New team launched to support frequent A&E users in Peterborough

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The service will help those with needs which would be better met by other professionals.

A new specialist team has been launched to help to reduce avoidable visits to Accident and Emergency departments across Peterborough and Cambridgeshire.

This service will help those who often attend A&E for reasons that extend beyond medical interventions and for needs which would be better met by other professionals.

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Known as the High Impact Use team (HIU), the service is a partnership between NHS Cambridgeshire & Peterborough and Cambridgeshire County Council on behalf of the Integrated Care System (ICS).

Peterborough City Hospital A and E department.Peterborough City Hospital A and E department.
Peterborough City Hospital A and E department.

Since its launch, the HIU team found that many of the frequent visitors to A&E at Peterborough City, Hinchingbrooke, and Addenbrooke’s Hospitals were experiencing issues such as loneliness, financial problems, and poor physical and mental health, rather than medical emergencies that require urgent hospital care.

The HIU team will work alongside partners to build a trusted relationship with each person identified as requiring non-clinical support through their frequent attendances at A&E, creating an open, person-centred approach to help meet the individuals’ needs.

Jon Bartram, Programme Director of Strategic Commissioning at NHS Cambridgeshire & Peterborough, said: “Our HIU team provides additional support to help address the underlying causes of frequent attendances at A&E departments. Such frequent visits are often due to complex social factors and are often non-clinical in nature.

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“The type of help given depends on the person’s needs but can include arranging and attending appointments with the patient, enrolling them in community groups or charity services, and assisting them to access other support such as counselling services, housing advice and employment guidance.

“By working with people in this way, we aim to reduce A&E attendances, 999 calls, and ambulance call-out rates while ensuring people get the appropriate care and support they need.”

Julie’s Story

Julie was referred to the HIU service in September 2024, feeling trapped by her circumstances. She struggled with Chronic obstructive pulmonary disease (COPD), severe anxiety, and loneliness, spending most of her days isolated at home. “I feel like people don’t believe me,” she said, “I don’t know if it’s medical or if they just think it’s all in my head.” Julie’s goals were deeply tied to reclaiming her independence: she wanted to feel better, stop smoking, find friendships, and participate in her local community.

When the HIU team first met Julie, she felt disconnected and lacked confidence. They provided practical support, referred her to Talking Therapies for anxiety, and enrolled her in a smoking cessation programme, helping her make small but meaningful changes, like feeling confident enough to sleep upstairs again.

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With regular support, Julie gradually regained her confidence and sense of agency. She began taking short walks, eventually venturing further and finding new reasons to go out. Encouraged to attend a local community centre, she built up the courage to join group activities. “I wish everyone was like you,” she said. “You’ve helped me feel positive because you listen and understand me.”

Julie began opening up to her family, feeling more confident to discuss her anxieties. With support and coaching, she had open conversations about her feelings, leading to stronger connections and a sense of belonging. These small wins are helping Julie believe in herself again.

Julie recently said, “If the team wasn’t here, I would call an ambulance,” showing her trust in the HIU service. Julie can now pause and reflect during crises, reaching out to a suitable service, the HIU team, or her family.

Julie’s A&E attendances are reducing (from six in September/October to three in December/January). When Julie does attend A&E, this is appropriate, and she is much better able to advocate for herself and communicate her needs whilst there.

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Aaron’s Story

Aaron was referred to the HIU service in October 2024, overwhelmed by mental health struggles, alcohol misuse, self-harm, and falls, alongside incidents of aggression toward hospital staff. “I’m lost. I’m scared,” he said during his first meeting. “I don’t want people to be scared of me.”

At the time, Aaron had visited A&E 16 times in two weeks and 32 times in the past year. However, he was keen to reconnect with his children, manage his behaviour and his addiction, and create a safe, welcoming home.

The HIU team ensured Aaron received regular medication deliveries and coaching to keep his flat safe and tidy. In doing so, he repaired relationships and got support from his friends. Multi-disciplinary team (MDT) meetings connected him with social care, addiction services, and probation, while outreach from Change, Grow, Live (CGL) accommodated his mobility challenges to support his addiction recovery.

Aaron continues to work with the HIU team to build a better future for himself. Aaron has reduced his alcohol intake and joined a detox programme. His A&E visits have dropped significantly from 16 visits in two weeks to one visit in two months. Reflecting on his growing independence and ability to manage challenges with community support, Aaron feels hopeful and determined to rebuild trust and relationships.

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