Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data

Watkins, Alan; Aslam, Rabeea'h; Dearden, Alex; Driscoll, Timothy; Edwards, Adrian; Edwards, Bethan; Evans, Bridie; Farr, Angela; Foster, Theresa; Fothergill, Rachael; Gripper, Penny; Gunson, Imogen M; John, Ann; Khanom, Ashrafunnesa; Noakes, Tessa; Petterson, Robin; Porter, Alison; Rees, Nigel; Rosser, Andy; Scott, Jason; Sewell, Bernadette; Tee, Anna; Snooks, Helen; Khanom, Ashra

doi:10.3310/pwgf6008

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Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data

Alan Watkins

, Rabeea'h Aslam

, Alex Dearden

, Timothy Driscoll

, Adrian Edwards

, Bethan Edwards

, Bridie Evans

, Angela Farr

, Theresa Foster

, Rachael Fothergill

, Penny Gripper

, Imogen M Gunson

, Ann John

, Ashrafunnesa Khanom

, Tessa Noakes

, Robin Petterson

, Alison Porter

, Nigel Rees

, Andy Rosser

, Jason Scott

, Bernadette Sewell

, Anna Tee

, Helen Snooks

, Ashra Khanom

Health and Social Care Delivery Research, Volume: 13, Issue: 37, Pages: 1 - 76

Swansea University Authors: Alan Watkins , Rabeea'h Aslam , Timothy Driscoll , Bridie Evans , Angela Farr , Ann John , Alison Porter , Nigel Rees , Helen Snooks , Ashra Khanom

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DOI (Published version): 10.3310/pwgf6008

Abstract

Emergency ambulance services aim to respond to patients calling with urgent healthcare needs, prioritising the sickest. A small minority make high use of the service, which raises clinical and operational concerns. Multidisciplinary ‘case management’ approaches combining emergency, primary and socia...

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Published in:	Health and Social Care Delivery Research
ISSN:	2755-0079
Published:	National Institute for Health and Care Research 2025
Online Access:	Check full text
URI:	https://cronfa.swan.ac.uk/Record/cronfa71381

