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Mental Health Care for Emergency Department Frequent Attenders: a Regional Collaborative

A collaboration between Emergency Departments in the Thames Valley region will enable us to share best practice for frequent attenders requiring mental health care, to better understand patient flow and to design collaborative strategies based on our collective knowledge..

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  • Winning idea
  • 2018

Meet the team: Thames Valley Starling Collaborative


  • Dr Deon Louw, Departmental Lead for Mental Health, Personalised Care Planning Team, Emergency Department, John Radcliffe Hospital, Oxford University NHS Foundation Trust

The final straight or just the beginning?

Leading up to the Q-event in September we have been working hard to engage with the Q-Community and build your ideas into our project development. Thank you for all those commenting and supporting! Of course we hope to go on with the Q Exchange project but even if we don’t, the feedback we received confirmed what we believed all along – this project is essential for both patients and professionals!

So what have we done and what are the next steps?

– Networking in our region: We now have representatives at all the major Trusts who recognise this as a project that can deliver real outcomes.

Brainstorming with diverse stakeholders: We have invited ED and mental health teams, lay representatives and non-ED clinicians (GPs are key!) to join us in a dedicated session at an upcoming ED Collaborative Event next week. Based on previous events this forum has been a melting pot of ideas where shared learning can be transformed into true QI.

– Engaging with patients: Building on feedback from lay representatives we have acknowledged the need to have hands-on active involvement from the word go. Their involvement will enhance the outcomes of our project. We anticipate real change in how we design this model and believe our patients will benefit directly. It will also be an example of how to give a voice to a group of patients who have been previously underrepresented.

– Aligning our goals with the future of the NHS: We have examined the resources and visions expressed by national organisations like NHS Improvement and the NHS Five Year Forward View. Our systemic goals have been adopted to provide immediate outputs to these (and similar) organisations. In real terms we believe it will add value in the future planning of Sustainability and Transformation Partnerships throughout the country.

– From regional to national: We have made contact with individuals with a shared interest beyond the Thames Valley. The results of our project will be a replicable model that can be adopted elsewhere. In addition, once we have learnt from this project we will be able to face challenges (e.g. Information Governance) and expand the network to a much wider region. The Thames Valley Regional Collaborative can indeed become a nation-wide ED mental health network!

In summary – this is truly just the beginning and we have laid the foundations for a value-driven and meaningful project. Support from the Q-Community will significantly boost our chances of success in the short and near-term. We hope to see you at our stand in a few weeks.

Best wishes from our team. And remember – the more we work together in QI the more beautiful (and bigger) the starling murmuration of the modern NHS becomes!


Another week on and we continue to learn from Q-member comments. Thank you!

So far we have received a lot of questions on how we plan to work with other stakeholders, especially patients and primary carers. The answer is twofold. First of all, our idea remains above all a collaborative approach. So working with others is written into the essence of the project. More specifically, we are hosting a dedicated session at an upcoming ED Collaborative event being held in Milton Keynes. It will act as a brainstorming session and we have invited local Q-members to present (or join via teleconferencing). This includes representatives from peer support experts and GPs.

Keep the comments coming fellow Q-Members. The more you question and criticize, the more opportunity we have to improve our project in line with what you think!

Thank you!


Wonderful to be shortlisted!! Please support us, leave comments, get in touch, etc…Regular conversations on recently set up twitter account @mental_ED. Much of what we aim to do is share experiences and learning. Patient involvement essential!


Conceptually there is no group more in need of a collaborative approach than patients frequently attending the Emergency Department. Of particular significance is the fact that mental health conditions are more prevalent in this population. This is acknowledged in the design of CQUIN 4 for 2017/19,  which is aimed at ‘improving services for people with mental health problems presenting to Emergency Departments’. The CQUIN specifically focuses on reducing the Emergency Department use by frequent attenders .

A few issues underlie this topic. Firstly, frequent attenders typically have unmet psychological needs. Secondly, as stated in the CQC report on patients in mental health crises (Right here, Right now, 2015), frequency of attendances may be a sign that local services are failing to provide comprehensive support.

However, the problem is potentially much bigger.

