Qualitative findings

In this chapter, we report on three qualitative aspects of the study:

• Interviews with key service providers in each site in order to 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 used the logic model developed in WP1 to structure the analysis of data and to present findings.
• Interviews with people who had been identified as recipients of case management in one of the ambulance service sites.
• Interviews with people with experience of frequently calling ambulance services, recruited through third-sector organisations and social media (the STRETCH-UP substudy).

Interviews with service providers

Respondents

We conducted 31 interviews with key service providers. In each site we interviewed the ambulance service frequent caller lead, plus between five and eight people involved in providing a response to frequent callers, working for the ambulance service or partner organisations. Details are shown in Table 16.

Inputs to case management

Identifying frequent callers

The first step in delivering case management was to identify the people classed as high-intensity users or frequent callers – both terms were used by respondents, sometimes interchangeably. There were various routes for identification: all ambulance services would routinely scan data from the call centre and flag people who met the FreCaNN threshold, and additionally referrals could be made by front-line ambulance clinicians.

Every day I wake up to new emails from staff who’ve attended a patient, signpost them to me, tell me it might be someone new, tell me it’s someone old who’s back on the radar … I probably get about five a day.

All respondents discussed the range of people classed as frequent callers, and there was some consensus that they could be grouped into three main categories: people with acute healthcare needs which were not being resolved, perhaps because they were not matched with the appropriate service providers; people with long-term health or social care needs with recurrent exacerbations triggering contact; and those who were described as ‘traditional’ (AS2-5 paramedic) frequent callers, that is, perceived as having issues with behaviour rather than what would be seen as legitimate healthcare needs. There was a range of perspectives on what proportion of people fell into each category. Generally, the third category was regarded as making up the smallest group, with one paramedic suggesting that they might encounter one or two such patients a month; though in the opinion of another clinician, 80% of the frequent caller patients had behaviour which needed managing.

In other areas, senior clinicians identified the problem much more clearly as being about failure of health or social care systems to address people’s needs. There was also sympathetic understanding from some that patients could respond in a range of way to physical symptoms:

They’re unable to cope with their illness or they perceive it to be more severe than it might be.

One respondent working directly in a support role described their understanding of the complexity and cyclical nature of many people’s needs:

Frequent attenders tend to be, I think in a word lost … it’s like a vicious cycle of you’re in crisis, you’re really struggling, you call an ambulance, you go down there you feel cared for, and then you’re discharged, so you’re rejected again. And then you’re back with the family, they’ve had enough of you, so you drink again and you get into crisis, you feel like you’re going to harm yourself, you ring an ambulance, you go back in, you feel cared for, you’re rejected again during discharge, there’s almost that rejection after. So, yeah, round and round it goes …

Selection of people to work with

Although there were set procedures for putting people onto the list of frequent callers, this did not necessarily mean that they would all be selected for the frequent caller intervention. Before taking any further steps, some ambulance services might do further work to understand the person’s needs, and identify them as potentially benefiting from a multidisciplinary response:

Once we find patients triggering the threshold for the frequent callers [frequent caller lead] goes into the history, and what we’ve found was that most of the calls were not ever going to be solved by sending an ambulance … a lot of them were loneliness and social problems.

A certain number of those identified as frequent callers would be selected for putting forward to case management via MDT meetings; there was acknowledgement that numbers in need would always be greater than the capacity to offer a case management response. Decisions about who would be offered case management were informed in part by geography (case management tended to be delivered in localities much smaller than the territory of the ambulance service, and provision was uneven); and in part by the volume of calls, though there was an understanding that the highest users might not be the ones where there was some potential for change.

Don’t look for the wins on the top ones. To me, you’ve just got to contain them.

For some respondents, processes for selection were unclear:

A lot of what’s happening locally for me is very ad hoc. It doesn’t seem to be based on, you know, regular reporting of presentations and identifying the … highest volume service users. Nor does there seem to be any system-wide approach in terms of marrying-up how people are accessing multiple services.

Multidisciplinary team meetings

A key component of case management is the MDT. This is an opportunity for different healthcare providers, sometimes alongside providers of social care and housing, and the police, to share experiences about high-intensity users and identify possible courses of action.

Case management is effectively a multidisciplinary team get together. So there’ll be people from the ambulance service, from the primary care, district nurses, community matrons, GPs, mental health teams, that will discuss individual patients, try and understand the reason that they are reliant on, in our case, the ambulance service as much as they are and what things could be put in place that will lessen their demand on the ambulance service and try and get them the correct help that they generally do require.