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A small minority make high use of the service, which raises clinical and operational concerns. Multidisciplinary ‘case management’ approaches combining emergency, primary and social care have been introduced in some areas but evidence about effectiveness is lacking.AimTo evaluate effectiveness, safety and costs of case management for people frequently calling emergency ambulance services.DesignA mixed-methods ‘natural experiment’, evaluating anonymised linked routine outcomes for intervention (‘case management’) and control (‘usual care’) patient cohorts within participating ambulance services, and qualitative data.Cohorts met criteria for ‘Frequent Callers’ designation; we assessed effects of case management within 6 months on processes, outcomes, safety and costs. The primary outcome combined indicators on mortality, emergency hospital admission, emergency department attendance and emergency ambulance call.Focus groups and interviews elicited views of service providers on acceptability, successes and challenges of case management; interviews with service users examined their experiences.SettingFour United Kingdom ambulance services each with one intervention and one control area.ParticipantsNatural experiment: adults meeting criteria for ‘frequent caller’ classification by ambulance services during 2018.Service providers: service commissioners; emergency and non-acute health and social care providers.Service users: adults with experience of calling emergency ambulance services frequently.InterventionsUsual care comprised within-service management, typically involving: patient and general practitioner letters; call centre flags invoking care plans; escalation to other services, including police.Intervention care comprised usual care with optional ‘case management’ referral to cross-service multidisciplinary team to review and plan care for selected patients.ResultsWe found no differences in intervention (n = 550) and control (n = 633) patients in the primary outcome (adjusted odds ratio: 1.159; 95% confidence interval: 0.595 to 2.255) or its components. Nearly all patients recorded at least one outcome (95.6% intervention; 94.9% control). Mortality was high (10.5% intervention; 14.1% control). Less than 25% of calls resulted in conveyance (24.3% intervention; 22.3% control). The most common reasons for calling were ‘fall’ (6.5%), ‘sick person’ (5.2%) and acute coronary syndrome (4.7%).Case management models varied highly in provision, resourcing, leadership and implementation costs. We found no differences in costs per patient of healthcare resource utilisation (adjusted difference: £243.57; 95% confidence interval: −£1972.93 to £1485.79).Service providers (n = 31) recognised a range of drivers for frequent calling, with some categories of need more amenable to case management than others. Some service users (n = 15) reported deep-seated and complex needs for which appropriate support may not have been available when needed.ConclusionsPeople who called frequently had a high risk of death and emergency healthcare utilisation at 6 months and were a heterogeneous group. Case management may work for some, but we did not find effects on emergency healthcare utilisation or mortality across the population.LimitationsThis retrospective study provided limited options in selecting control areas, or in meeting recruitment targets. Data quality was variable. Arranging patient interviews proved challenging.Future researchThis should prospectively evaluate different forms of case management; improve data collection; and include patients fully in qualitative components.</abstract><type>Journal Article</type><journal>Health and Social Care Delivery Research</journal><volume>13</volume><journalNumber>37</journalNumber><paginationStart>1</paginationStart><paginationEnd>76</paginationEnd><publisher>National Institute for Health and Care Research</publisher><placeOfPublication/><isbnPrint/><isbnElectronic/><issnPrint/><issnElectronic>2755-0079</issnElectronic><keywords/><publishedDay>1</publishedDay><publishedMonth>10</publishedMonth><publishedYear>2025</publishedYear><publishedDate>2025-10-01</publishedDate><doi>10.3310/pwgf6008</doi><url/><notes/><college>COLLEGE NANME</college><department>Medical School</department><CollegeCode>COLLEGE CODE</CollegeCode><DepartmentCode>MEDS</DepartmentCode><institution>Swansea University</institution><apcterm>Other</apcterm><funders>This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 18/03/02).</funders><projectreference/><lastEdited>2026-03-03T10:39:13.1078510</lastEdited><Created>2026-02-03T12:43:43.3420164</Created><path><level id="1">Faculty of Medicine, Health and Life Sciences</level><level id="2">Swansea University Medical School - Health Data Science</level></path><authors><author><firstname>Alan</firstname><surname>Watkins</surname><orcid>0000-0003-3804-1943</orcid><order>1</order></author><author><firstname>Rabeea'h</firstname><surname>Aslam</surname><orcid>0000-0002-0916-9641</orcid><order>2</order></author><author><firstname>Alex</firstname><surname>Dearden</surname><orcid>0009-0002-8529-0192</orcid><order>3</order></author><author><firstname>Timothy</firstname><surname>Driscoll</surname><orcid>0000-0001-9879-2509</orcid><order>4</order></author><author><firstname>Adrian</firstname><surname>Edwards</surname><orcid>0000-0002-6228-4446</orcid><order>5</order></author><author><firstname>Bethan</firstname><surname>Edwards</surname><orcid>0000-0001-7413-056x</orcid><order>6</order></author><author><firstname>Bridie</firstname><surname>Evans</surname><orcid>0000-0003-0293-0888</orcid><order>7</order></author><author><firstname>Angela</firstname><surname>Farr</surname><orcid>0000-0002-2087-9310</orcid><order>8</order></author><author><firstname>Theresa</firstname><surname>Foster</surname><orcid>0000-0002-6395-0885</orcid><order>9</order></author><author><firstname>Rachael</firstname><surname>Fothergill</surname><orcid>0000-0003-1341-6200</orcid><order>10</order></author><author><firstname>Penny</firstname><surname>Gripper</surname><orcid>0009-0002-5957-7843</orcid><order>11</order></author><author><firstname>Imogen