Realising the Three Shifts

Why Preventing Crisis Must Be a Core Measure of Success

A small but highly vulnerable segment of the population experiences recurrent crises, manifesting as frequent attendance at Accident & Emergency (A&E) departments. This pattern, driven significantly by unmet social, emotional, and practical needs rather than solely clinical issues, places immense strain on NHS resources and reflects deeper health inequalities.High Intensity Use (HIU) services offer a proven, community-based model for addressing these underlying needs, providing holistic, person-centred support that demonstrably reduces A&E attendance and improves wellbeing. The UK government's ambitious "three shifts" health policy – moving care to the community, embracing digital transformation, and focusing on prevention – finds a powerful practical application in scaling such interventions. Successfully implementing these shifts, particularly through strengthening community-based preventative care like HIU services, offers a pathway to intervene earlier and prevent individuals from reaching crisis point. Therefore, a reduction in crisis incidence, exemplified by lower rates of frequent A&E use, should be considered a critical measure of the three shifts' success, offering profound benefits for patient outcomes, health equity, and the sustainability of the NHS.

1. The Crisis Behind the Crisis - Understanding Frequent A&E Use

1.1 Defining the Problem: High Intensity Use (HIU) of A&E

The challenge of frequent attendance at Accident & Emergency (A&E) departments by a relatively small group of individuals represents a significant pressure point within the NHS. Data indicates that while less than 1% of the English population attends A&E frequently – defined as more than five times a year, and in some cases, multiple times per month – this group accounts for a vastly disproportionate share of urgent and emergency care resources. Specifically, they represent 16% of all A&E attendances, 29% of all ambulance journeys, and 26% of all hospital admissions. This pattern of High Intensity Use (HIU) signifies not only recurrent crises for the individuals involved but also a substantial operational burden on acute services.

The financial implications of this concentrated demand are considerable. Research estimates that high intensity use of A&E costs the NHS approximately £2.5 billion annually. This figure underscores the significant economic rationale, alongside the clinical and ethical imperatives, for developing effective strategies to support this population group and address the root causes of their frequent attendance. The sheer scale of resource consumption by this small cohort points towards potential systemic inefficiencies, where the current configuration of services may struggle to adequately meet complex needs that span beyond immediate medical requirements.

1.2 Unpacking the Drivers: Beyond Clinical Need

While individuals frequently attending A&E often present with genuine clinical needs requiring acute care, the underlying drivers for this pattern are frequently rooted in complex, non-clinical factors. Research and analysis consistently show that unmet social, emotional, and practical needs significantly contribute to worsening mental and physical health, leading individuals to seek help repeatedly in crisis settings. Factors such as housing insecurity, loneliness, social isolation, and coping with sudden, destabilising life events like job loss or bereavement can profoundly impact overall health and wellbeing. For many in this situation, A&E becomes the perceived 'only place to turn' when other support systems are absent, inaccessible, or inadequate.

Crucially, high intensity use of A&E must be understood fundamentally as an issue of health inequalities. Evidence highlights a strong correlation between frequent A&E attendance and markers of deprivation and vulnerability. Collaborative research involving the British Red Cross (BRC) and Dorset Integrated Care System revealed that individuals frequently attending A&E in Dorset were 72% more likely to reside in an area of deprivation compared to infrequent attenders. Furthermore, this group was more likely to experience mental ill-health and live with multiple long-term conditions. This data strongly suggests that HIU is not merely an isolated healthcare utilisation pattern but a symptom of broader societal issues and systemic disadvantages. The concentration of frequent A&E use among deprived populations indicates that the factors driving individuals to crisis point are deeply intertwined with the social determinants of health. This observation implies that solely focusing on interventions within the A&E department itself is unlikely to resolve the issue; rather, it points to a failure or fragmentation across a wider network of health, social care, and potentially other support services (like housing or employment) to provide adequate preventative or early intervention support before a crisis escalates.

1.3 The Inadequacy of Acute Settings

A&E departments are designed and staffed primarily to deal with acute medical emergencies and injuries. While essential for providing immediate, life-saving care, they are rarely, if ever, the appropriate environment to address the complex constellation of non-clinical needs that often underpin frequent attendance. The time constraints, focus on clinical stabilisation, and lack of resources or expertise to tackle issues like homelessness or profound loneliness mean that A&E can offer only temporary respite, failing to address the root causes that will likely lead to future attendances. This mismatch between the service offered by A&E and the underlying needs of many frequent attenders highlights a critical gap in the current system's ability to provide holistic, preventative care for this vulnerable population.

