Identifying the members of the A&E frequent flyers club

The BBC’s research on frequent users of accident and emergency departments, published yesterday, makes for interesting reading. It found that nearly 12,000 people made more than 10 visits to the same unit in 2012-13, and a small number of those attended more than 50 times. This is an eye catching finding and it is important to consider what those numbers might actually mean.

‘Despite the number of people using A&E regularly rising since 2010, they clearly are not the main cause of the increasing pressure on A&E’

While the 200,000 attendances by people attending A&E more than 10 times a year is a big number, it represents just a tiny fraction of the 14 million total attendances at major A&Es in 2012-13. Despite the number of people using A&E regularly rising since 2010, they clearly are not the main cause of the increasing pressure on A&E departments.

But what does it mean for the patients who use A&E in this way? Repeated visits to emergency departments are unlikely to be the most effective way for them to receive care. Busy A&E departments are just not set up to provide the sort of continuing and preventative care that it would appear these patients need.

It is also a very expensive way of delivering care if it could be provided another way − for example, even the simplest A&E attendance costs the NHS much more than an appointment with a GP.

Trivial misconceptions

There is a common preconception that patients who are frequent users of emergency units are presenting with trivial cases that do not need the level of facilities available in A&E. Indeed, some studies suggest that up to a third of all people attending A&E could be treated by a lower intensity service. However, evidence from the US suggests that the rate of “avoidable” use by regular attenders may be no different to the general population of A&E users. 

The Nuffield Trust is carrying out ongoing analysis of national A&E data as part of our QualityWatch programme with the Health Foundation. Our findings show that the more often a patient attends A&E means, the more likely they are to be admitted to an inpatient bed, but only up to a point. 

Patients attending more than eight times per year are less likely to be admitted for each additional attendance, although it is not until a patient attends more than 50 times that their chances of admission return to the national average. It appears that while there may be better ways for these patients to receive care, they are not using A&E needlessly.

Identifying these patients presents an opportunity to improve care for individuals and use NHS resources more efficiently. So who are they? Our analysis finds that people attending A&E more than 10 times in one year are typically between 20 and 55 years old.  Patients in their 40s are particularly over represented compared with all users of A&E. 

‘It appears that while there may be better ways for these patients to receive care, they are not using A&E needlessly’

In the three years we examined, frequent users of A&E in one year tended to use A&E more than once in both other years. What’s more, more than 90 per cent of frequent users are registered with a GP. Taken together, these two facts suggest that regularly attending patients are likely to be established in the UK, at least in the short term.

Deprivation plays a part, but not as much as you might think. Although half of regular attenders live in the 20 per cent most deprived areas, 10 per cent of regular A&E attenders live in the top fifth most affluent areas. Anecdotally, many regular attenders have combinations of mental health, substance misuse and social care issues.

What can be done? 

The most appropriate approach will depend on the reasons underlying the way each patient has been using services. In some cases simply highlighting alternatives to A&E will give patients more options when seeking urgent care. 

Other examples include coordinating the care a patient receives, such as booking follow-up appointments with their GP while they are still in the A&E department. Patients with particularly complicated situations might be assigned “care navigator” to help them manage their interactions with health and social care services.

As the latest NHS England figures show, A&E departments are struggling to meet waiting times targets and the incense scrutiny on emergency care is likely to continue. Our analysis of the patients who use A&E most frequently − far more frequently than would be expected − suggests that they are not major contributors to the current pressure on A&E. 

However, finding out more about these patients and their characteristics is a real opportunity to ensure that they receive the care they need. 

Ian Blunt is senior research analyst at the Nuffield Trust. This article also appears on the Nuffield Trust blog.