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As a one of the fortunate teams who received Q Exchange funding in 2018, our aim is to improve care for patients who frequently attend Emergency Departments. These individuals have expressed feeling stigmatised as ‘attention seekers’ or ‘time wasters’. We recognise the need to redefine the issue, acknowledge the vulnerability of this group, and work with regional partners to reduce risk while improving patient experience. Why? Because many patients attend multiple EDs and a more understanding and consistent approach is required beyond one Trust’s borders. It also required a quick learning curve in performing QI, something foreign to a clinician usually working with broken bones and failing organs. So here’s my stab (no pun intended) at putting some of this learning on paper!

Step 1: Acknowledge ignorance!

Writing a blog forces you to reflect. And when I started this one my first thought was “what were we thinking?” We were taking on a project built on the premise that hundreds of clinicians do not understand the patients who frequently attend the various Emergency Departments in our region. A lack of understanding, patients who are by definition complex, multiple organisations over a large geographical footprint … there are a few clues here that suggest this was not going to be an easy 12 months. But that’s what we committed ourselves to. And we knew the first step was always going to be putting our hands up and saying “what’s going on here … and there?” In other words, peer learning (QI speak).

Step 2: Make friends and invite yourself to their conference!

The first part of our learning journey (apart from the constant literature and Google searches) was quite literally … well, a journey! A friendship that started at last year’s Q Exchange event (‘networking’ in QI speak) resulted in us taking a trip to North Wales where we attended the Welsh ED Frequent Attender Network (WEDFAN) conference. It gave us an opportunity to witness the challenges of building a network between many hospitals and across Trust boundaries. Importantly, the theme of the conference was having an “unconditional positive regard for the patient”, not this malarkey about reducing attendances and saving money! Although there is that too … as we could see from WEDFAN’s achievements.

Using patient and ex-service user insight, we have laid down the foundations of a psychosocial assessment template which will help us better understand how to approach the patient-specific unmet needs that result in someone becoming a ‘frequent attender’.

Step 3: Make more friends and ask more questions

In the first few months, we held two workshops and travelled to all five localities in our region to introduce the project and build an understanding of how our neighbours care for frequently attending patients. As it turned out, one of the hospitals did not have a formal programme in place, and we have been able to assist them in setting up an evidence-based model. Crucially, from the word go, we asked patients and ex-service users to help us, thereby sticking to our promise of making co-production (more QI speak) a core part of the project. Using their insight, we have laid down the foundations of a psychosocial assessment template which will help us better understand how to approach the patient-specific unmet needs that result in someone becoming a ‘frequent attender’.

Step 4: Have a big party!

With all the friends we made and lessons we learnt we thought it an ideal opportunity to arrange a large sharing-event. Not necessarily a party in the true sense of the word (although the sandwiches were not bad) but with representation from all over the region, and speakers from beyond our borders, we definitely had energy in the room. Kicking the day off with a bang were three service users giving their perspective. It assured a focus on patient-centred care and proved to be one of the most popular sessions. It also dispelled any ideas that the high-intensity patient population was too complex for co-production. Indeed, not only is service user input from this group possible but their unique insights are an essential element in developing these services.

With the experience of our other speakers we managed to identify achievements to strive towards and challenges to overcome. Notably, it was acknowledged that in most localities there is a service gap in terms of psychological support for patients who regularly visit EDs with complex physical complaints, i.e. not mental health crises. We also established widespread interest in improving the information-sharing required to manage a vulnerable group of patients. If anyone out there knows a simple answer to the IG question, this is your cue!

Step 5: Watch this space …

We started with a complex problem. Does that mean we are looking for a complex solution? Possibly … we don’t know the answer yet. But we need to make it simple enough to be sustainable and replicable. It has to show impact for patients and professionals (including Trust boards and commissioners). So the plan now is to design an informed model, refine it with the help of all the partners we identified (particularly patient representatives), and present it to our colleagues throughout the region. But that’s not all. We also need to find an answer to the IG question. We need to identify a suitable platform that will enable us to share data with multiple stakeholders. This will determine how pro-active the network can be in picking up risk and helping patients get comprehensive and consistent care. And ultimately, that is what QI is about!

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