MDTs offer an opportunity to identify people who are having repeat contact with a range of providers:

At those groups we all might discuss maybe ten to fifteen patients each month, and they will be on a kind of rolling case management with the high intensity user group. So normally the patients that are discussed at those meetings are ones that are affecting a lot of services, so they’re not only just ringing us but are ringing 111, they’re also going to the hospital a lot, they might be ringing their GP a lot, and the high-intensity user group picks them up as high-intensity users and takes over the kind of case management from the day to day case management that maybe their own GP was doing.

For most of those taking part, the MDT was on top of the ‘day job’ and tended to demand a certain amount of commitment and enthusiasm. Some respondents identified that organisations would only be motivated to have staff attend if they could see direct benefit.

Pre-pandemic, MDTs would be face-to-face – challenging to arrange, and time-consuming. In all sites, there had been significant shift to online meetings, which has been positively received by respondents, as faster to arrange and more productive:

[W]ithin twenty-four to forty-eight hours we can get a full MDT of twenty professionals with the data in front of them … I’ve never elicited so many responses for MDTs.

Only on very rare occasions would the person at the centre of the discussion take part in the MDT; in many cases, the conversation was conducted by professionals who had no personal contact or relationship with the frequent caller, taking more of a strategic role, and this was identified as potentially problematical. A number of respondents identified the importance of trying to ensure that the caller is put at the centre of the conversation:

I think the main thing is to include the patient themselves, you know, get a very good understanding of what their needs are and why they are calling so frequently.

Creation of care plans

While the discussion process is multidisciplinary, care planning tends to be more single agency based. In some cases, the first step is finding out more about the patient’s needs – for example, the HIUG intervention in the East of England would often begin with a community nurse or matron visiting the patient in their own home. There was an acknowledgement that any planned intervention needed to be informed by, and tailored to, the caller’s needs:

It’s quite hard to have like a blanket system about how you would support them and help them to stop calling.

There was a recurrent theme of the centrality of primary care to the provision of case management. Although there was also acknowledgement that access to primary care could be challenging, it was seen by many respondents that presentations by frequent callers were in many cases primary care sensitive conditions:

The vast majority of people should be rocking up on my door, not in the back of an ambulance.

The interagency nature of the work can present its own challenges, particularly in terms of information sharing:

In order to send one email, we have to use six different areas of information from six different systems.

Mechanisms of change

Identifying and responding to unmet needs

Case management has a crucial role in identifying where people are not accessing the health care which will benefit them, and in signposting, referral and active engagement with other providers. Problems with access may be, for some callers, to do with incomplete information or awareness on the part of the person making the calls:

[S]ome of them were just calling because … they don’t understand how the health system worked, but we have shown … significant reductions and better patient care as a result.

Problems were also seen as arising on the provider side:

[A] couple of real stunning successes where we actually have had people that have been labelled as, you know, they’ve come from really deprived areas and it’s just one of these sort of patients and actually when you start digging down, they’ve been let down by the GP practice, they’ve been let down by secondary care, and actually when you plug all the holes and you get people what they need, they disappear completely. You don’t see them on the list ever again, and that’s the best bit.

Personalised support

Respondents described a range of interventions which provided personalised support as required to people identified as potentially benefiting from case management. Sometimes this was as simple as just being at the end of the phone for regular contact; in other cases, support workers were able to introduce interventions which addressed people’s social needs. Some of these were quite unexpected – beekeeping was an example.

The case management service in the LAS area was run by a primary care provider, where a nurse and a health coach were able to deliver personal support to those who might benefit:

We have these particular patients that we select have access to our nurse kind of Monday to Friday, nine to five but via phone, so hopefully instead of ringing 999 they’ll ring the nurse instead. The nurse will kind of quickly triage it, if they’re having central chest pain, sweating, vomiting, she’ll say, actually we do need to call 999. If it’s something social, or something related to trauma or stress she might be able to talk them out of it, and kind of calm the patient down, and kind of reduce the crisis, so that they don’t need to ring 999 at all hopefully. And our health coach will put in strategies in the community, so link them with support groups, help with benefits, alcohol support groups, loneliness is very common, mental health groups as well.

Personalised support can only have an impact if people engage with it, and reluctance or inability to engage was described as presenting a major challenge to interventions:

Many of them don’t engage with support services or they’re sporadic, you know, they may involve with one particular person and then that might drop off again … They will tend to maybe engage initially and then completely disengage, or some just won’t engage with any services at all.