Evidence shows that while researchers acknowledge the likelihood that patients may be visiting multiple emergency departments, studies on frequent attenders are regularly limited by a lack of data on service-use beyond single hospitals. Not knowing how patients access services, impacts directly on the quality and safety of the care we provide. For example, patients who frequently attend various emergency departments may do so because of unhealthy drivers such as drug-seeking behaviour. Instead of addressing the underlying problem, inconsistencies between individual emergency departments may accentuate it.

Similarly, patients with somatoform disorders regularly attend hospitals with physical complaints. These patients are known to be at significant risk of healthcare induced harm due to over-investigation or over-medicalisation, made more substantial by different emergency departments repeating the same interventions.


The idea behind the Thames Valley Starling Collaborative is symbolised by the flawless murmurations of the birds we share our name with. To effectively provide care for frequent attenders requires an acute awareness and relationship between a large number of stakeholders.

The Thames Valley Starling Collaborative is aimed at peer support of teams across the Thames Valley and has two goals:

Goal 1 Sharing of Frequent Attenders Programme models across the Thames Valley region aiming to identify and implement best practice

Goal 2 Using existing data our project will be able to categorise groups of frequent attenders (e.g. based on presenting complaints) and evaluate the outcomes of specific interventions. We hope to identify which frequent attenders are more receptive to particular interventions, thereby allowing trusts to work together in optimising their efforts of influencing patient flow into the emergency department.

These goals are based on the analysis of data across the region which will inform the investigation of patterns of attendance and unwarranted variation between emergency departments.

Matching data across the Thames valley will not only help us comprehend the scope of the problem, but also enable us to identify if we have high regional users. Building a region- wide network of stakeholders and services will enable us to coordinate the consistent and safe delivery of care. These are very practical steps with real outcomes for individual patients.

Our second goal is to categorise and then analyse already-collected anonymised detailed  data sets within our emergency departments and to use clinical knowledge and experience to determine which interventions produce the best outcomes thus helping us to design interventions to help stop these individuals from developing healthcare -seeking behaviour.

Emergency Department clinicians at the Oxford University Hospitals NHS Foundation Trust have worked closely with their local mental health liaison team, known as the Emergency Department Psychiatric Service (EDPS) to create the Oxfordshire Frequent Attenders Programme.  The Frequent Attenders Programme team has had remarkable results, not least in outperforming what was believed to be the almost unattainable CQUIN indicators. The Year 1 targets included a 20% reduction of attendances in a selected cohort of patients. After being enrolled into the Frequent Attenders Programme, the Oxfordshire patient cohort steadily decreased their Emergency Department use, with a 63% reduction in monthly attendances achieved by Quarter 4. In acknowledgement, NHS England has distributed a write-up of the Frequent Attenders Programme (attached) to the wider ‘CQUIN community’ for other Trusts to learn from the model.

The Oxfordshire Frequent Attenders Programme has a diverse core team representing Emergency Departments, Emergency Department Psychiatric Service, South Central Ambulance Service, community psychiatric services, the hospital psychological medicine department, and an Emergency Department-based community safety officer. The variety within the group means they have much expertise to draw on and also facilitates the sharing of accurate and up-to-date data. By positioning Emergency Departments as the central stakeholder in this collaborative network of professionals, they continue to steer patients to the most appropriate services. This collaborative project will enable best practice for frequent attenders which has been developed across the Thames Valley to be shared and adopted as appropriate.

Funding from Q exchange would pay for time for an emergency department consultant and nurse to lead the project, and three stakeholder workshops to identify and report on two improvement cycles and a dissemination phase.

The timescale of the project is one year, allowing for stakeholder ownership of the project, the development of detailed plans followed by two improvement cycles

How you can contribute

  • A big part of our project is built around the idea of collaboration and networks (hence the name). We believe that members of the Q- community will be able to enrich and promote our project by tapping into their own networks.
  • Involving patients in the case management and care planning process is usually not complicated when dealing with individuals and has been a key component of the Oxfordshire model.However, we want patient representatives to inform the the strategic side of our project,we are hoping that the Q-community will be able to help us explore how this can be achieved.
  • Of particular benefit is the technical expertise we hope can be offered by the Q-community. While we have experience in working with data sets, experience of this particular topic analysis will enable us to build efficiency into the project from the outset.
  • On the strategic side, technical expertise will also be useful to inform the process of 'profiling' the patient at risk of becoming a FA.
  • Local knowledge of relevant stakeholders in and beyond our region, or insight into similar projects elsewhere will be valuable in building a relevant professional network.

