This chapter contains reproduced material from Aslam et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes additions and formatting changes to the original text.
A note on language and terminology
Language and terminology in this area are neither fixed nor universally agreed upon; terms used by one person, organisation or group without intention to cause offence may, nonetheless, be regarded as pejorative by others. In adopting specific instances of terminology, often those used by interested parties in this research, or by including this terminology in quotations from such parties, we do not intend to imply any moral judgement, nor should any such judgement be inferred.
As the term ‘999’ does not distinguish between emergency services, we generally use the term ‘emergency ambulance service’; where the term ‘999’ is used here – for instance, in quotations – it should be taken to refer to a call to the emergency ambulance service, unless explicitly stated otherwise.
There are a range of international counterparts to the UK’s emergency response service. The pan-European equivalent to 999 is 112, which can also be used in the UK; the USA and Canada use 911.
Background
Ambulance services are an integral part of the UK’s NHS. Following mergers in the 1990s, UK ambulance services cover large areas, each serving a population of between 3 and 9 million people generally across a mixture of urban and rural locations. Ambulance services provide a range of emergency responses including telephone advice, attendance of an emergency vehicle for face-to-face assessment by a paramedic or Emergency Medical Technician, and conveyance to hospital for further care when judged clinically appropriate.
This care, free at the point of use, is usually initiated by dialling 999; these calls to the UK’s nationwide emergency response system are then routed to an appropriate service, including the local ambulance service.
The NHS is under sustained pressure, particularly in the area of emergency and urgent care, with emergency calls to the ambulance service increasing by at least 6% every year,2,3 although fewer than 10% of calls relate to patients with life-threatening conditions.3 The volume of emergency calls to ambulance dispatch centres in England alone has increased from 4.72 million in 2001–2, to 13.2 million in 2022–3.4 This dramatic rise has not been matched by an equivalent increase in resources. In addition, regular media reports describe unsustainable demand for ambulance services with concerns about delays in reaching high-risk patients, particularly in emergencies.5 This has led to public and political pressure to improve emergency response processes including increasing ambulance staffing and funding and improving ambulance dispatch systems.6 Some reports have also highlighted the issue of people who frequently call the ambulance services – sometimes almost daily.2
Definitions of frequent calling
Definitions for frequent calling in the pre-hospital emergency service settings have varied internationally and terminology is contested.7,8 Thresholds usually mirror the emergency department (ED) description of frequent use, namely > 5 attendances a year, but have ranged from as low as > 2 emergency ambulance service calls a year9 to the highest criteria used in the UK of 5 or more calls in 1 month or 12 calls or more over 3 months.2,10–12 This UK definition was agreed nationally with all UK ambulance services, though it has recently been simplified to just five or more calls in 1 month.13
Terminology to describe people calling frequently have included ‘frequent flyers’, ‘frequent callers’ and ‘super-utilizers’.14 Addressing the needs of people who call frequently can result in increased costs for the healthcare system in terms of time and resources. In London, 1.7 million emergency calls were received in 2014–5. During this period, 1622 people meeting the national ‘frequent caller’ criteria generated 49,534 ambulance attendances, at a cost of £4.4 million to the London Ambulance Service (LAS).2 A similar story is repeated around the country where many services struggle to meet demand.15,16 Operating in this pressured environment, ambulance services are required to focus resources on people with urgent or life-threatening conditions.17 The national target of reaching 75% of Category A (life-threatening) calls within 8 minutes was not met for 32 consecutive months in England.9 The figures for the Welsh ambulance service have been worse with only 47.5% of Category A calls attended to within 8 minutes in March 2023, failing to meet the Welsh target of 65% for 32 months in a row.18
People who make frequent calls to the emergency ambulance service may not be experiencing an emergency situation or require immediate medical assistance from emergency services. These individuals are often vulnerable patients who may be feeling panicked, frightened or overwhelmed and are seeking help to address long-standing chronic health or mental health issues2,7,10,19–22 and are more likely to:
- be under socioeconomic stress
- live alone
- experience mental health problems
- have a history of trauma or abuse
- live with chronic conditions
- fall
They may call the emergency ambulance service frequently because their problems are unresolved, or because they may not be aware of alternative and more appropriate pathways to access healthcare services.2,7 Although this patient group may seek to address their problems through the emergency ambulance service system, without the necessary clinical or care expertise available to them, they may continue to seek help through emergency services, placing them at a higher risk of further crises and deterioration in their condition. As a result, they may require multiple interventions from different parts of the healthcare system and community-based agencies21–23 placing a disproportionate burden on resources. Moreover, research shows that people who make high use of emergency ambulance and ED services frequently have higher mortality rates than those seeking care less often.20,21,23,24 Most do not require acute clinical intervention by the emergency ambulance service or transportation to an ED and could be better cared for at home or by an alternative community-based care provider.7,20
Recent United Kingdom policy reviews
Major national policy reviews in England25 and in the devolved administrations of the UK26 have called for a whole-system approach to care, with care pathways and protocols to be further developed across unscheduled care, along with greater clinical autonomy and decision-making within the ambulance service to reduce unnecessary pressures on ED. Emergency call operators are trained to assess the situation and provide appropriate guidance to the patients who call while dispatching the necessary emergency services to the scene.