However, there was also acknowledgement that engagement was a two-way activity, in which it was necessary for providers to form relationships with frequent callers over a period of time.

Behaviour change

One potential mechanism of change appropriate for some callers was identified as encouraging the caller to change their behaviour. Tied in with this was work to manage patients’ expectations, as well as helping them to recognise the impact of their actions. Some respondents presented their perspective on this as being in terms of moral responsibility:

So you try to make the patient responsible for their own actions before you go any further.

This process might involve direct face-to-face contact with the caller:

I’ll give a general appraisal of calls, the numbers. I’ll talk about sort of resources being involved to manage it and then I’ll just sort of gently talk about, you know, there’s sort of other patients out there that probably could do with an ambulance … I’ll try and shock to a degree but I just try and point out, I try and say to the patient, look, I’m not saying never ring us, you know, because we’re always there for somebody in an emergency, but what I’m telling you is that you could probably resolve most of your need through the doctor.

Encouraging behaviour change is not necessarily a quick fix; it may need to be tied in with intensive support work over a long period of time:

The first thing is building trust, and that can take sometimes with some people quite a long time. It’s taken me with one gentleman I think about [nine months] … And he over the past month has just actually started opening up to me about the actual crux of the problem that leads to the behaviour, that leads to the ambulance to be called. So now that we know what that is, we can address it and we’ll work through it together. He knows I’m there to support him whereas before, he just said people hadn’t listened, you know, they don’t want to know, that sort of thing.

Behaviour change was not necessarily an approach to be applied alone, but could also be part of a programme of personalised support – with trust and engagement an essential component:

Being very clear and open about the interventions proposed and the support that was being provided, putting in place well-boundaried care to sort of give clarity to the individuals to what was appropriate and what would be provided … and what wouldn’t be provided … So I think that where that kind of model’s implemented there’s a lot more sort of engagement and ownership by the patient of the process, which I think can be so beneficial.

Expected impact and identifying success

Respondents discussed their perspective on what the case management intervention could or should be achieving in terms of impact. Although there was some mention of positive impact on the quality of life of callers, for most respondents, the primary marker of success was identified as fewer healthcare contacts, such that the patient no longer met the FreCaNN definition. There was acknowledgement that for many patients this reduction in calling would not necessarily be immediate, or definitive:

The patients that we moved across to the closed list, they’ll be monitored still, so we won’t sort of discharge them completely so to speak, and they’ll be there to be brought back up if they do sort of re-present to the service.

Being able to resolve the needs of callers over the telephone (a Hear and Treat response rather than sending out an ambulance) was also seen as a sign of success:

Not necessarily calling so much, cause I guess that’s a bit out of their control, but limit the amount of resources that they get and the amount of time that they take up of the ambulance service.

Reduction in healthcare contacts might be felt across the system – not just in terms of ambulance costs, but also, for example, attendances at the ED.

Reduction in costs for ambulance services and for other providers was also seen as a positive impact of case management, and something which was worth measuring and reporting in order to secure sustained funding for the intervention:

I don’t think that until [frequent caller lead] started collecting the data, that it hadn’t been really presented in a coherent way at that high level, was the amount of time and resource we were spending on a relatively small number of people that were calling the Ambulance Service very frequently. And when we started to look at those cases it became obvious that there were things that we could do … So the investment in the team then, you know, well [frequent caller lead] clearly was able to demonstrate a reduction in the resource. And of course, once you link that to the money, it becomes very cost-effective.

Context

Links with front-line ambulance crews

Across all the services, there seemed to be a disconnect between the experience of front-line ambulance clinicians and the frequent caller initiatives. Many seemed vague about the detail of what case management provision was and who delivered it, and in some cases even whether or not there was an initiative in place. Those who were aware of initiatives for frequent callers were likely to have a role in identifying people who might benefit from an intervention. In some areas, ambulance clinicians described making referrals to the frequent caller teams, but didn’t find out what happens next to the patient:

It’s a very opaque kind of process.

Links with caller management

Case management work (interventions to identify and respond to caller needs) takes place against the backdrop of ‘traditional’ ambulance service management responses to frequent callers (interventions to manage the workload of the service). These caller management interventions may include limiting the number of calls per day which the service will take, or operating a ‘no send’ policy for ambulances. Staff working in call centres would see a flag to identify the frequent caller on their system, alerting them that a particular response was expected in line with the action plan for that patient:

You have a warning system. So, if there is somebody who has an action plan against them … the warning marker would show you why they’re a frequent caller.