Further information

FAP write-up (PDF, 927KB)

Reviewer feedback

This is a great project because…

The team are planning to start their project by analysing and understand the groups of patients that they might be able to support. By starting with a clear understanding of patient groups and developing and testing interventions that might have most impact for those groups we think there is real potential for impact and future further spread.

By the time of the event we encourage the project team to think more about…

The project would be strengthened with further thought about how patients and carers can be involved in the design and delivery of the project. Also, we think the project could produce good generalisable learning so would like to see a more developed plan for sharing that learning with the Q community.


  1. We're very excited about our multi-stakeholder meeting next week with NHS and non-NHS partners, including patient representation. Focus: Assessing and understanding the needs of patients frequently attending ED. Aim: We hope to design a bio-psycho-assessment tool that can be implemented regionally. Using a standardised best-practice approach to comprehend drivers of attendance.

  2. Excellent project, very well done for securing the funding for it! It is a very important topic and I would appreciate it if you could keep me posted about the findings of your research. Please feel free to get in touch, should you need any help.

  3. Guest

    douglas findlay 3 years, 9 months ago

    Congratulations Eileen, Deon and Fran on a successful bid for funding. Like all of the other projects, you have worked hard to get to this point and I think what's outstanding about this particular project is that you have highlighted the very important but often underfunded and overlooked area of mental health. I'm looking forward to seeing how this work can be advanced and I look forward to working with you on this collaborative project in the future.

  4. Almost forgot - thank you for the note on publication. Will definitely explore as it is one of our planned outputs!

  5. Hi Deon, Fran and Eileen,


    A really important piece of work both for patients and also the wider system. Some great comments from Q members above and I think you've addressed all the points, thank you!


    I had one query - as an ex A&E department manager, I often found us having many conversations with the local police teams too, who would inappropriately bring patients to the department because there was nowhere else for them to go. Are they, or other non health stakeholders, involved in this project?


    On another note, you mentioned that, if successful, you'd be carrying out some improvement cycles. I wanted to take the opportunity to remind you that as Q members, you have free access to publish in BMJ open quality; the details are here


    Look forward to meeting you and all the teams next week!


    1. Thank you Dimple!

      You are absolutely right about challenges shared with the police, and while I believe this is much better than it used to be (e.g. better use of section 136), we know that collaboration is the only way to manage problems. Interestingly, frequent attenders as a group have made us more aware of shared challenges and enabled us to work on solutions together. Many Trusts have developed a closer working relationship with police and have formal meetings with law enforcement representatives (in Oxford we call it Partnership in Practice). It gives us the foundation to involve the police service in the Q-Exchange project. The same goes for the involvement of other non-NHS stakeholders. For example, the evidence shows that the voluntary/third sector is much better at supporting mental health patients than some formal health services. So clearly we have to work together and Mind has been a great local partner. Others include homeless services, social workers, housing, etc. Great work happening in Reading and regionally we hope this project will enable us to learn from each other and come up with a best practice model. I have to also mention one group we regularly forget about - relatives. Their voices are too often not heard.

  6. Deon

    Firstly congratulations on getting to this stage with the proposal.

    One connection that may be worth making is into Northumberland, Tyne and Wear (Stewart Gee would be a good starting point) where they really picked up on the issue of starting from the patient's need and working how to best meet it and not just push them through a system based on rules that often directs them to an inappropriate, or at least sub-optimal place.

    At a more national level, I am happy to connect you into any national structures/work that may be of use.

  7. Brilliant to see this shortlisted.  It's also great to see that the local ambulance trust are involved.  I wonder if you have any links with the national ambulance groups?  There are both mental health and frequent caller lead groups which meet regularly.  Between the two of them, they may be able share some examples of similar work which may be helpful.

    1. Thank you Jaqualine. We have not had national contacts. Anyone you would suggest? I'm aware similar ambulance projects exist but beyond regional have no links. May be useful to see their model. Could also act as a channel to share learning from our project.

  8. GPs are essential to the project in the sense that they are the primary carers with whom the ED should be working to get vulnerable patients the right support. An advanced model of information sharing will be much easier with GP involvement as all ED visits should generate an ED discharge letter.

