
Main author: Anna Sussex

Email: [email protected]

Telephone: 02920748274

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