2. The Policy Landscape: Defining and Interrogating the "Three Shifts"

2.1 Outlining the Ambition: The 10-Year Health Plan

The UK government has signalled a commitment to significant health system reform through the development of a 10-Year Health Plan for England. This plan aims to create a modern health service capable of meeting the evolving needs of the population, particularly in the context of people living longer, often with multiple complex health conditions. Central to this vision is the implementation of "three shifts" – fundamental changes in the way healthcare is conceptualised and delivered. These shifts represent a strategic direction agreed upon by government, health service leaders, and policy experts as necessary for the future sustainability and effectiveness of the NHS.

2.2 Defining the Three Shifts

The government's proposed transformation is structured around three core strategic shifts, intended to reorient the health and care system :

The first shift, From Hospital to Community, aims to move care delivery away from acute hospitals towards primary care, community settings (like clinics, pharmacies, and health centres), and people's own homes. The goal is to address long-term conditions more effectively and reduce the pressure and cost associated with hospital care. Examples include expanding services in GP clinics and pharmacies, developing 'Hospital at Home' models, investing in neighbourhood facilities, and integrating community health teams.

The second shift, From Analogue to Digital, focuses on making better use of technology to improve efficiency, accessibility, patient experience, and support for staff. It also aims to enable better data sharing and analysis for population health. Activities under this shift could involve implementing shared electronic patient records, increasing the use of virtual consultations and remote monitoring, investing in digital diagnostics like AI-powered tools, improving digital access for patients, and ensuring staff have the necessary technological tools.

The third shift, From Sickness Treatment to Prevention, seeks to focus effort and resources on preventing illness, spotting it earlier, tackling root causes, and promoting overall health and wellbeing. The objective is to improve population health, reduce preventable illnesses, and ease long-term demand on services. This could involve expanding screening programmes, investing in public health initiatives like smoking cessation and weight management, promoting healthier lifestyles, intervening early for chronic conditions, addressing wider determinants of health, and potentially ringfencing spending specifically for prevention.

These three shifts, while distinct, are inherently interconnected. Progress in digital transformation (Shift 2) is fundamental to enabling the effective delivery of care in community settings (Shift 1) – for instance, through shared records and remote consultations. Similarly, digital tools are essential for the data analysis required for sophisticated population health management and targeted prevention strategies (Shift 3). Success hinges not just on advancing each shift individually, but on ensuring they work synergistically.

2.3 Strategic Intent and Challenges

The ambitions encapsulated within the three shifts are not entirely novel; variations of these goals, particularly moving care closer to home and emphasising prevention, have been part of health policy discourse for decades. However, implementation has proven "stubbornly difficult," with progress often described as "glacial" and sometimes even moving in the opposite direction, particularly regarding the shift of resources away from hospitals.

Several challenges hinder the realisation of these shifts. A significant tension exists between the long-term strategic goals and the immediate operational and political pressures facing the NHS, most notably the intense focus on reducing acute waiting lists. This focus can inadvertently draw resources and attention away from community and preventative services.Furthermore, achieving the shifts will necessitate "difficult decisions," particularly concerning the allocation of funding.Shifting resources towards community and prevention may require trade-offs with acute sector budgets, a politically and operationally complex manoeuvre. Public understanding and support for these changes are also critical factors.

Effective implementation demands strong leadership, clear mechanisms for enacting change, and robust accountability structures. While there is rhetoric about liberating local leaders , there is also a recognised need for national frameworks, standards, and support to guide Integrated Care Systems (ICSs) and ensure equitable progress across the country.Navigating this balance between local empowerment and national direction will be crucial. The shift towards prevention, arguably the most complex and potentially impactful, faces particular hurdles. Its broad scope, the difficulty in demonstrating short-term returns compared to acute activity, and the need for cross-sectoral action make it vulnerable to being deprioritised amidst immediate pressures. Overcoming the "doom loop" – where cuts to prevention lead to escalating crisis demand later – requires sustained political commitment and potentially new funding models.

