The Asgard (advice, support, guidance, advocacy, referral and direction) project aims to reduce the number of 16- to 19-year-olds in North East Lincolnshire who repeatedly use the Accident and Emergency (A&E) service.
On average 20 young people every day were presenting to the Emergency Care Centre at Diana Princess of Wales Hospital in Grimsby with complaints ranging from substance misuse and self harm to undiagnosed or poorly managed chronic illnesses.
The project involved extensive research with young people, which laid the foundation for the appointment of a new community intervention team that works one-to-one with vulnerable young people to help them tackle complex health challenges. It is complemented by a parallel initiative to raise young people's aspirations by offering the opportunity of work at the Care Trust Plus (CTP), thereby broadening their horizons and offering alternative life choices for the future.
Results to date
- 12.5 per cent reduction in the number of young people presenting at least twice in one month to A&E for the same health issues
- 16.7 per cent increase in the number of young people engaging with related support services referred to them by Asgard
- 32 young people on work placements
According to the index of multiple deprivation, North East Lincolnshire (NEL) is the 49th most deprived local authority out of 354 in England. 24.9 per cent of children and young people live in families where no adult is working and a further 15 per cent come from second or third generation workless families.
In NEL, preliminary research identified that there were approximately 650 to 700 young people who are known to be at significant risk of or already enduring: social exclusion, health inequalities, teenage pregnancy, substance misuse, disrupted families, low aspiration, low self esteem, inability or unwillingness to use universal, specialist health or social care provision, and misuse services like Accident and Emergency (A&E).
Asgard grew out of the recognition that there was a pattern in 16- to 19-year-olds repeatedly presenting at the Emergency Care Centre (A&E and the GP out-of-hours service) of Diana Princess of Wales Hospital in Grimsby. 16- to 19-year-olds were ‘falling between the gaps' with the existing service provision because of a lack of targeted health support for this particular age group. Under-15s are supported through Children's Services, whilst those over 19 are covered by Adult Services.
Through the provision of targeted care and support services, the project seeks to address the underlying behavioural and social determinants that were causing this pattern and effectively intervene before individual situations resulted in emergency call outs. A performance indicator of reducing Emergency Care Centre (ECC) contacts with 16- to 19-year-olds by 10 per month or 120 per year was set to monitor progress of the scheme.
This aligned with national policy drivers outlined in the Chief Medical Officer’s Annual Report 2007, Under their Skin: tackling the health of the teenage nation, where Sir Liam Donaldson recognised the need for more concerted effort to engage young people regarding their health needs.
“I learnt quickly that a group of about 600 to 700 [young people] who were identified as particularly vulnerable went everywhere that we didn’t want them to. But a common point of reference was the emergency care services – nearly 92 percent had been through the emergency care services within the last 6 months. So this was a good point of contact, especially when you looked at the re-attendance. Some were having 10 to 12 attendances a month. So I put a business case together saying that this would be cost-effective because it would save us money in the long-term. The minute they come through the door at the Emergency Care Centre it costs £120.” (Annie Darby, Asgard Programme Lead)
Funding for the work comes from the ‘Invest to Save Budget’ which is a joint Treasury/Cabinet Office initiative with an aim to achieve long-term efficiencies in the delivery of public services in a more innovative and joined up manner.
An extensive programme of research guided the development of the project and informs its implementation across NEL social services.
Research began with a literature review and an assessment into the data on the use of ECC by 16- to 19-year-olds. This data outlined that on average 20 young people every day would attend the ECC with complaints such as substance misuse and related injuries, self harm, unsafe sexual practice, and undiagnosed or poorly managed chronic illness. Alcohol and drug issues contributed to 63 per cent of these incidents, but there was a tendency for the same young people to be admitted repeatedly with the same health issues, because they were unable to break the cycle of ‘risky' behaviours.
However, what was more significant was that 75 to 82 per cent of young repeat presenters were identified as being vulnerable in other areas of their lives such as homelessness, lack or absence of family support networks, mental health problems and involvement in criminal activity. 35 per cent of homeless young people were ‘frequent flyers', attending the ECC at least twice every month.
A social marketing company, ICE, was commissioned to consult directly with young people, key service providers and other stakeholders (i.e. social services, substance misuse services, education, emergency care providers, homeless services for young people, school health) in order to understand:
- Young people's lifestyles, their needs and priorities, and how they think and feel
- Why they engage in risky behaviours
- What types of behaviour result in ECC admissions
- Barriers to making healthy lifestyle choices
- How best to help young people feel more positive and facilitate behaviour change
- Barriers to accessing existing health services in order to improve service delivery
A mix of focus groups and individual in-depth interviews were conducted with young people who had been recruited through existing young people's networks. These were held in a range of ‘youth friendly' environments to encourage openness, such as youth centres, colleges, the YMCA, a Care Trust Plus run community café, and the ECC itself. Staff from the ECC were interviewed through their existing team building days. Members of the Care Trust Plus (CTP) team visited various departments within the Diana Princess of Wales Hospital and spent an overnight shift in the A&E department, speaking with patients and staff and gauging their perceptions.