  9. Thanks Eileen, happy to be involved in a conference call, not sure I would make it in person.

    You can email me directly with any details:

    Kind regards, Anne

  10. Hello Anne, thank you for your post and comments. We are keen to collaborate  with as many services that patients come into contact with as possible in order to inform the development of this work and ensuring that there are robust communication pathways between primary care /GP's is very key. Anne would you be interested in joining a brainstorming session either in person or by conference calling in? The work will be greatly improved by taking on board a wide range of stakeholder views .

    Thank you and kind regards Eileen Dudley

  11. This is a very interesting project, congratulations for getting shortlisted.  I like your projected outcome as this actually leads to change, as an improvement in appropriate management for this vulnerable group.  Most of these patients will have a GP caring for them so hopefully, GPs are also given information about their care.  This should help to support GPs when these patients present in primary care and enable them to liaise appropriately with teams that are already involved in their management.   This could also help to prevent crisis presentation to the ED.

    Good luck with this initiative, you seem to have a motivated team who are already achieving in this area.


  12. Thank you very much for taking the time to write this Dan. It is exactly the type of comment that makes the Q-Community so valuable. I have shared the pdf document many times and this is the first time I've had this type of feedback! I think I know why, and it is to do with who the original pdf was written for.  Let me share my thoughts and see what you think - I'll use your first point as an example.

    Many ED clinicians identify with the fact that EUPD patients in acute crisis are difficult to care for in the ED environment. Partly because medical students do not get enough training in this area (not only my opinion - widely acknowledged). In fact, most ED doctors (especially inexperienced ones) are more familiar and confident in managing the heart and lung transplant patients you refer to than an EUPD patient who is in need of a caring environment. Which brings me to my second point - ED is a difficult place to treat someone who is already anxious. We recently had a well-being worker from the charity Oxfordshire Mind working in our ED as part of a trial. And although she saw many patients with primary mental health problems, one of her observations was that 'there is no shortage of anxious people in ED'. From family, to patients (whether they have a psychiatric history or not), to staff. It stands as evidence of the impact this environment has on people. And adds to the challenging scenarios experienced by doctors and nurses...and patients!

    So I think the complexity has as much to do with the clinicians and the environment as with the patients who attend ED. It seems that was not made clear in the document, especially if read from the perspective you've shone a light on.

    Our project is built on the concept that by adopting a more holistic approach, working better with other services throughout a wider region, and including patients in shaping service design, the desired outcomes become more achievable. The main problem, as is too often the case, is the resource limitations. So if we do not have access to the resources needed to create a fully bespoke service, how can we achieve it? The attempt at a solution with both the frequent attender programme in Oxford (the topic of the pdf), as well as the Mind trial, is to tap into and collaborate better with services that already exist. The modern ED has to take a non-traditional role of becoming more involved with care even after the patient leaves the department!

    Which is what the symbolism of our Q-Exchange project as starlings in murmuration refers to. It is what we tried to do with the network referred to in the pdf. It is also a point made in the CQC report quoted in the project brief above - the inadequate transition (and I would add coherence) of care between the hospital and the community is part of the reason why vulnerable patients return to ED in crisis. And while there has been some good results in Oxford, we believe that a regional approach could have even better outcomes.

    Reflecting on your comments, I think that what we should do is look at adding another document; one not written by (and for) clinicians. A patient perspective document. We would certainly benefit from the co-production you mentioned in your tweet. In the interest of tapping into the Q-Community, would you be open to helping us with this? We are planning a brainstorming session soon and would love to have your thoughts, and those of other Q members, to help us shape our project further. I am also going to encourage our colleagues in Oxfordshire Mind to sign up to the community to join the conversation.

    Thanks again Dan.

  13. Hi! I welcome any attempt to make life better for these groups of patients. I had a strongly negative reaction to some of the wording in this idea. Please accept this comment in the spirit of constructive criticism.

    I'm going to talk about one group who will be covered by this idea. These are the people who have been given the diagnosis of personality disorder and who frequently and severely self harm.

    1) Why I struggle with words like "complex"

    There's lots of talk about "complex patients" and people with complex needs. This makes it sound like they need a heart and lung transplant. But when you look at what's being asked for it sounds a lot more modest.

    Strong care-coordination
    Joined up care
    Choice of a long term psychological therapy delivered by a skilled experience practitioner

    These are not complex needs. The systems are complex; the patient pathways (which never match the real patient route) are complex, but the needs are not.

