Posted on May 9, 2023
The SHarED (Supporting High impact users in Emergency Departments) project aimed to improve outcomes for the most frequent users of Emergency Departments (EDs). High impact users (HIU) of EDs suffer some of the most severe health inequalities in the UK.
Through a collaborative case management approach, significant improvements have been recorded through project SHarED for both EDs and patients.
The evaluation of the SHarED project, undertaken by NIHR ARC West and published in April 2023, demonstrates:
- 148 High Impact Users (HIU) were engaged across the six adopting EDs
- 33% reduction in HIU ED attendance in six months before and after taking part in SHarED
- 67% reduction in HIU hospital admissions in six months before and after taking part in SHarED.
Read our summary infographic which highlights key project information and evaluation findings and the full pre-print study of the SHarED evaluation.
The project was proposed by Dr Rebecca Thorpe and the team at University Hospitals Bristol as part of the Health Innovation West of England’s Evidence into Practice Challenge 2019. The model had been running successfully there for five years before being adopted and spread by the Health Innovation West of England throughout the region.
“Taking part in SHarED allowed our HIU Team the time, support and resource to really address the underlying issues which can drive patient requirement for large amounts of unscheduled care. By developing Personal Support Plans, in collaboration with patients and other professionals, we managed to reduce attendance rates, reduce admission rates to hospital and smooth the path of patients when they did attend the Department, thereby supporting our staff in dealing with these patients who often have complex health needs. Feedback from our ED staff was extremely positive. Looking to the future, with thanks to SHarED, we’re continuing to develop our HIU service.”
Dr Sarah Harper, Pain Consultant and HIU Team Lead, Gloucestershire Hospitals NHS Foundation Trust
Watch our SHarED project video.
The challenge
HIU of EDs suffer some of the most severe health inequalities in the UK. HIU are defined as those who attend the ED more than five each year. As a patient group, HIUs experience exceptionally high rates of mental health challenges; learning disability; homelessness; substance misuse; domestic abuse and safeguarding concerns. HIUs often attend the ED as they have nowhere else to go.
As well as the negative outcomes for HIUs attending ED when that service may be unsuitable for their needs, and the resulting strain on ED staff to manage high levels of repeat attendances, there is also a significant financial impact on the NHS. Some ‘super-users’ cost £30,000 per year in ED attendance and hospital admission.
Our approach
In 2019, Dr Rebecca Thorpe of University Hospitals Bristol put forward SHarED for Health Innovation West of England’s Evidence into Practice Challenge; an open call to healthcare professionals in the region with an evidence-based idea for an initiative or project that would improve healthcare. The initiative has been running at Dr Thorpe’s hospital for six years and had achieved great success in reducing attendances to the ED, as well as supporting users to seek healthcare and support in a more appropriate way. It was one of two programmes selected for adoption and spread across the West of England.
Health Innovation West of England worked collaboratively to spread SHarED to all six EDs in the region. Health Innovation West of England also developed a thorough SHarED Implementation Guide, run and managed ED staff surveys and created communications including videos .
All teams from across the region joined a monthly call to share progress, challenges and to discuss clinical case studies. They have since been supported in developing their business cases for ongoing service funding.
The HIU teams’ triage and prioritise patients based on multiple factors, including the number of attendances in the last 3 months, the impact on the department when they attend and a number of social factors. Once prioritised, patients are contacted and asked to contribute to a Personal Support Plan written by the HIU co-ordinator and the Multidisciplinary Team. The Personal Support Plan is then used by members of staff in the Emergency Department to provide a consistent approach to assessment and management. Additionally, the Multidisciplinary Team also seek to address any underlying issues through a holistic approach.
“The SHarED project has propelled our work to support some of the most vulnerable, marginalised patient groups in society, who access Emergency Departments frequently, for a variety of reasons. Working with teams from EDs all over the West of England, we’ve educated staff and supported patients to work towards safer patient care and an improved experience for patients and staff. It’s a fantastic example of cultural change across the whole patch.”
Dr Rebecca Thorpe, Clinical Lead for SHarED and ED Consultant, University Hospitals Bristol and Weston NHS Foundation Trust
Impacts to date
The evaluation of the SHarED project, undertaken by NIHR ARC West and published in April 2023, demonstrates:
- 148 High Impact Users (HIU) were engaged across the six adopting EDs
- 33% reduction in HIU ED attendance in six months before and after taking part in SHarED
- 67% reduction in HIU hospital admissions in six months before and after taking part in SHarED
- over 360 staff trained to support HIUs
- There were improvements in ED staff feelings of confidence, support and training, and a perception that HIUs were receiving more appropriate care.
Feedback from a 2021 staff experience survey included:
- “Dedicated HIU teams are making a real difference to the appropriate management of these patients.”
- “Our HIU team are brilliant and have made a huge impact on not only the number of attendances but patient outcome and reduction in violence and aggression cases.”
Read our news story and Plain English summary of the evaluation.
Next steps
While the Health Innovation West of England funding has now ceased, the ED teams are working with their trusts to secure ongoing support. Each team are passionate about continuing the important work that has been started by the SHarED project. Support is also now provided by NHS England High Intensity User Programme.