3. Bridging the Gap: Community-Based Interventions Like HIU Services

3.1 A Proven Model: High Intensity Use (HIU) Services

Amidst the challenges of frequent A&E use, specific service models have emerged that demonstrate significant success in supporting this population. High Intensity Use (HIU) services, often delivered by organisations such as the British Red Cross (BRC) and frequently based on the NHS Right Care framework, offer a targeted approach. These services typically work by identifying an agreed number of individuals who frequently attend A&E within a specific locality. Practitioners then proactively reach out to these individuals, offering them an alternative form of support.

The defining characteristics of HIU services lie in their holistic, proactive, and non-time-limited nature. They employ a person-centred and strengths-based methodology, working collaboratively with individuals to identify the unmet social, emotional, or practical needs that are contributing to their poor health and frequent crises. Crucially, the support offered is often explicitly de-medicalised and de-criminalised, focusing on building trust, providing practical assistance, and connecting individuals with appropriate community resources rather than solely clinical interventions. This approach has gained national recognition, being recommended within NHS England's operational planning guidance for both 2023/24 and 2024/25, as well as in the Urgent and Emergency Care Recovery Plan (2023).

3.2 Evidence of Impact

The effectiveness of HIU services is supported by compelling evidence. Studies conducted by NHS England have indicated that these interventions can lead to dramatic reductions in frequent A&E attendance, with decreases of up to 84% observed after just three months of engagement. While acknowledging that attendance patterns can be complex and require careful analysis for identifying those most likely to benefit long-term, these figures highlight the potential for significant impact on acute service demand.

Beyond the quantitative data, evaluations consistently point to positive patient experiences. Individuals receiving support through HIU services report feeling listened to, understood, and supported in a non-judgemental manner. They often gain confidence and feel more independent in managing their health and accessing appropriate care within the community. The relational aspect of the support – the trust and rapport built with support workers – is frequently cited by patients as being of primary value. This qualitative evidence underscores that the way support is delivered is as important as what support is provided. The success stems from addressing the person holistically, validating their experiences, and empowering them to find solutions outside of the acute hospital setting. This validation of addressing non-clinical needs directly translates into reduced pressure on the acute sector, offering substantial potential for cost savings when considering the estimated £2.5 billion annual cost associated with HIU.

3.3 Beyond HIU: Other Community-Based Examples

The principles underlying HIU services are reflected in a growing number of innovative community-based initiatives across England, all seeking to provide care closer to home and prevent unnecessary hospital admissions, aligning with the direction of the three shifts. Examples include:

• Virtual support services for care homes, aiming to triage residents' needs remotely and avoid hospital transfers, focusing on prevention and technology enablement.

• Trusts strengthening community teams and implementing 'home first' approaches to discharge patients safely and reduce reliance on emergency departments.

• 'Front door' services within emergency pathways designed to identify patients suitable for home-based care, avoiding prolonged waits and potential admission.

• Integrated urgent community response teams delivering rapid care in people's homes.

• Placing clinicians within local authority housing teams to support appropriate housing solutions and prevent health deterioration leading to admission.

• Developing 'Hospital at Home' services using data and digital technology to manage patients safely outside of acute settings.

These examples, alongside HIU services, illustrate a broader movement towards community-centred, preventative models of care, demonstrating practical ways in which the ambitions of the three shifts are already being pursued locally.

4. Connecting the Dots: How HIU Embodies and Informs the "Three Shifts"

4.1 HIU as Community Care (Shift 1: Hospital to Community)

High Intensity Use (HIU) services serve as a prime example of the first shift – moving care from hospitals into the community. By their very design, these services operate outside the acute hospital setting, delivering support within individuals' local areas. They embody the concept of a 'neighbourhood health service' – one that is more holistic, flexible, and responsive to individual needs than traditional hospital-based care can often be. This model directly aligns with the strategic intent to strengthen primary and community services, providing care closer to home and reducing reliance on overburdened hospitals.

4.2 HIU as Prevention (Shift 3: Sickness to Prevention)

Fundamentally, the work of HIU services is about prevention – specifically, intervening proactively to prevent individuals from reaching a crisis point that necessitates an A&E visit. This aligns squarely with the third shift's emphasis on moving from a reactive sickness service to one focused on prevention and proactive care. HIU represents a form of tertiary prevention: identifying individuals with known risks (a history of frequent A&E use driven by complex needs) and providing targeted support to prevent further deterioration or crisis episodes. By addressing the underlying non-clinical root causes – such as loneliness, housing instability, or lack of practical support – HIU services tackle the factors that drive repeated crises, rather than simply managing the acute symptoms when they occur.