A 2016 review of strategies to manage people who make use of the emergency ambulance service described two models of care which are in current use across the UK.27 A ‘Hear and Treat’ approach is used in the ambulance call centre for callers who are assessed as not needing an emergency ambulance response. Call-takers or clinical advisors in the call centre utilise protocols and local directories of services to advise self-care or to identify referral pathways for patients if immediate ambulance support is deemed not to be required. Provision of telephone advice or referral for emergency ambulance service callers without immediate clinical needs can be safe and effective,28 although the evidence base does not extend to patients who call frequently. ‘See and Treat’ models of care require face-to-face assessment by an emergency ambulance responder, who can discharge the patient at the scene of their emergency call without conveyance to ED. There is considerable policy support for such initiatives and a growing body of evidence supporting the safety, clinical and cost-effectiveness of this approach.29–32 However, people who are calling frequently may have complex medical histories and social backgrounds which can be challenging to manage in the emergency pre-hospital care setting.33,34 Government policies, such as ‘Taking Healthcare to the Patient’,3 the Keogh report,35 Six Goals for Urgent and Emergency Care: Policy Handbook for 2021–636 and the NHS Long Term Plan37 encourage the establishment of alternatives to hospital transport for non-urgent care. These policies recommend that patients receive appropriate care in the most suitable setting, but challenges remain in identifying which patients can be safely and effectively managed in the community, particularly in the absence of accessible community-level diagnostics and investigations.
The policy directive towards alternative care pathways has been further influenced by a push towards patient-centred care, and an attempt to mirror initiatives in primary care with the aim to prioritise the care of frail older patients who are at risk of emergency hospital admission.17,25 Commissioners now require ambulance services to have management strategies in place for people who frequently call the emergency services.25 While some new cross-sector case management approaches have emerged, the overall aim is to prevent people from calling the emergency services by referring them to other appropriate healthcare providers.38 In rare cases, punitive interventions have been taken against individuals who are being vexatious in their calls, including the pursuit of criminal sanctions.5 However, best practice guidelines focus on developing alternative care plans for individuals with complex health and social needs that can reduce their health-seeking behaviour through the emergency services route. These plans aim to reduce the reliance on the emergency services and ensure that patients receive appropriate care in appropriate settings.4,35–37
United Kingdom ambulance service initiatives
Several UK ambulance services have developed initiatives to manage patients who call 999 frequently, although approaches can vary across services. In 2019 we completed a survey of practice by e-mail and telephone through designated ‘frequent caller’ leads located at each of the participating ambulance sites.11 We received responses from 12 out of 13 UK ambulance services. All ambulance services compile a list of patients meeting the national criteria for classification as a ‘frequent caller’ and are flagged on the ambulance call dispatch system but subsequent responses to patients differ. Eight services reported that they had implemented cross-sector case management models in at least one area within the service, with two services reporting that case management was in place across the entire service area. There was variation in the consistency of approach across services, despite nationally agreed best practice guidelines. The variation can be attributed to a variety of factors, such as funding arrangements, resource availability and local priorities. Each ambulance service operates within a specific geographical area and may have different challenges in providing care to patients who frequently call. As a result, they may need to adapt their approaches to manage these patients effectively within the constraints of their available resources.
In areas where case management approaches are implemented, the focus is on developing comprehensive care plans for patients who frequently call the emergency ambulance service. This is done through the use of multidisciplinary teams (MDTs), cross-sector management groups or forums that are specifically designed to address the needs of people who call frequently. The approach involves identifying, sharing and managing patients collaboratively. Key decision-makers from commissioning, acute, primary, secondary, third-sector health and social care providers including law enforcement meet with ambulance service staff to share information, stratify patients based on their level of need, and manage patients through regular MDT meetings. This collaborative approach is intended to ensure that patients receive appropriate care from the right provider, in the right setting, at the right time. It also ensures that resources are used effectively, and duplication of services is avoided.2,28,38–40 The introduction of case management has the potential to provide safe and equitable out-of-hospital care for this patient group, and prevent patients being passed along the emergency care system or wider NHS without their care needs being addressed.39,40 Initial research on this patient group in ambulance services has shown promising results. Research conducted at the LAS saw significant reductions in calls after the introduction of case management in one area of London. Although the sample size was small (n = 110) and the study design was a before-and-after comparison with no control group,2 the study illustrated the complex range of resources, skills and services required to address need.