    2)  Stigma.

    The word stigma does not appear anywhere in the PDF. When looking at why some people will travel miles to visit a distant ED we must recognise that a small number of staff will display unacceptable, sometimes unlawful, behaviours and attitudes to people who frequently and severely self harm. The ED triage nurse who, arms folded, says "We're not going to treat you, you'll have to go elsewhere" (patient later admitted to different hospital needed IV antibiotics); the plastics junior doctor saying "It's only pieces of glass and people have been walking around with glass in them since the war"; the orthopaedic consultant saying (in a place we could, but were not meant to, overhear) "They're the one who hammers nails in. I'm not taking them out." There's some focus on somatoform disorders and drug seeking behaviour - patient "blame", but no recognition that patients may be seeking better quality care.

    3) We're told to go to ED.

    People get stuck in loops of circular referral. Contact your GP, who contacts Crisis Team, who tell you to go to ED if it's an emergency, who tell you to contact crisis team. I understand a bit of the frustration that HCPs have with this, but it would be nice to see some recognition that it's not the patient's fault. The patient didn't design those systems that cannot interface; the patient does not want this.

    4) Appropriate care

    I live in Gloucestershire. My nearest burns unit is out of county in Bristol. I know  if I attend my local ED that they will ask me to go to Bristol. I can save my local ED time and money if I just go directly to Bristol. This is one example of a patient using a non-local ED, but doing so for the right reasons.


    I welcome the fact that you're looking at this. I would urge you to get some coproduction involved from local SU groups, because I can predict that the current language is going to be seen as stigmatising and discriminatory by many.

    I understand that severe and frequent self harm lasting for many years is confusing and challenging to deal with, but I'd love it if there was a bit more recognition that the patient does not want this and is trying to escape unimaginable pain.

  14. Thank you Dan Beale Cocks for twitter comments. We're keen on making this project meaningful for patients and we would really value your thoughts. Please get in touch...I regularly check messages on Q-site. Deon

  15. Induction week. In my talk on frequent attenders our new doctors and trainees in the deanery confirmed patients who regularly attend our hospital also visit other EDs. More important now than ever to have a regional approach. For consistency and safety of vulnerable patients.

  16. Very excited that our project will feature at the upcoming Regional ED Collaborative Event. For all those interested in QI in ED in the Thames Valley Region see  3rd Regional Emergency Department Collaborative Event and sign up! For everyone else - watch this space. We hope to see our project grow even more!

    1. Guest

      Eileen Dudley 3 years, 11 months ago


      Interested in using some of the techniques from The Power of Liberating Structures to maximise this wonderful opportunity and get the most out of the conversations at the Emergency Department  Collaborative Event in Milton Keynes on September 6th. Would love to hear from any Q member out there who has experience and knowledge to share. My colleague Jo Murray is an enthusiast but unavailable on the day.

  17. We feel so privileged to have been shortlisted. Now the real work starts. Douglas, we should build on the foundations of patient involvement and lay membership you are talking about - I think it is a major challenge with previously unexplored potential in this vulnerable group of patients.

  18. Indeed, being shortlisted is a great recognition of the the combined effort and enthusiasm given over to this regional collaborative project. I fully support the comments of the reviewers regarding spread of the lessons learnt. Considering the enormous pressures on the current system and staff involved in EDs across the UK, I hope that the learnings are picked and disseminated up by others. A note to the reviewers, the Oxford Academic Heath Science Network team are really committed to Patient and Public Involvement Engagement and Experience as evidenced by the really high number of lay members connected to and fully involved in each of their project teams. I think our (lay members) involvement has become so much part of the way in which the teams work that their failure to pick out lay involvement in their project was a oversight rather than a reflection of lack of involvement.

    1. Douglas, we have to meet up!

  19. Well done for getting shortlisted team!

    1. Guest

      Eileen Dudley 3 years, 11 months ago


      Congratulations to all of the projects who have made it to this stage and condolences to those who were unlucky this time. Hopefully there will be more opportunities as there was such an enormous amount of fantastic work submitter for consideration. I am delighted on behalf of the team and excited to see how the project develops in the coming months.

      Good point Jo about supporting project on the reserve list , we shall indeed!

