Realising the three shifts: preventing more people from reaching crisis point will be one measure of success

A small but significant part of the population are attending A&E frequently. In 2021, the British Red Cross (BRC) published Nowhere else to turn. This report showed that while less than 1% of the English population attend A&E frequently, they account for 16% of all A&E attendances, 29% of all ambulance journeys, and 26% of all hospital admissions.  

This group of people are attending A&E more than five times a year (sometimes up to five times a month). This is happening because unmet social, emotional and practical needs are worsening people’s mental and physical health. And many feel they have nowhere else to go to seek help. 

Fortunately, there are existing approaches that can make a big difference to these populations – for example, the High Intensity Use (HIU) services that the BRC (among other organisations) deliver across England. These types of services have been recommended in the NHSE operational planning guidance in 2024/25 and 2023/24, and in the Urgent and Emergency Care Recovery Plan (2023). The services have been hugely impactful by providing the holistic, proactive and non-time limited support that these populations need and want: the kind of care that goes beyond what it is possible to deliver in A&E.  

So how does this all connect with current and upcoming national policy on the three shifts? In March, The King’s Fund brought together a range of experts from national bodies and local systems to discuss this question. This blog reflects some of the issues and ideas we explored. 

Fundamentally, work to better support those who frequently attend A&E is about intervening early to prevent people from reaching crisis point. Much of this work is, and should be, delivered in the community. That is, outside of hospitals, and with a workforce well equipped to support people’s non-clinical needs. In short, a ‘neighbourhood health service’ that is much more holistic and able to support people more flexibly than is often the case presently. And the potential for a more digital system is huge: to help link datasets across organisations, enabling population health approaches to identify people in need and share the necessary information to provide timely and effective interventions.  

If successfully realised, the three shifts could help to deliver the kind of system that is better able to prevent people from reaching crisis.  

This is significant for several reasons. First and foremost, there is a moral imperative to help those most in need. Doing nothing to prevent people reaching crisis should not be an option. In addition:  

• It could improve care and outcomes for patients. Many of those who frequently attend A&E have clinical needs that require acute care. But they very often also have a range of non-clinical needs, such as housing insecurity, loneliness, dealing with sudden life changes (eg, job loss or grief), all of which can have hugely negative impacts on their overall health and wellbeing. However, A&E is rarely, if ever, the best place to provide support for these types of issues.  

• It is an opportunity to make significant progress on tackling health inequalities. Fundamentally, high intensity use of A&E is a health inequalities issue. The BRC’s latest research, which was conducted in collaboration with Dorset Integrated Care System, shows that people who frequently attended A&E in Dorset were 72% more likely to live in an area of deprivation, and were more likely to experience mental ill health and live with multiple long-term conditions, than those who do not frequently attend A&E. If the government is serious about addressing health inequalities – as it signalled it was in the health mission – then identifying and prioritising support for people who are at greater risk of frequently attending A&E could be one way to make progress towards this.  
  

• It could help to reduce pressure on the NHS. The BRC’s research estimates that high intensity use of A&E costs the NHS £2.5 billion a year. And that intervening early to prevent people reaching crisis can drastically reduce attendance at A&E – by up to 84% (see below) – and therefore the burden on acute services. So alongside the moral case for providing better support to those most in need, there is also a strong economic reason to do so.  

The BRC’s HIU services are based on the NHS Right Care model, in which an agreed number of people who frequently attend A&E in a particular area are identified by practitioners and asked if they would like to try something different. The support provided involves a person-centred and strengths-based approach to identifying unmet needs that are worsening people’s health. Importantly, the approach is demedicalised and decriminalised.  

Evaluations of HIU services show how they can make patients feel listened to and supported to be more confident and independent in accessing care in the community. Patients attribute much of the value of the services to the non-judgemental and relational nature of the support. NHS England studies have shown that HIU services can be associated with drops in frequent A&E attendance by as much as 84% after three months. However, patterns are complex and BRC analysis shows how to best identify those who are the most likely to attend frequently over long periods of time without effective intervention.  

So, as the government works to deliver the three shifts, and the anticipated Urgent and Emergency Care strategy, it should consider the huge potential of non-clinical approaches to improving the nation’s health and our health and care system. HIU services are one such example. They can, and already do, connect the data around people to deliver care in the community, prevent worsening ill-health, and ultimately ensure that fewer people frequently attend A&E.