This response might be asking people not to call again within a certain time period, or passing the caller to a clinical advisor for a telephone consultation before an ambulance was sent. Even with this response, access to triage might be controlled:

You can tell them that they’re not going to have another triage for another eight hours. Some will call again [in] 10 minutes, some will try and call before you’ve even got off the phone, [from] another phone. And some will call eight hours on the dot, they’ll call again, knowing that their time is up.

Ambulance services were aware that there was a risk attached to such responses, with the clinical advisor in the call centre having to make decisions about whether a physical (ambulance response) was needed. Some clinical advisors working in call centres would become familiar enough with frequent callers that their personal relationship would help to inform their judgement:

One of the frequent caller paramedics … that’s specifically her job, and she’s absolutely brilliant. She knows them by name, they know her, and because she knows them she can take – she knows what’s normal and what’s not normal [for them].

For some respondents, these caller management responses were case management, the two approaches getting conflated in their minds. Others described the two approaches to management as distinct but complementary:

For us it’s kind of a two-stage process, do we set them on an internal to try and just manage the call impact to us whilst we then do the bigger piece of work which is linking with the other professions to try and find out what’s going on with this patient and what we can do to help.

Overlapping case management models

Case management of high-intensity users was not delivered in isolation, since organisations may at the same time be involved in other initiatives focused on responding to particular needs, as well as high-intensity user initiatives led by other emergency care providers such as EDs. Respondents described a range of needs-based case management, often multidisciplinary, including those targeting people with alcohol and drug issues, multiple deprivation (a ‘postcode group’ in an area of extremely high deprivation), older people who call, people experiencing homelessness and people with mental health problems. Some of these were explicitly aiming to reduce emergency healthcare contacts:

There are schemes in place to try and catch patients early before they go into full crisis and end up in an accident and emergency department.

Some respondents described how the work with frequent callers overlapped with their routine workload:

We’ve always got names that we know who are on the frequent flyer list.

Interviews with people referred for case management

Respondents

Six respondents were recruited for interview by an ambulance service (AS3) because they received case management having frequently contacted the emergency ambulance service. This group was recruited in line with our initial qualitative plan. Individuals are identified by the prefix AS3 (e.g. AS3-201). Respondent characteristics and calling behaviour are omitted to preserve participant anonymity. Two of the respondents had a partner present during the interview, who made minor contributions to the conversation.

These respondents all experienced mental health needs, usually alongside or exacerbated by physical symptoms linked to other conditions. One had a diagnosis of autism and attention deficit hyperactivity disorder (ADHD). Although they experienced acute health needs which prompted emergency ambulance service calls, their circumstances reflected a complex interaction of factors including long-term health needs, childhood trauma, bereavement, homelessness and unstable mental health.

Experience of calling the emergency ambulance service

All respondents provided accounts of their interactions with emergency health services which were often vivid for the level of dissatisfaction and despondency their reports conveyed. They said they called for emergency ambulance service help as a last resort, when access to other support was not available or because their situation seemed to overwhelm them.

A number of them identified inadequacies in other aspects of care provision, particularly not being listened to by regular care providers, as leading to them seeking emergency care to fill the gaps:

I’ve tried the GPs, and out of hours GPs, and solicitors, and other people that I’ve worked with that don’t believe that I have it either but it’s very hard to, like, tell the psychiatrist and stuff like that because, you know, they don’t listen. They don’t listen to me anyway, that’s part of the problem – That I don’t get listened to.

If they were there to help you, they should listen to what the people say, give me a chance … I think they’ve got to hear how I feel. They can’t feel what’s going on in my body, I can, they need to have a little bit of leeway and let me do what I’ve got to do to prove it.

One called a mental health helpline and another called 111 instead of 999 and it was these call-takers who alerted the emergency ambulance and police when they felt the situation warranted further action. Triggers to calling could be related to physical exacerbations of symptoms, but also to a sense of not being able to cope with symptoms, sometimes becoming panic. AS3-202 described his fear of dying and need for reassurance when experiencing a crisis.

I just want them to make sure I’m not on my deathbed. It’s so easy for somebody to just lose their life, through something like epilepsy and stuff like that. So I get over-paranoid, it plays in with the psychosis, and I can start fitting and it’s terrible.

Respondents said they felt criminalised by the way they were treated by emergency services. Four of the six were attended by police officers when calling for an emergency ambulance. One said she was arrested for violent behaviour linked to a psychotic and self-harming episode. Another was warned for wasting police time with regular 999 calls. A third recalled escaping from police and security guards when he discharged himself from hospital. These accounts, made within longer reports of their emergency calling, suggested that police involvement was a normalised element of their experiences. One respondent also said he was threatened by the ambulance staff for refusing treatment during a mental health crisis because of his fear of hospitals.

