High Intensity User Service

Supporting people who need extra help to stay well

The situation

Some people need to use NHS services much more often than others because they are living with several long-term health conditions, mental health needs, frailty or difficult social circumstances.

This can mean repeated visits to A&E, frequent GP appointments and ongoing support from community services. Often, these people have complex needs that cannot be addressed through a single appointment or service.

The Apollo High Intensity User (HIU) Service has been developed in North Warwickshire to identify people who would benefit from more joined-up, personalised support. By understanding the whole person and the challenges they face, the service aims to help people stay healthier, improve their wellbeing and reduce the need for emergency care.

The Health Data and Intelligence (HDI) Platform helps identify people who may benefit most from this support by bringing together information from GP practices, hospitals and community services across the local area.

What we did

Using the HDI Platform, the Apollo Primary Care Network (PCN) identified adults who were regularly using A&E, GP and community services and may have unmet health or wellbeing needs.

The first group of patients will be invited to take part in a six-month programme of personalised support.

Each patient will receive a longer first appointment with a multidisciplinary team, which may include:

A GP or Advanced Clinical Practitioner
A clinical pharmacist to review medicines
A physiotherapist
A social prescriber
A mental health practitioner
A care coordinator

Together, the team will work with each patient to understand what matters most to them, create a personalised care plan and arrange any additional support they may need from NHS, local authority or voluntary organisations.

Patients will receive regular follow-up appointments and ongoing support from a care coordinator to help them manage their health and access the right services when they need them.

The impact

The service is designed to improve care for people with the most complex health and wellbeing needs by providing earlier, more coordinated support.

The programme aims to:

Help people feel more confident managing their own health
Improve wellbeing and reduce loneliness or social isolation
Reduce unnecessary visits to A&E
Reduce emergency hospital admissions and ambulance call-outs
Improve coordination between GP practices, hospitals, community services and local organisations
Ensure patients receive the right care, from the right professional, at the right time

The HDI Platform will also help the team measure how the service is performing by monitoring patient outcomes and changes in the use of NHS services over time.