STRatagies to manage Emergency ambulance Telephone Callers with sustained High needs - an Evaluation using linked Data (STRETCHED)

Contact details

Rabeea’h Aslam: r.w.aslam@swansea.ac.uk

Principal / Lead investigator

Helen Snooks

Co-investigators / research team

Helen Snooks, Ann John, Alan Watkins, Ceri Phillips, Nigel Rees, Sarah Black, Alison Porter, David Fletcher, Robin Petterson, Bethan Edwards, Penny Gripper, Jason Scott, Bridie Evans, Anna Tee, Ashrafunessa Khanom, Adrian Edwards

Type of study



Ambulance services are assessing how they respond to the small number of people who frequently phone 999 (more than five times a month or 12 times in three months), but often without a medical problem requiring immediate treatment. Some services have introduced local "case management" initiatives, with referrals to a team from different agencies (social services; primary care (GP); community mental health services; Emergency Departments; ambulance service) that devises individualised ‘treatment plans’, aiming to provide or redirect callers to the appropriate treatment and to reduce their contact with emergency services.

We will study: the characteristics of people who call frequently; what is currently being done for them; what helps them to stay well and not need to call 999 or other emergency services; and assess how well case management helps them. Using routinely collected NHS data for ambulance services, we will: see if frequent callers have fewer emergency episodes when "case management" is available; gauge the safety of this approach; and determine associated costs and savings. We will work with four ambulance services that have introduced a new case management approach in some parts of its catchment area, but still operate the standard 999 service in other parts.

We expect to recruit 316 high users per service (n=1264), allowing us to detect a change in rate of further emergency events/death of 10% with 90% power and 95% confidence.

We will also interview: 32 patients treated through case management to explore how they feel about this service; and 36 health, social care and other professionals involved in case management initiatives to identify operational issues in providing such services.

How could this research potentially benefit patients?

People who frequently call 999 may be vulnerable and unable to access more appropriate services, such as primary care. They seek help through the 999 route because available services do not meet their complex needs. However, this route to help seeking is often unsuccessful and inefficient, for them individually and for the NHS. This has consequences also for other patients who do not get the speedy response required when in urgent need as resources are tied up with patients who do not need acute care. Multi-disciplinary case management approaches may reduce demand on emergency services and emergency hospital admissions because people are effectively treated. However, these initiatives are not based on any rigorous evidence of what works most effectively for this patient group. 

There is currently inadequate evidence to inform commissioning, policy or practice development. While these approaches are still innovative and diverse and multi-agency interest in this work is strong, this is a unique opportunity to undertake a natural experiment to learn how to successfully respond to patients who frequently call 999. Our study will provide evidence about case mix, clinical and cost effectiveness, safety, effects on patient experience, optimum configuration of intervention and challenges in cross sector working.

Public / patient involvement

We have attempted to enable active and meaningful Patient and Public Involvement (PPI) throughout to enhance research quality, rigour and ethical standards, in line with the Swansea Trials Unit Standard Operating Procedure (SOP) on service user involvement.



Total grant value

£ 637,313

Amount accruing to Wales

£ 424,069

Start date


End date


Further information (e.g. related web link)

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Outputs generated (Reports / Publications / Impact) 

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