4.3 HIU Enabled by Digital (Shift 2: Analogue to Digital)

While the core strength of current HIU models often lies in relational, face-to-face support, the second shift – from analogue to digital – offers significant potential to enhance and scale these interventions. Effective identification of individuals who could benefit most from HIU services relies on robust data analysis. Linking datasets across different organisations – including NHS trusts, primary care, social care services, and potentially third-sector providers like the BRC – is crucial for implementing population health management approaches. Such integration, enabled by digital infrastructure and interoperable systems, allows for more accurate identification of individuals at high risk of frequent A&E attendance before they reach crisis point. Furthermore, shared digital care records can facilitate better coordination among the various professionals and agencies involved in an individual's support network, ensuring interventions are timely, informed, and avoid duplication. Digital tools are therefore key enablers for optimising the reach, targeting, and efficiency of HIU-like services.

The practical success of HIU services thus provides a compelling case study not just for individual shifts, but for their synergistic potential. They demonstrate how community-based (Shift 1), preventative (Shift 3) interventions can achieve significant impact, and how digital transformation (Shift 2) can act as a powerful catalyst to improve and scale these models. Moreover, the fact that HIU effectively addresses a problem deeply rooted in health inequalities highlights a critical point: realising the three shifts successfully necessitates an explicit focus on equity. Generic implementation may not reach the most vulnerable. Targeted approaches, informed by data (Shift 2) and designed to address specific needs within disadvantaged communities (Shift 1 and 3), are essential if the shifts are to genuinely reduce, rather than inadvertently widen, health disparities.

5. Measuring Success: Crisis Prevention as a Litmus Test for the Three Shifts

5.1 Proposing a Key Metric

Given the profound impact of crisis episodes on individuals and the healthcare system, and the clear alignment between preventing crisis and the goals of the three shifts, this report proposes that a reduction in the number of people reaching crisis point should be adopted as a key measure of success for the government's 10-Year Health Plan. Frequent A&E attendance, as addressed by HIU services, serves as a tangible and measurable indicator of such crises. Focusing on this outcome moves beyond tracking processes or intermediate outputs towards assessing the real-world impact of policy changes on vulnerable populations.

5.2 Rationale - Why This Metric Matters

Adopting crisis prevention as a central metric for evaluating the three shifts is justified by several compelling reasons.Firstly, there is a moral imperative to support the most vulnerable and prevent avoidable suffering associated with crisis points. Community-based, preventative support (Shifts 1 & 3) addresses root causes, while digital tools (Shift 2) can help identify those in need earlier. Secondly, it leads to improved patient outcomes and experience. Proactive, holistic support tailored to individual needs offers better, more appropriate care than reactive crisis management in A&E, making patients feel heard and empowered. Shift 1 delivers this care closer to home, Shift 3 focuses on wellbeing, and Shift 2 enables coordinated planning. Thirdly, it represents an opportunity for tackling health inequalities, as frequent A&E use is strongly linked to deprivation. Targeting resources towards accessible community and preventative services (Shifts 1 & 3) and using population health analytics (Shift 2) can directly address these disparities. Finally, it helps reduce NHS pressure and costs. Preventing crises dramatically cuts demand on expensive acute services, contributing to financial sustainability. Shifts 1 and 3 manage needs proactively in less costly settings, while Shift 2 improves efficiency.

Focusing on crisis prevention inherently encourages the integration of the three shifts. Success in reducing A&E attendance requires effective community services (Shift 1), robust preventative strategies (Shift 3), and the data infrastructure to identify, coordinate, and monitor (Shift 2). It necessitates looking beyond NHS boundaries to address the social determinants handled by local government and the voluntary sector, reflecting the cross-cutting nature of the drivers of crisis. Furthermore, adopting crisis prevention as a key performance indicator would represent a significant evolution in NHS performance management. It challenges the traditional focus on easily quantifiable acute activity targets, such as waiting times, demanding instead the development and prioritisation of metrics that capture the impact of preventative and community-based care – areas where robust measurement is currently less developed. This requires valuing long-term population health outcomes alongside, and potentially even above, short-term throughput, necessitating a cultural as well as a measurement shift.