The insights gained from young people demonstrated that mistrust of their GP and over use of Emergency Care services went hand-in-hand. Example responses from young people included:
- "Don't like my GP - he talks down to me"
- "The receptionist is a cow"
- "My doctor is miles away"
- "I can't get seen without an appointment"
- "My mates can come with me to Accident & Emergency"
- "At Accident & Emergency I get seen quick"
- "I know where the hospital is"
- "I don't think I have a doctor"
Most of the young people interviewed had low aspirations and poor job prospects. This particularly applied to East Marsh Ward in Grimsby, which is in the top 1 per cent of deprivation in the UK and has very high teenage pregnancy rates. The qualitative research highlighted a direct correlation between 16- to 19-year-olds neglecting their health (either through risky behaviours, such as drug taking, or simply missing medical appointments) and a lack of concern for their long-term future and what they could potentially achieve in their lives.
The research identified a number of barriers for the target audience to reduce their use of A&E:
- Poor support network - many young people come from dysfunctional, fractured families, where worklessness and homelessness are major issues
- Low aspirations and poor job prospects
- Practical barriers, such as not having a family doctor and lack of affordable transportation
- Poor understanding of universal services, e.g. many young people expected to see a GP when they went to the surgery, and needed educating about the role of Practice Teams and Practice Nurses, as they may not need to see the GP at all.3
It also became clear that the main source of competition for reducing young people's use of A&E were issues at home. Most of the young people come from home environments where health needs are a low priority. Family history has demonstrated that in 77 per cent of cases there has been little family involvement in preventative health care, poor uptake of antenatal, screening and chronic disease management programmes, and erratic relationships with universal providers. For example, one youth was repeatedly admitted with asthma attacks, mainly because he had a limited support network to help him manage his condition.
A large stakeholder day was held and facilitated by ICE to explain the research and the findings to a diverse group of stakeholders to ensure that the project could gain as much buy-in as possible. Following this a smaller steering group was established, which included:
- Representatives from Public Health
- Representatives from Young People’s Substance Misuse
- Lead nurse from the A&E department
- Lead nurse for out-of-hours care
- Youth Services Manager
- Commissioning Manager
Asgard from Norse mythology meaning ‘a place of safety reached by a rainbow bridge’
The primary aim of Asgard was to reduce repeated presentations at A&E by 16- to 19-year-olds in NEL. Based on the research, the project team and steering group identified that this aim would achieved by:
- Enhancing personal responsibility around health and wellbeing
- Increasing resilience by creating a proactive relationship with universal health and social care services
- Promoting economic independence
The project team set a series of key targets for the initial six month pilot period, including:
- Reduce the number of ‘frequent flyers' (those who attend the ECC at least twice a month with the same inappropriate health and/or social care issues) by 5 per cent
- Increasing direct contact with young people (KPI of 120)
- Increasing direct contact with families (KPI of 5)
- Reduce the ‘Did Not Attend’ rate for follow-up appointments following treatment at the ECC by 5 per cent
- Young people to be followed up after emergency contraceptive use (KPI of 10)
- Referrals to additional appropriate agencies (KPI of 100)
- Financial savings to NELCTP (£66,000)
- Places generated on new year training scheme (KPI of 6)
To obtain these targets the project team needed to develop interventions that tackled the root cause of the repeated inappropriate use of emergency care services as identified by the research. The team came up with the name Asgard (advice, support, guidance, advocacy, referral and direction), which is a phrase from Norse mythology meaning ‘a place of safety, reached by a rainbow bridge’. The Asgard project would try to provide a ‘rainbow bridge’ from exclusion to inclusion, poor health to optimum health, low aspiration to economic and social wellbeing.
Subsequently the following interventions were developed:
Community health intervention (Asgard) workers
Two Asgard workers would be recruited to follow up vulnerable patients aged 16 to 19 directly following their discharge from A&E. ECC staff would provide young people who attend A&E with literature informing them of a free follow-up service from Asgard specialist health intervention workers, which is confidential and optional. Asgard workers would liaise with ECC staff to identify vulnerable young people and contact them (usually by text) directly following their discharge from A&E (usually the next day).
The worker would meet the young person in their chosen venue and assess the young person's needs, whether it be substance misuse support, access to a GP, contraception, or just a chat over a cup of coffee. The Asgard worker would then support the young person to engage with and access the necessary service(s).