It’s basically like refusing to be arrested, isn’t it? It’s like they threaten me for refusing to go there, isn’t it? They start mentioning things like, ‘Oh, you won’t get benefit anymore because you’re not taking our advice and our services’. And suddenly your back’s, like, isn’t it, it’s just I’m petrified of hospitals.

Experience of case management and related support

Respondents did not appear to know they were receiving case management. Respondents said they relied primarily on family, friends or neighbours, because they felt alone and unsupported in their mental and physical health needs. Several reported self-medicating with alcohol or drugs. Their comments conveyed a strong sense that they felt unheard and ignored. One respondent, many months into an application to be rehoused, said she had a letter of support from the ambulance service and was helped by the charity MIND. She was the only person to mention the ambulance service role outside a 999 response. One person said she received a monthly call from a community psychiatric nurse, but this didn’t prevent her making emergency ambulance service calls when experiencing panic attacks, and self-harming. Her husband could not reassure her either, she said.

He tries to put me off it, calling, he tries to talk me out of it because there’s more serious cases than you, so don’t you dare, but I – if I – it gives in – I give in then and say, ‘Look, I’ve got to’.

Another said she had a support worker and management plan, but these were imposed on her and did not meet her needs when experiencing crisis.

I do have twenty-four-hour support workers where I live but again the management plan tells them they’re not allowed to come and support me when I have suicidal feelings, or I’ve self-harmed, or I’m going to self-harm. They’re not allowed to support me, so I don’t understand who I’m meant to turn to.

It was clear during these interviews that some respondents were afraid of hospitals and health services, distrustful of therapies such as counselling which required them to regularly engage and communicate and also nervous of social and probation services. Even though they were in emotional and physical pain, fear appeared to shape their interaction with health providers and prevented them from taking care of themselves.

Like I’m not going to my appointments, I’m missing them all the time ’cause I won’t go out. Like hospital, GP – anything like that, or dentist appointments, or anything … so I don’t know my results from my CT scan neither.

They also felt angry and disillusioned that their problems were not acknowledged and addressed.

I’m just pissed off with like going back and forward to the hospital to these meetings, when they can just keep me in there, just like they do with anyone else, and see what the situation is … they would see my issue comes on every now and then, and my body feels like it’s not working. They think I’m just being lazy.

If they were offered treatment, it often did not fit their needs or lifestyles. One respondent specifically asked for support so he didn’t need to rely on family but said he was still waiting to receive help.

I’m looking to get another support worker. I just don’t know how to go about it … I was meant to be going for counselling before, a long time ago, but I never heard nothing about it.

They usually wanted input at times of crisis rather than receive a programme of contacts at a set time which may not coincide with their symptoms. These respondents often felt their needs would be resolved by non-health interventions, such as better housing, training, paid or voluntary work.

[A]ll I want to do at the moment is get my own place, so my mental health issues can drop.

People who identified as making frequent or regular emergency ambulance service calls (STRETCH-UP)

Respondents

There were nine respondents in this group, recruited through social media and the third sector. They lived in a range of locations in England and Wales.

Three respondents reported mainly mental health problems which caused suicidal and self-harming behaviour. Three respondents – a mother, father and daughter – were from a family with a history of making emergency calls, for a range of physical health issues. One respondent was a carer looking after his sister with physical and mental health diagnoses. One respondent said a family member mostly made the emergency call because he was not usually conscious while another said 111 call handlers called the emergency ambulance. One respondent said that the local high-intensity user group was involved in his care planning, though he only found this out some time later, after his emergency calling ceased.

Experience of calling the emergency ambulance service

Although the respondents had long-term issues, it took particular triggers for them to call the emergency ambulance service. Respondents said their emergency call was made as a last resort. They, or someone calling on their behalf, genuinely believed the situation was urgent and they were a danger to themselves. Some respondents described steps they took to delay or avoid an emergency ambulance service call. These included taking extra medication, waiting to see if the problem would resolve, contacting a GP or pharmacist or phoning a helpline.

It’s only when it’s absolutely necessary that I ring 999 and ask for ambulance … We do not make demands on any public services including ambulance service unless it’s absolutely necessary.

