Background
‘Frequent flyers’ form a group of clients repeatedly admitted to hospital or attending Accident and Emergency for treatment for alcohol–related conditions.
Reducing alcohol–related hospital admissions is a priority for the NHS as alcohol–related problems are known to place a considerable financial burden on the NHS, particularly for those needing treatment in a hospital setting. Nationally 13-20% of all hospital admissions are alcohol-related, rising to 35% of all A&E attendances (NHS Evidence, 2011). In 2006/7 hospital-based care accounted for 78% of NHS expenditure on alcohol misuse (NHS Confederation and Royal College of Physicians, 2010 in NHS Evidence, 2011). Currently, reducing alcohol –related hospital admissions is particularly relevant as the NHS Operating Framework provides an option not to reimburse hospitals for the cost of treating patients readmitted to hospital within 30 days of being discharged (DH, 2011)
Frequent flyers are not a new client group; they have recently come increasingly under the spotlight, in efforts to reduce alcohol-related hospital admissions and as the impact on alcohol on their health has become better understood. Although we have used the term, ‘Frequent Flyers’ we recognise that the terminology used is subject to ongoing discussion, with particular concerns that the term ‘frequent flyer’ may appear flippant and patronising. We are aware that this is just one ‘working’ term among others with practitioners varyingly referring to this group as ‘frequent attenders’, ‘high volume service users’, or ‘high impact users. Although there seems to be a shared understanding of who we mean, what we should call them, and indeed if it is appropriate to refer to this cohort under an umbrella term, is up for discussion.
While concern has been growing about frequent flyers, little data has been systematically collected and shared and few services currently target them, yet they are familiar to a wide range of professionals in the health and other sectors. Following on from projects identified within the CPI South East Alcohol Innovation Programme (CPI, 2011), we know that a number of innovative approaches specifically addressing the needs of frequent flyers have emerged out of the day-to-day practices of healthcare staff. Some of these have been piloted and identified as successful in reducing numbers of alcohol-related hospital admissions e.g. the work in Portsmouth and Hastings (Herring et al, 2011). We are also aware that while some projects specifically focus on this group, other areas of practice are more generic, where practitioners are responding to their needs as part of a more holistic approach e.g. Brighton hostel project, or where Alcohol Care Teams have been developed to provide integrated treatment pathways for ‘frequent attenders’ (NHS Evidence, 2011 – see www.evidence.nhs.uk/qualityandproductivity). Although evidence is accumulating regarding different models of response at the local level, there seems to be a lack of co-ordination and support in helping practitioners to respond to the needs of this group, the emergence of the ‘Frequent Flyer Forum’, set up as part of the CPI South East Alcohol Innovation Programme on the Alcohol Learning Centre website being a noteworthy exception (see http://www.alcohollearningcentre.org.uk/discuss/).
Aims
We believed that there was currently enough interest in frequent flyers, and in practitioners and others sharing their knowledge and experiences in developing interventions for this client group, to host a workshop whose overall aim would be to explore working with frequent flyers.
There is currently no consensus on the composition of this group or on how they should be defined; as already mentioned, practitioners refer to them using a repertoire of names. Important issues needed to be explored and clarified in order to best develop interventions for this group – including separating A&E attendances from hospital admissions; frequency of attendance/admission required for particular definitions; the health conditions of this client group and how best to work with them (they tend to be characterised as having complex needs and a high degree of vulnerability).
The workshop
The event took place in London on March 23rd 2012 and was hosted by the Drug and Alcohol Research Centre at Middlesex University in collaboration with CPI and Improving Health & Wellbeing UK. We had underestimated the interest the workshop would generate and demand for places proved exceptional. 63 participants took part in the event and included a broad spectrum of professions; among them were alcohol commissioners, alcohol workers, A&E staff, a Department of Health Alcohol Policy representative and a Fire Officer. A further 34 names were held on a waiting list in the hope of holding a similar event in future. The workshop explored a range of issues and was the first of its kind that brought together and enabled a range of practitioners, policy makers and ex service users to discuss their experiences of working with this client group.
Evaluation
All delegates were sent a link to an online survey asking for their response across a number of dimensions including participants’ personal development, usefulness of event and whether learning outcomes were met. (Click here for survey.) Participants found the event extremely useful – 74% rated the value of the workshop to their job role as high /very high, while 68% rated the effectiveness of the workshop as high/ very high. It was very well regarded, especially for facilitating the sharing of learning with colleagues (83% rated it on this dimension) and confirmed the potential of this type of medium for disseminating issues around knowledge and practice in what is essentially an emerging field.
Themes emerging from workshop
The day generated a lot of useful discussion and debate around a number of key areas that we have outlined below. Needless to say passion abounded!