The Asgard workers would work closely with a range of organisations (defined in the scoping phase) to work towards buy-in for the service from the wider community. This would be vital to drive home messages about the wider support mechanisms that may help prevent visits to A&E.
As part of the methods mix, the team also worked with ICE to produce a range of collateral for the target group, including banner stands and A&E leaflets, as well as promotional giveaways such as lip balms, torches and wrist straps. These were tested with young people who decided which materials should to be used. The objective was to ensure messages around access to support services were delivered in their simplest and clearest form, to ensure they were seen and remembered.
Further support would include:
- A lodging scheme, where a young person ‘lodges' with a ‘Host' adult who has been trained and CRB checked. This supported accommodation would provide stability, emotional support and safety whilst encouraging independence. Living in an environment with routines and boundaries helps young people make the transition to education, training and/or employment.
- Providing bikes and/or bus passes so young people can travel to work or medical appointments. Lift shares would also be arranged during inclement weather.
- Driving lessons arranged and part-funded, since the ability to drive is essential for most health and social care roles. All the young people come from second or third generation workless families, where members are unlikely to have ever driven or owned a car.
- Outreach workers to engage with identified families and encourage members to use universal screening programmes for breast, cervical, prostate, and bowel cancer. They would also conduct opportunistic blood pressure and urine tests to detect other conditions like hypertension and diabetes. While linked to the Asgard programme, this would be a separate service.
Asgard Young People's Employment Project
The research identified that low aspiration was a key problem for the ‘frequent flyers’ in A&E. So the team sought to join up the project with a parallel scheme aimed at ‘NEETs’ (Not in Education, Employment or Training) that had started six months previously. This scheme would come under the Asgard umbrella and would work in partnership with the Asgard community health intervention strand of the project. This Young People’s Employment Project involved the following:
- The CTP provides one year paid work for young people recruited from the Havelock Academy and local East Marsh area who are at significant risk of becoming ‘NEETS'. Posts are available within a number of the CTP's directorates, including finance and commissioning, IT, mental health and public health.
- All trainees are provided with training to industry standard in a range of basic skills, including answering phones, how to dress for work, the interview process and form-filling.
- In keeping with the underlying objective of inspiring young people to make positive life and health choices, good work is incentivised by directly linking the quality of work with agreed pay increases over specific timescales.
- Trainees are supported with accommodation, transportation and start-up costs (like work clothes), as well as a home liaison to ensure each individual has a robust support and advice mechanism outside the workplace. This holistic package ensures that other issues are addressed, like budgetary management and family tensions.
- Underlying health and wellbeing problems are also proactively addressed through counselling and self-esteem building activities. These are provided by a number of agencies, including the CTP, occupational health and a specialist provider for anger management.
- Trainees are supported at the end of their year-long contracts into permanent CTP or external posts.
The Asgard project was launched in February 2009. The parallel Young People’s Employment Scheme was brought under the Asgard banner, but had begun in August 2008.
The speed of service uptake was a surprise to the Asgard team, who expected it to take some time for referrals to be made. By the end of the first day however, approximately 30 referrals into the Asgard programme had been made by the ECC.
Another surprise to the team was the nature of some of the referrals. Many referrals were made relating to accommodation, self-harm, domestic violence, anger management and chronic illnesses. One example was a 17-year-old who was living in the YMCA and attending the ECC every night due to poor management of his asthma. The Asgard worker identified that there was no GP involvement and helped him re-establish contact with his GP, educating both the young person and the practice staff about working together. This young person now sees his practice nurse regularly and no longer attends the ECC.
As the programme developed the Asgard team formed relationships with additional services appropriate for the nature of referrals they were receiving, such as those that can help with accommodation issues, the self-harm team and the health visitor specialising in domestic violence.
“It’s easy to be wise with hindsight. If you’d told me when I started it that our major issue would be accommodation, I wouldn’t have thought that. Now we are involved with accommodation issues with young people, more than we ever were. There’s other agencies that we work with very closely now, where work wasn’t envisioned in the beginning, for instance the self-harm team and the health visitor for domestic violence. We use her a lot for teenage girls in abusive relationships and changing that behaviour. The model of working is working very well.” (Annie Darby, Asgard Programme Lead)
The Asgard team worked to ensure they addressed the root of the problems of those being referred to them. Certain issues can be quickly fixed - for example, one young man had cut his finger and required follow-up Hepatitis B injections, but his family were unwilling to transport him to suitable appointments. The Asgard team was able to transport him to a local medical centre and ensure he received the care he needed. Others require strengthening relationships between the young person and the appropriate service. The involvement of the Asgard team tends to be short-term and ends once the young person is confident in using the right service. However, young people can access the Asgard team at any time after their initial engagement. Often young people will contact their Asgard worker requesting support with a new problem or additional intervention.