Links to other healthcare settings
Clinical case management has been used in other healthcare settings, such as emergency departments, for people who attend frequently, which has relevance to the pre-hospital context. A systematic review on the effectiveness of case management in ED settings41 identified that there was heterogeneity in how the model was implemented among studies of variable quality, with the evidence pointing towards modest reductions in emergency department use and costs following intervention. Case management interventions within pre-hospital settings11,15,39,40,42,43 taking person-centred care approaches also found modest improvements in further service use, but those with complex needs required longer intervention and more resources.43
The British Red Cross recently published a report on high-intensity use of emergency departments. The report called for improved access to case management services that can help to address the wider determinants of health that contribute to people using services frequently, including improved access to community-based care.44 While such interventions are yet to be robustly evaluated in the UK, evidence from Switzerland suggests that similar case management interventions in ED settings can improve self-reported health literacy and motivation, with the majority of patients being satisfied with the service45 and noting an improvement in self-reported quality of life.46 Together, the evidence suggests some uncertainty around the effectiveness of clinical case management for people who use ED and ambulance services frequently, with suggestions that it should, at best, be considered an approach to demand reduction that does not necessarily address wider determinants of health.47 Alternatively, it has been argued that the success of case management is largely dependent on how it is resourced and implemented.48 Moreover, community-based services tend to be complicated in terms of organisational interfaces, inconsistency in resource use and insecure funding which represent an area of challenge for new systems.2,28,38–40
The NHS Long Term Plan37 and Welsh Government’s Six Goals handbook36 indicate the high priority given by those working in the NHS and policy settings to improve the care of people who frequently access emergency care. Greater integration of emergency ambulance care with other parts of health and social care provision underpinned by patient-centred care is encouraged. The introduction of case management into emergency ambulance care settings is part of a wider movement to reduce the care burden in the acute sector and improve patient experience. Internationally, evidence indicates improved patient care and service delivery where case management has been used in ED and ambulance settings.39,40,48
STRETCHED aims, research objectives and work packages
Aims
STRETCHED aimed to evaluate effectiveness, safety and efficiency of case management approaches to the care of people who frequently call the emergency ambulance service, and gain an understanding of barriers and facilitators to implementation.
It was hoped that the study would provide evidence of the effectiveness, cost-effectiveness and impact of case management.
Given the lack of evidence to inform commissioning, policy or practice development, the STRETCHED study1 was designed as a mixed-methods retrospective natural experiment in four ambulance services in England and Wales. STRETCHED was designed to have relevance internationally, in particular to the World Health Organization (WHO) agenda of investing in public and community-based services to improve patient experience,49 with maximum transferability of learning beyond any one specific healthcare system.
It was also hoped that the in-depth insights generated from STRETCHED should assist ambulance service commissioners in implementing evidence-based practice for patient benefit. Findings can inform future service provision closely aligned to policy. The use of linked data in STRETCHED had the potential to develop a holistic picture of service use in areas where multidisciplinary case management is practised compared to areas where standard ‘within-service’ management is in place.
These intentions were distilled into the following research objectives.
Research objectives
- Develop an understanding of predicted mechanisms of change to underpin evaluation.
- Evaluate case management approaches to the care of people who call the emergency ambulance service frequently in terms of:
- further emergency contacts (emergency ambulance service calls, ED attendances, emergency hospital admissions) or death
- effects on other services
- adverse events (deaths; injuries; serious medical emergencies; police arrests)
- costs of intervention and care.
- Describe the epidemiology of sustained high users of emergency ambulance services.
- Understand the views and experience of patients.
- Identify challenges and opportunities associated with using case management models, including features associated with success, and develop theories about how case management works in this population.
We devised the following work packages (WPs) to achieve these objectives.
Work package 1: logic model
This WP, addressing the first research objective, developed a logic model in consultation with stakeholders to underpin the evaluation and inform data collection and finalisation of outcome selection. The logic model included definition of key components of case management in this setting; predicted mechanisms of change; and possible outcomes, positive or otherwise.
Work package 2: evaluation
To address the second and third research objectives, we undertook an evaluation using a natural experiment cohort design in four ambulance services, using quantitative anonymised linked routine data to describe epidemiology and assess effects of the intervention on processes, outcomes, safety and costs of intervention and subsequent health and social care up to 6 months later, with adjustment for covariates including prior service use.
We also collected qualitative data from focus groups and interviews in each intervention site about the views and experiences of patients and other stakeholders (commissioners, emergency and non-acute health and social care providers) regarding acceptability, successes and challenges of case management approaches for this group of patients.1
Work package 3: synthesis of quantitative and qualitative findings
We synthesised quantitative and qualitative findings from WP2, informed by the logic model developed in WP1 and in consultation with stakeholders.
Study timelines
STRETCHED started on 1 April 2019 with a planned end date of 30 September 2021. Ambulance service activity was paused during the early months of the coronavirus disease discovered in 2019 (COVID) pandemic in 2020. This pause and other delays, most notably in the provision of data from NHS Digital and the SAIL databank, required extensions to the planned end date (see Appendix 1).