There was a consistent theme that people called for an emergency ambulance because they felt they had no other options:

A period of regular help seeking which had failed at every point. And really where I hadn’t known where to turn. And so the ambulance service had kind of been the last resort … Well I exhausted – I tried all other options and repeatedly got nowhere …

Respondent SUP-02 also said the way her needs were dealt with was ‘brutal’ and undermined any sense of self-worth. She said she felt rejected when repeatedly discharged from the ED because her suicidal thoughts had not resulted in an injury which needed treatment.

Respondent SUP-05 experienced severe asthma which left him choking for breath if a flare-up did not respond to his usual medication. Out of hours, he was unable to access the emergency treatment which could resolve these attacks. An hour’s drive to the ED was not feasible in this state and with very young children to care for, so he would call for an ambulance. But he was shocked by the off-hand manner of emergency ambulance service call handlers and waiting as long as 12 hours with symptoms which left him unable to breathe. As a regular caller, he queried how his needs were prioritised by the system.

I only call at the absolute latest, when I think I can’t take it no more. That’s the time I need the most support … There are times when I just can’t breathe. I’m gasping for air. I can’t breathe through my nose, I can’t breathe through my mouth, I get palpitations and I’m gasping for air. That’s no less than a heart attack in my view. So, what priority am I? Am I a one or am I a ten? If I’m a two, after a heart attack, then how long should I wait, and how is that allocated? It’s happened before where I’ve fainted and blacked out when I couldn’t breathe … There’s no empathy, there’s no compassion. And I think some of the staff are just admin staff. They read off a script. It’s passed like a sausage factory to somebody else.

For the family group and the carer, the triggers to calling tended to be related to physical health and care needs. The carer (Respondent SUP-04) usually needed help to lift his sister or check her when her medication made her non-responsive.

The family group said they were encouraged to use 999 services when newly arrived in the UK and continued to seek emergency help, particularly if unable to get a GP appointment or access a pharmacist. They were full of praise for how their calls were addressed.

I think [999] is the best because if you have language, or you don’t have language, they will still find a way to get contact with you, or to get the best care for you.

Experience of being managed as a frequent caller

Only one of the respondents reported experience of having a specific response to calls as a result of being identified as a frequent caller. Respondent SUP-01 realised he was flagged as a regular caller when call handlers deflected or terminated his emergency calls, made when feeling suicidal. He described how he started making high numbers of emergency calls after his regular community-based mental health support was stopped, in line with service policy that support could not be indefinite. He started calling the emergency ambulance service and 111 as he felt these were the only options open to him.

So I wasn’t ever a person to call up begging for help in distress … my support was completely cut off and that was the trigger for me trying to call in services for other support … I was calling in both for support and to try and get a more long term solution.

Since the two services were both provided by the ambulance service in his area, calls to both numbers were linked as part of the service’s monitoring of high levels of use. Respondent SUP-01 said his need for help was misinterpreted by emergency and mental health professionals and he felt labelled as a nuisance. When his case was taken on by the high-intensity user group without his knowledge, no one listened to his perspective or provided the support he wanted. He said he felt bullied and dehumanised by health professionals.

It’s brutal – it’s not having the flag, it’s how you’re treated because the flag is there … If they have a system whereby they want to say, anyone that’s calling more than five times is a frequent caller, then I’m okay with that, put me up on the system as a frequent caller. But it’s what you do with that flag – rather than have it as a label with a stigma attached that he’s a nuisance, say we’ve got a vulnerable adult that’s in distress and needing help. It’s not the flag, it’s what they do with it.

Respondent SUP-03 echoed this impression of isolation and desperation. He said he feared that a system which identified frequent callers to emergency ambulance service call handers could stop people receiving necessary treatment.

By contrast, Respondent SUP-04, caring for his sister, welcomed the idea of being identified by the ambulance service for additional support, seeing it as a way to remedy the uncoordinated and inadequate care he received from the health and social care sectors. His greatest wish, as a carer, was for some brief periods of respite in a clearly precarious domestic situation.

With the ambulance crew being the first contact, I think it’s an excellent method for them to be using their eyes and ears to observe what needs to take place and then they make the referral to this support team who will then come and assess the needs of the person. That could only be a positive because they can make a referral to more appropriate services.

Similarly, Respondent SUP-02, despite having negative and distressing experiences in relation to emergency care, seemed to recognise that there was scope for care to be improved by identifying frequent callers and so being able to provide help for unresolved problems.

If someone is a frequent caller they often have unmet needs of some kind. So, you know, it should be a flag to indicate someone has unmet needs and that should be acted upon.