To help smooth out the referral process, the Asgard team employed a full-time administrator, who acts as a bridge between the Asgard project and the ECC. Referrals are sorted and work allocated appropriately, so that work is not duplicated by the Looked After Children’s team.
Problems arose with the Young People’s Employment Scheme, with about half of the young people dropping out during the first year. This eroded some goodwill from the CTP staff who work with the young people. However, improvements have been made in 2010. More training and support are given to the CTP staff working with the young people. This has improved the confidence of the staff and their relationships with the young people. The full-time administrator can also resolve problems as they arise and provide additional support when necessary.
The recent reductions in public sector spending caused further problems for the Young People’s Employment Scheme. While in its first year the young people were paid by the CTP, this had to be discontinued in light of reduced funding. Instead, the employment scheme was then linked to the Education Maintenance Allowance (EMA). However, due to government announcements that the EMA will be abandoned in January 2011, this will mean the employment scheme will need to be adapted further, but plans remain for it to continue running.
The KPIs and measurements for the project were decided at the development stage of the project. Quarterly evaluations and yearly reports have been used from the start of the project to track and monitor progress.
External evaluations are also being conducted. Hull University is currently evaluating the Young People’s Employment Scheme, while a PhD student is evaluating the ECC strand.
Asgard met or exceeded most of the targets for the initial six-month pilot, including:
- 11 per cent reduction in the number of ‘frequent flyers' in A&E - against a 5 per cent target
- 13 per cent increase in the number of young people engaging with services referred to them by Asgard workers 3
Following the success of the pilot, the project is being continued. Results to date include:
- Asgard has worked with 432 of the 652 vulnerable young people aged 16 to 19 presenting at A&E
- Reduction of 547 contacts to ECC by the target audience in 2009/10, compared with 2008/09. This is believed to have saved the CTP approximately £66,000.
- Nine ‘hidden homeless' young people identified by Asgard workers and helped to engage with housing support
- 15 young women under the age of 17 who have had unsafe sex have been helped by Asgard workers to access contraceptive services
- 32 young people on work placements through the Asgard employment scheme in its first two years
- Four young people have secured posts with the CTP, seven have gained employment elsewhere and two have returned to full-time study
The difference Asgard is making is also being measured using the Rickter Model, undertaken at three points during the project (beginning, midway and discharge) to gauge young people's perceptions of the service. These scores compare their confidence in using universal services at discharge, compared with their initial perceptions at the point of referral. Results from this directly feed into the continued development and improvements to the service.
The service is now ‘going mobile,' allowing Asgard to deal with referrals from other agencies (e.g. GP clinics, Direct Access Centre, Outpatient Clinic) to proactively support vulnerable young people before they end up at A&E.
Reports on each of the two strands of the project are developed yearly and are circulated amongst key stakeholders.
Another worker has been employed to work on the Young People’s Employment Scheme, specifically working with parents of the young people on the project to ensure that the service is providing a joined up approach. This is because it has been identified that many of the young people involved in the project come from families with high degrees of worklessness. This post is funded from the Working Neighbourhood Fund, which will finish in June 2011.
Further work is being developed with GP surgeries to ensure stronger partnerships are developed. A pilot is underway with an Asgard worker located at certain times within a GP surgery.
When conducting work like this, be sure to target and engage parents as well. It was quickly established that the families needed to be involved in a proactive rather than reactive way. This would enable Asgard to move families forward together rather than as individuals, thereby enhancing their resilience and aspiration. This learning led to the application for additional funding for the outreach worker to support families.
While Asgard set clear targets and KPIs, there is a need to improve processes. For this reason external impartial evaluation and analysis is recommended, as well as gathering regular feedback from service users, their families and agencies.
This project relies on the coordination and communication of support services. This needs to be constantly assessed and improved. The Asgard team introduced a quarterly Asgard networking meeting, to which all partner agencies are invited. This is integral to reducing duplication and promoting coordination and effective communication.
Be inventive about the type of workers you use. Think carefully about what you want the person to do and what skills they need. This might not require someone particularly senior who requires a high salary. Instead the qualities that are needed are empathy, good communication, an understanding of local services, assertiveness, emotional maturity, ability to instigate and maintain appropriate professional boundaries, and a good basic knowledge of the health needs of young people.
“I went for what I felt was a very lean, mean, machine. My view is that you don’t need high level staff – your bands 6’s and 7’s. You need workers that can engage on the ground. At the end of the day, they’re not going to be doing any health interventions, it’s about getting them to the right place. What’s the point of having a nurse taking them to see another nurse? I need a bridge builder. Someone who can engage with the rock, assess needs quickly, have an outstanding knowledge of local services and know the cultures, and be tenacious” (Annie Darby, Asgard Programme Lead)