This project was funded between April 2019 and March 2020.

  • Project led by West Kent Clinical Commissioning Group, in partnership with Kent Community Health NHS Foundation Trust, and Maidstone and Tunbridge Wells NHS Trust.
  • Aiming to address the unmet needs of children and young people in West Kent who use urgent care services most frequently.
  • Will introduce a holistic, de-medicalised, non-judgemental approach to caring for these children and young people, which will also improve joint working between organisations.

Frequent use of urgent care by some patients puts a significant burden on the NHS, and suggests that the care needs of these patients are not being met. 

In West Kent in 2017/18, 16 children and young people attended A&E 10 or more times, totalling 204 attendances; and 295 attended five or more times. 

This project will identify these frequently attending children and young people, and improve the care provided by introducing an innovative care pathway.

Once these children or young people are identified by the service and consent is given, a Paediatric Frequent Service Use Manager (PFSUM) will make direct contact with the parent/guardian or patient (depending on the situation), and arrange to visit them, either at home or another location where the patient feels most comfortable. This will help to uncover and address broader issues than is possible in the A&E environment.

The PFSUM will be the point of contact and will coordinate care around the patient. They may attend appointments as an advocate for the patient. This will help bring together multiple organisations and promote collaborative working.

The PFSUM will also provide social prescribing interventions, where appropriate, such as peer support groups for parents, and theatre workshops for children and young people. The service will encompass the entire family, rather than splitting adults and children into separate services; providing a balanced, whole-picture perspective.

The service will be modelled on a successful adult frequent user service. The first cohort will involve 20 to 25 patients, with two cohorts being seen within the year.

Contact information

For more information about this project, please contact Laura Bottle, Commissioning Manager, West Kent Clinical Commissioning Group.

About this programme


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