M</firstname><surname>Gunson</surname><orcid>0000-0001-8335-3335</orcid><order>12</order></author><author><firstname>Ann</firstname><surname>John</surname><orcid>0000-0002-5657-6995</orcid><order>13</order></author><author><firstname>Ashrafunnesa</firstname><surname>Khanom</surname><orcid>0000-0002-5735-6601</orcid><order>14</order></author><author><firstname>Tessa</firstname><surname>Noakes</surname><orcid>0000-0001-5245-3835</orcid><order>15</order></author><author><firstname>Robin</firstname><surname>Petterson</surname><orcid>0009-0002-3448-9214</orcid><order>16</order></author><author><firstname>Alison</firstname><surname>Porter</surname><orcid>0000-0002-3408-7007</orcid><order>17</order></author><author><firstname>Nigel</firstname><surname>Rees</surname><orcid>0000-0001-8799-5335</orcid><order>18</order></author><author><firstname>Andy</firstname><surname>Rosser</surname><orcid>0000-0002-5477-4269</orcid><order>19</order></author><author><firstname>Jason</firstname><surname>Scott</surname><orcid>0000-0002-6566-8007</orcid><order>20</order></author><author><firstname>Bernadette</firstname><surname>Sewell</surname><orcid>0000-0001-5471-922x</orcid><order>21</order></author><author><firstname>Anna</firstname><surname>Tee</surname><orcid>0009-0009-9564-2391</orcid><order>22</order></author><author><firstname>Helen</firstname><surname>Snooks</surname><orcid>0000-0003-0173-8843</orcid><order>23</order></author><author><firstname>Ashra</firstname><surname>Khanom</surname><order>24</order></author></authors><documents><document><filename>71381__36341__f3b9f32e30954c879b21fa7994118b74.pdf</filename><originalFilename>71381.VoR.pdf</originalFilename><uploaded>2026-03-03T10:36:50.9595315</uploaded><type>Output</type><contentLength>2405835</contentLength><contentType>application/pdf</contentType><version>Version of Record</version><cronfaStatus>true</cronfaStatus><documentNotes>© 2025 Watkins et al. 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spelling	2026-03-03T10:39:13.1078510 v2 71381 2026-02-03 Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data 81fc05c9333d9df41b041157437bcc2f 0000-0003-3804-1943 Alan Watkins Alan Watkins true false 59fdd275cfdafa2f251eb5264a31cc7e 0000-0002-0916-9641 Rabeea'h Aslam Rabeea'h Aslam true false 2be5c329c44d14550ceac4934fcb409e 0000-0001-9879-2509 Timothy Driscoll Timothy Driscoll true false 6098eddc58e31ac2f3e070cb839faa6a 0000-0003-0293-0888 Bridie Evans Bridie Evans true false ab00dbaa888f32b41b07ef223d0e2987 0000-0002-2087-9310 Angela Farr Angela Farr true false ed8a9c37bd7b7235b762d941ef18ee55 0000-0002-5657-6995 Ann John Ann John true false fcc861ec479a79f7fb9befb13192238b 0000-0002-3408-7007 Alison Porter Alison Porter true false 8c440a0df599a0b6eef3927ebd515b72 0000-0001-8799-5335 Nigel Rees Nigel Rees true true ab23c5e0111b88427a155a1f495861d9 0000-0003-0173-8843 Helen Snooks Helen Snooks true false 1f0f14742e3a36e8fd6d29f59374a009 Ashra Khanom Ashra Khanom true false 2026-02-03 MEDS Emergency ambulance services aim to respond to patients calling with urgent healthcare needs, prioritising the sickest. A small minority make high use of the service, which raises clinical and operational concerns. Multidisciplinary ‘case management’ approaches combining emergency, primary and social care have been introduced in some areas but evidence about effectiveness is lacking.AimTo evaluate effectiveness, safety and costs of case management for people frequently calling emergency ambulance services.DesignA mixed-methods ‘natural experiment’, evaluating anonymised linked routine outcomes for intervention (‘case management’) and control (‘usual care’) patient cohorts within participating ambulance services, and qualitative data.Cohorts met criteria for ‘Frequent Callers’ designation; we assessed effects of case management within 6 months on processes, outcomes, safety and costs. The primary outcome combined indicators on mortality, emergency hospital admission, emergency department attendance and emergency ambulance call.Focus groups and interviews elicited views of service providers on acceptability, successes and challenges of case management; interviews with service users examined their experiences.SettingFour United Kingdom ambulance services each with one intervention and one control area.ParticipantsNatural experiment: adults meeting criteria for ‘frequent caller’ classification by ambulance services during 2018.Service providers: service commissioners; emergency and non-acute health and social care providers.Service users: adults with experience of calling emergency ambulance services frequently.InterventionsUsual care comprised within-service management, typically involving: patient and general practitioner letters; call centre flags invoking care plans; escalation to other services, including police.Intervention care comprised usual care with optional ‘case management’ referral to cross-service multidisciplinary team to review and plan care for selected patients.ResultsWe found no differences in intervention (n = 550) and control (n = 633) patients in the primary outcome (adjusted odds ratio: 1.159; 95% confidence interval: 0.595 to 2.255) or its components. Nearly all patients recorded at least one outcome (95.6% intervention; 94.9% control). Mortality was high (10.5% intervention; 