6. Recommendations: Realising the Potential

To translate the potential of the three shifts into tangible reductions in crisis incidence and improvements in care for vulnerable populations, several actions are necessary:

• 6.1 Embed and Scale Effective Models: National bodies should actively support, fund, and facilitate the scaling of evidence-based, non-clinical, community-based interventions proven to prevent crisis, such as HIU services.Learning from the successes and challenges of existing local initiatives is crucial. This requires clear commissioning guidance and sustainable funding streams.

• 6.2 Foster Genuine Integration: Integrated Care Systems (ICSs) must be empowered and resourced to move beyond rhetoric to deliver genuinely integrated care pathways. This involves commissioning services that effectively bridge health, social care, housing, employment support, and the voluntary, community, and social enterprise (VCSE) sector, with an explicit focus on improving population health and tackling inequalities.

• 6.3 Invest in Enablers: Sustained investment in the core enablers of transformation is critical:

  • Workforce: Strategic investment is needed in the community-based workforce, including clinical, social care, and non-traditional roles (e.g., link workers, peer supporters, housing support officers embedded in health teams). Training should emphasise relational, person-centred, trauma-informed, and culturally competent approaches.

  • Data & Digital: Acceleration of investment in interoperable digital infrastructure, including shared care records accessible across organisational boundaries, is paramount. This underpins effective data linkage for population health management, identification of at-risk individuals, care coordination, and outcome measurement. Efforts must actively address potential digital exclusion to avoid exacerbating inequalities.

  • Funding: Payment and incentive structures within the NHS need reform to reward preventative activities, holistic care, and population health outcomes, not just acute activity. This may involve shifting resources from acute budgets to community and primary care, exploring ringfenced budgets for prevention, and implementing multi-year funding settlements to provide stability for long-term planning.

• 6.4 Refine Performance Measurement: A revised national performance framework is needed that balances acute targets with robust outcome measures for prevention, community care effectiveness, patient experience, health inequalities reduction, and crisis incidence (including HIU rates). Leaders across the system should be held accountable for delivering progress against the goals of the three shifts.

• 6.5 Maintain Dialogue: Continuous engagement with patients, service users, carers, diverse communities, and frontline staff is essential. This ensures that service redesign meets genuine needs, builds trust, and helps embed the necessary cultural changes towards partnership working and prevention.

Implementing these recommendations requires more than just policy adjustments; it demands a fundamental cultural shift across the health and care landscape. Moving away from siloed operations and an ingrained focus on acute treatment towards genuine partnership, proactive prevention, and holistic population health management is essential. This transformation hinges on sustained political will to navigate the inevitable tensions between long-term goals and short-term pressures, ensuring that the ambition to shift care towards the community and prevention is protected and prioritised, avoiding the pitfalls that have hindered previous attempts.

7. A Call for Preventative, Community-Focused Action

The pattern of frequent A&E attendance among a vulnerable population group starkly illustrates a gap in the current health and care system's ability to meet complex needs proactively. It highlights the human cost of unmet social, emotional, and practical needs manifesting as recurrent health crises. Interventions like High Intensity Use (HIU) services provide powerful evidence that community-based, person-centred, and preventative approaches can effectively break this cycle, improving lives while reducing pressure on acute services.

These successful models directly embody the principles of the government's proposed "three shifts" – moving care to the community, enhancing prevention, and leveraging digital enablers. They demonstrate not just the validity of these policy directions but also their potential synergy when applied to complex real-world problems. Therefore, measuring the success of the three shifts through the tangible outcome of preventing more people from reaching crisis point offers a meaningful, patient-centred, equitable, and economically sound benchmark.

Realising this potential requires more than policy statements; it demands sustained commitment to embedding and scaling effective community interventions, fostering genuine integration across sectors, investing strategically in the workforce and digital infrastructure, reforming funding and performance frameworks to prioritise prevention, and maintaining an ongoing dialogue with communities. By embracing these actions, the health and care system can move closer to achieving the vision of the three shifts, ultimately building a system that is more resilient, more equitable, and fundamentally more effective at preventing crisis and promoting wellbeing for all.

Regards,

Kevin McDonnell
CEO Coach & Advisor
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Learn more at kevinmcdonnell.co

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