- Defining frequent flyers - terminology
There is currently a variety of terms used to describe what appears to be the same target group and several ways of defining who should count as a frequent flyer. While it is important to develop a common understanding of the group, there is a need to define the parameters i.e. what makes an individual fit within the frequent flyer category. Currently there are multiple measures and criteria in use, for example, drawing on frequency and intensity of service use, degree of assessed dependence etc. It is also important to bear in mind that inclusion and exclusion criteria at service level differs and may be influenced by workload and economic considerations and constraints among other factors. - Communicating the issues and needs of frequent flyers
Consideration needs to be given to communicating the issues and needs associated with this client group. Getting the message across may involve: developing a common understanding of the problems, the target group and their needs etc.; educating clinicians/ A&E consultants/ service providers and commissioners; reaching professionals and groups less centrally involved but likely to encounter the target group in the course of their work e.g. fire service. - Overview of current responses and different models
Developing appropriate responses to frequent flyers has been very much a ‘bottom up’ effort deriving from grass roots service developments. Interestingly both the DH representative and other key project initiators came to the event to find out more. Approaches have been developed partly through testing out ideas at the local level rather than based on theory or empirical evidence (which has been lacking). Some evaluations are now available and these indicate that interventions can achieve positive outcomes. Further work could be undertaken to develop more theoretically based models of interventionWe need to know what models and types of responses already exist for frequent flyers. These appear to range from highly focussed services to broader ‘packages of care’. These approaches could be collected and better described, for example through scoping, case study work and talking with professionals. Analysis of the core components that are working well and may be similar across programmes is needed with the aim of developing ‘good practice’ or possibly a set of ‘standards’.The results of current service and project interventions for frequent flyers indicate the need to develop a flexible framework of understanding and intervention possibilities. These should allow for some commonality across projects but be able to accommodate local variability and allow for diversity of local needs, infrastructures and traditions of response. - Workforce issues – burnout, need to develop certain skills, job specs etc
Discussions during the event highlighted workforce issues such as the highly intensive nature of working directly with frequent flyers both in hospital and community settings. There is a need to consider and plan workforce development i.e. how to develop the knowledge and skills required to provide an acceptable, appropriate service for frequent flyers; what kinds of skills are needed in different job specifications associated with working with this client group. In order to do this, some of the issues noted above need to be addressed e.g. defining the target group, developing an understanding of their needs, providing examples of response models and evidence of effectiveness/ cost effectiveness.
It is also interesting to see that currently no particular profession dominates or has ownership of this field. This multi-professional ownership is a hopeful sign and may be indicative of a shift away from a particular culture dominating the field.
Some examples of good practice
- Supporting staff as well as clients
- Removing stigma associated with label ‘frequent flyer’ by reconsidering our terminology
- Recognition that for the client ‘non-alcohol’ issues e.g. housing, pending court appearance etc may be more pressing and require intervention before they can begin to address alcohol use.
- Allowing staff to work flexibly to address the needs of clients, e.g. accompanying clients to appointments, helping sort out ‘non alcohol’ related issues including debts, housing as required.
Recommendations
- This is an issue which requires policy and research attention.
- Addressing these issues can require intensive and, often, quite costly service approaches. There is a need to ‘sell’ the issue, to develop a business case for intervention with this target group, to elicit buy-in across top/senior levels, clinicians and policy makers, as well as getting support from local ‘champions’. This will ensure that the issue is high on policy agendas and deserving of monetary and other support.
- Frequent flyer services need to liaise across a wide range of health and other services and it is important that roles are clearly understood across the local environment supported by mutually developed care pathways.
- This first workshop has underlined the interest and commitment to working with frequent flyers, evident among service providers and other representatives such as the fire service. Efforts should be made to continue the dialogue, to expand opportunities to share knowledge and experiences and to develop intervention models and evaluate their effectiveness in different local contexts.
Next steps
- North of England workshop - As part of the evaluation, participants were asked to say what they would like to happen next. Those attending from areas outside the South East indicated that another workshop held in the North of England would be of value to them. CPI together with Middlesex University are currently seeking funding to host a further workshop in the North.
- Toolkit - Data from the evaluation suggested that well over two thirds of workshop participants would find a toolkit useful. CPI in collaboration with Middlesex University are currently seeking funding to develop a toolkit which would be piloted, monitored and evaluated before being mainstreamed.
- Journal paper - The findings from each workshop together with the evaluation data will be written up as short reports and the data from both workshops used to inform a journal article.
References
Alcohol Learning Centre (Accessed 15th May 2012)
Centre for Public Innovation (2011) South East Alcohol Innovation Programme: evaluation report, Centre for Public Innovation. (Accessed 15th May 2012)
Department of Health (2011) The operating framework for the NHS in England 2012-13. (Accessed 15th May 2012)
Herring, R., Bayley, M., Thickett, A., Stone, K. and Waller, S. (2011) Identifying promising approaches and initiatives to reducing alcohol related harm. Report to Alcohol Research UK and the Joseph Rowntree Foundation. (accessed 15th May 2012)
NHS Evidence (2011) Alcohol Care Teams: To reduce acute hospital admissions and improve quality of care. The British Society of Gastroenterology and the Royal Bolton Hospital NHS Foundation Trust. (Accessed 15th May 2012)
Team
Mariana Bayley, Rachel Herring, Betsy Thom
Drug and Alcohol Research Centre, Middlesex University
Mark Napier
The Centre for Public Innovation
Iain Armstrong and Damian Mitchell
Improving Health & Wellbeing UK
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