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Version 1 of ALFA nurses idea

will help ALFA patients get a better service through co-development specific for their needs.

Read comments 11
  • Idea
  • 2022

Meet the team


  • Local Alcohol and Drug Partnership
  • police
  • housing
  • addiction / alcohol / psychiatric teams
  • Third sector organisations / charities (such as WeAreWithYou Scotland).

What is the challenge your project is going to address and how does it connect to the theme?

Alcohol related Frequent Attendance of a relatively small number of patients to A&E departments and hospitalisations is a significant problem in Scotland. The result of frequent attendance is a vicious cycle of dissatisfaction with a health care services and further loss of engagement of ALFA patients for whom current services are not user friendly / useful.

Development of a patient centred service combining expertise in mental (addiction) and physical (in particular liver) health, local knowledge and people with lived experience in design and conduct of this service will find better ways of patients in the (usually crisis) situations which would otherwise trigger emergency attendance or hospital admission.

Collaboration between a quality improver (MH) who has developed, set up and is supervising a similar service in a previous post (Paisley / Scotland) and local primary care as well as third sector teams (eg WeAreWithYou Scotland) will bring a positive change to ALFA patients.

What does your project aim to achieve?

The project will improve care for patients who have alcohol problems and do not engage with conventional healthcare and other community services but frequently attend (typically when in a crisis) hospitals through A&E leading often to emergency hospitalisations. Using qualitative research and early experience with a similar setup, the project will c0-design a service with frequent attenders involving community resources and assertive outreach. This will allow a more patient focussed and individualised care for patients with multiple severe disadvantages and complex needs including mental health (addiction) and physical health. Development of such a service will directly reduce inequities, will improve the engagement of ALFA patients with other services and will decrease the use of healthcare resources in overstretched A&E departments, medical assessment units and hospitals.

How will the project be delivered?

From previous quantitative and qualitative we have experience in identifying frequently attending patients through routinely collected hospital data in real time and we have conducted qualitative interviews allowing us to start develop a service which better serves the need of ALFA patients with often very complex needs. The development of the service will be recursive with frequent PDSA cycles involving hospital, primary care and third sector leads as well as the to be established ALFA nurses team. Impact will be measured through engagement with the ALFA nurses as well as effect of A&E attendance rates and admission rates of ALFA patients. One idea for improvement of the service and experience of the patients is to create an ALFA patients hospital handover sheet. This lays out under different headings important aspects and needs of the patients if they attend the hospital using a “What Matters to Me” approach.

How is your project going to share learning?

The project will publish on a dedicated website learning experiences and will endeavour to present their experience and data at national and international meetings to allow wider learning from this important project specifically designed to improve health inequities for this most vulnerable patient group.

How you can contribute

  • General sense check - although we have some experience with nurses dealing with these patients, the general workload often makes it difficult to concentrate on dealing with the ALFA patients.
  • Links / networking with third sector / community services who would be interested / could help with these patients
  • Data collection / analysis of attendance / admission data can be complex but will be necessary because of significant resource use for these patients (with and without dedicated nurses).

Plan timeline

21 Feb 2022 outreach to D&G data analysts to establish data strategy
18 Apr 2022 job description and advertisement
4 Jul 2022 start of ALFA nurses secondment and up-skilling as necessary


  1. This sounds like a really important project. I remember hearing a few years ago about something similar in Northern Ireland and focusing on a very small number of the most frequent attenders made a huge difference. We also have a number of programmes including housing and Mental Health that will be really interested in the learning being shared from this.

  2. Hi Mathis and team,

    It sounds like a much-needed service. Building on Elizabeth's comment above about virtual wards, how does your idea specifically relate to the theme of ‘Bringing together the worlds and methods of improvement and digital, to enable better outcomes and faster, more sustainable change’? Are you looking to build on learning from how different health and care, and community organisations, have worked remotely and used digital tools in the last couple of years? Are you looking to explore whether and how remote monitoring or remote consultations (or other 'healthcare centric' digital innovations) could be appropriate for this population group? From what I've been hearing from our participants in the current Q Lab project on remote monitoring, it seems to offer a lot of potential for a 'what matters to me' approach. I was wondering if this is something you've thought about?

    For the co-design work, it sounds like you have a lot of previous experience on this, but you may find ideas and learning from previous Q Exchange projects helpful - a few that have engaged with often-excluded groups are listed on p14 of this insight summary

    Good luck with the proposal!


    (commenting in a personal capacity, not in my capacity as a member of the Q team)

    1. Thanks again Jo for your kind words and links. Yes, we really do need to work on this and I would love to have a chat to you to have some more ideas for both projects. The ALFA nurses project is very data driven using real time hospital data where the digital data is in our experience much more reliable and objective in identifying frequent attenders. Reaching out to them using digital means can be difficult in the population we aim to serve (any suitable digital possession risks getting sold / traded for alcohol or drugs). Digital reminders could help for certain people and a virtual ward type idea is I think the most realistic way forward. I would be interested in how a "what matters to me type" follow up / monitoring would work. There might be people who would agree to for example an transcutaneous alcohol measuring tag? Liver health is unfortunately not as easy to monitor as blood sugar and many other things. Also, co-design is difficult with the risk of the most deprived people not attending standard co-design meetings (with social anxieties, addiction...) being additional barriers to the deprivation. Would be great to have a chat on your ideas and experience!

  3. This looks like an excellent and much needed initiative, building on your work elsewhere.  It comes across as person-centred, and a recognition of the integrated working needed across all agencies concerned.  Good luck with this proposal.

    1. Thanks Helen for your kind words,
      Yes, the idea is very centred. I would hope that we will be able to get the ALFA patients help write their own hospital handover sheets (summary of what matters to them, what the issues of their attendances often is, what they want them to get out of an attendance, what their strengths and their support mechanisms are...). What do you think? Do you think the is too optimistic?

      Thank you very much again, kind regards,

  4. I think you may benefit from collecting some PROMs at the individual level.  At R-Outcomes Ltd, I have developed a portfolio of short generic PROMs and PREMs, which might be useful. These include measures of social determinants of health (influenced by Marmot's Health Gap), social contact etc.

    1. Thanks Ben,

      Yes, I have looked at these now. I wasn't aware of this collection. Very good to have the reading age with the questions (a lot of these patients have problems...). This certainly gives some inspiration and fits in well with the "What Matters to Me" theme. I was thinking of asking what matters to the patient and then rating this as the person specific outcome measure. I would hope that the patients reflect on whether they can improve what matters to them through other ways than attending / being brought to the hospital and whether looking after themselves better helps them improve the person specific measures... Thank you very much again, kind regards, Mathis

  5. Guest

    Trish Jay 4 months ago

    Hi Mathis and team - this is a great idea. Active engagement, with trust between the person and the clinician is key to changing behaviour. God luck with the project.

    1. Thanks Trish for your kind words. Keep checking on the idea. Any help for improvement is very much appreciated.

      Kind regards,

  6. Important area and might benefit from linking with primary care networks or their equivalents in your area. Another aspect might be virtual ward oversight with input again from both primary care and other teams and voluntary sector

    1. Guest

      Mathis 4 months ago

      Thanks Elizabeth,

      Good ideas. We are planning in linking in with clusters (and allowing them to get the data on "their" frequent attenders in real time), we should probably elaborate on that more...

      Virtual ward is a good idea (although the idea of a "ward" is very healthcare centric - need to ask about our people with lived experience about that). Maybe a "virtual ALFA support space" is more what the patients want?

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