  20. A super project with great potential to benefit a very vulnerable group of patients and free up overstretched and valuable ED resources


  21. Hello Ed

    Deon Louw the project Clinical Lead is not yet a Q member (he is applying in the current window!) so I am posting his reply to you comments a follows:
    Absolutely. Every clinician knows this challenge. The economic perspective you mention is difficult to define. In addition to the high number of attendances and impact on overstretched emergency departments, published evidence also shows this group has a higher rate of admissions. The resource use is therefore potentially much greater. Even though we have not included costing the issue as part of our stated project goals, we know that it is a major concern. We are hoping that healthcare colleagues in the Q-community and beyond will recognise it as a shared problem that affects us all (and by implication our ability to focus resource-use to provide all patients with the most appropriate care). Thank you for the comments.     On behalf of Deon Louw

  22. Hello Ed

    Thank you for your comments and support for the project aims, in trying to tackle a difficult and complex area of need for an especially vulnerable group of patients. Your observation on the impact of frequent attenders on the already heavy workload of ED staff and resources has been observed by Douglas our Lay representative who volunteers in his local ED . Patients can face a very long wait while ED staff struggle to meet their needs. We are committed to this work and appreciate the input from Q members.

  23. This sounds like a really interesting and positive approach to managing a really challenging group of individuals, usually with complex needs. These patients have a disproportionate impact on the ED team and as such their needs can be neglected and sometimes overlooked completely, leading to patient harm. From a strict economic perspective this group must be worth tackling even if all other aspects are neglected.

  24. A really important and often neglected topic - focusing at the real issue may have a benefit not just for ED priorities but how to support these vulnerable frequent attenders in a more suitable environment

    1. Response from Deon Leow, Clinical lead:
      You've hit it on the nail Katie. Reducing attendances may be a proxy for success, but you're right that the focus should always be better and safer care for complex individuals.

  25. I think this is a really interesting idea, having a region-wide approach to this difficult problem seems to be a really positive move.

    1. Dear Katherine

      It is such a positive message to see the interest in this project among the ED Collaborative and the enthusiasm and leadership shown by Deon is inspirational.

      The opportunity through the Q Exchange to reach out to the Q community is marvelous and the response has been really helpful in developing this proposal.

    2. Response on behalf of Deon Louw, clinical lead for the project:
      Thanks for the positive comments Katherine. We're hoping that the regional approach will give new insights that will benefit patients as well as professionals, both within emergency departments and beyond. GPs, community services, elective clinics, social workers, the third sector...we are all responsible for these patients.

  26. Guest

    Douglas Findlay 4 years ago

    Congratulations Eileen, Fran and Deon on driving this much needed initiative. As I travel across the region, I get the impression that frequent ED attendance affects mental health patients and their carers in a big way, particularly with longer waiting times in primary care becoming more of an issue.

    As the Thames Valley area are so keen to integrate Patient and Public Involvement Engagement and Experience in all of their work, I would like to become involved as a patient contributor in this area of interest. Are you considering having a patient on your steering group? I would be very interested to hear from others in the Q community in the Thames Valley who might want to connect to this project.

    1. This is a message from Deon:

      Thank you Douglas. Yes, yes, yes! Almost all frequent attender projects (both in practice and in the literature) have one major shortcoming - effectively engaging with patients at a design level. We would be very happy to have a patient representative on-board. It is an exciting aspect in which your experience would be greatly valued.

  27. Thank you for your comments Simon - Deon Louw, the clinical lead for this work, is not a member of Q yet so I am posting his comments here.  Deon says '
    Thank you Simon. Equally important to know how moderate frequent attenders become extreme frequent attenders. Maybe we could prevent progression in an unhealthy pattern. We're looking into that angle. What do you think?

  28. Good afternoon Simon

    Thank you for taking the time to read and comment on this project. This is exactly what we are hoping for from the Q community and I will follow up your suggestion to connect with the team in Exeter with Deon, the Clinical Lead for this work.

    1. My pleasure Eileen

      I understand from a conversation with our MD that there are quite mature processes in place for managing mental health FAs here. But they remain a challenge, of course, and the prospect of identifying individuals "at risk" is very exciting.

  29. Great project and a really serious issue for frantic EDs. If you aren't in touch, it might be worth contacting the team in Exeter who are currently kicking off a Flow Coaching Academy pathway on mental health triage and pre-triage in ED.


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