14.1% control). Less than 25% of calls resulted in conveyance (24.3% intervention; 22.3% control). The most common reasons for calling were ‘fall’ (6.5%), ‘sick person’ (5.2%) and acute coronary syndrome (4.7%).Case management models varied highly in provision, resourcing, leadership and implementation costs. We found no differences in costs per patient of healthcare resource utilisation (adjusted difference: £243.57; 95% confidence interval: −£1972.93 to £1485.79).Service providers (n = 31) recognised a range of drivers for frequent calling, with some categories of need more amenable to case management than others. Some service users (n = 15) reported deep-seated and complex needs for which appropriate support may not have been available when needed.ConclusionsPeople who called frequently had a high risk of death and emergency healthcare utilisation at 6 months and were a heterogeneous group. Case management may work for some, but we did not find effects on emergency healthcare utilisation or mortality across the population.LimitationsThis retrospective study provided limited options in selecting control areas, or in meeting recruitment targets. Data quality was variable. Arranging patient interviews proved challenging.Future researchThis should prospectively evaluate different forms of case management; improve data collection; and include patients fully in qualitative components. Journal Article Health and Social Care Delivery Research 13 37 1 76 National Institute for Health and Care Research 2755-0079 1 10 2025 2025-10-01 10.3310/pwgf6008 COLLEGE NANME Medical School COLLEGE CODE MEDS Swansea University Other This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 18/03/02). 2026-03-03T10:39:13.1078510 2026-02-03T12:43:43.3420164 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Health Data Science Alan Watkins 0000-0003-3804-1943 1 Rabeea'h Aslam 0000-0002-0916-9641 2 Alex Dearden 0009-0002-8529-0192 3 Timothy Driscoll 0000-0001-9879-2509 4 Adrian Edwards 0000-0002-6228-4446 5 Bethan Edwards 0000-0001-7413-056x 6 Bridie Evans 0000-0003-0293-0888 7 Angela Farr 0000-0002-2087-9310 8 Theresa Foster 0000-0002-6395-0885 9 Rachael Fothergill 0000-0003-1341-6200 10 Penny Gripper 0009-0002-5957-7843 11 Imogen M Gunson 0000-0001-8335-3335 12 Ann John 0000-0002-5657-6995 13 Ashrafunnesa Khanom 0000-0002-5735-6601 14 Tessa Noakes 0000-0001-5245-3835 15 Robin Petterson 0009-0002-3448-9214 16 Alison Porter 0000-0002-3408-7007 17 Nigel Rees 0000-0001-8799-5335 18 Andy Rosser 0000-0002-5477-4269 19 Jason Scott 0000-0002-6566-8007 20 Bernadette Sewell 0000-0001-5471-922x 21 Anna Tee 0009-0009-9564-2391 22 Helen Snooks 0000-0003-0173-8843 23 Ashra Khanom 24 71381__36341__f3b9f32e30954c879b21fa7994118b74.pdf 71381.VoR.pdf 2026-03-03T10:36:50.9595315 Output 2405835 application/pdf Version of Record true © 2025 Watkins et al. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence. true eng https://creativecommons.org/licenses/by/4.0/
title	Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data
spellingShingle	Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data Alan Watkins Rabeea'h Aslam Timothy Driscoll Bridie Evans Angela Farr Ann John Alison Porter Nigel Rees Helen Snooks Ashra Khanom
title_short	Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data
title_full	Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data
title_fullStr	Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data
title_full_unstemmed	Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data
title_sort	Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data
author_id_str_mv	81fc05c9333d9df41b041157437bcc2f 59fdd275cfdafa2f251eb5264a31cc7e 2be5c329c44d14550ceac4934fcb409e 6098eddc58e31ac2f3e070cb839faa6a ab00dbaa888f32b41b07ef223d0e2987 ed8a9c37bd7b7235b762d941ef18ee55 fcc861ec479a79f7fb9befb13192238b 8c440a0df599a0b6eef3927ebd515b72 ab23c5e0111b88427a155a1f495861d9 1f0f14742e3a36e8fd6d29f59374a009
author_id_fullname_str_mv	81fc05c9333d9df41b041157437bcc2f_*_Alan Watkins 59fdd275cfdafa2f251eb5264a31cc7e__Rabeea'h Aslam 2be5c329c44d14550ceac4934fcb409e__Timothy Driscoll 6098eddc58e31ac2f3e070cb839faa6a__Bridie Evans ab00dbaa888f32b41b07ef223d0e2987__Angela Farr ed8a9c37bd7b7235b762d941ef18ee55__Ann John fcc861ec479a79f7fb9befb13192238b__Alison Porter 8c440a0df599a0b6eef3927ebd515b72__Nigel Rees ab23c5e0111b88427a155a1f495861d9__Helen Snooks 1f0f14742e3a36e8fd6d29f59374a009_*_Ashra Khanom
author	Alan Watkins Rabeea'h Aslam Timothy Driscoll Bridie Evans Angela Farr Ann John Alison Porter Nigel Rees Helen Snooks Ashra Khanom
author2	Alan Watkins Rabeea'h Aslam Alex Dearden Timothy Driscoll Adrian Edwards Bethan Edwards Bridie Evans Angela Farr Theresa Foster Rachael Fothergill Penny Gripper Imogen M Gunson Ann John Ashrafunnesa Khanom Tessa Noakes Robin Petterson Alison Porter Nigel Rees Andy Rosser Jason Scott Bernadette Sewell Anna Tee Helen Snooks Ashra Khanom
format	Journal article
container_title	Health and Social Care Delivery Research
container_volume	13
container_issue	37
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publishDate	2025
institution	Swansea University
issn	2755-0079
doi_str_mv	10.3310/pwgf6008
publisher	National Institute for Health and Care Research
college_str	Faculty of Medicine, Health and Life Sciences
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hierarchy_top_id	facultyofmedicinehealthandlifesciences
hierarchy_top_title	Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id	facultyofmedicinehealthandlifesciences
hierarchy_parent_title	Faculty of Medicine, Health and Life Sciences
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description	Emergency ambulance services aim to respond to patients calling with urgent healthcare needs, prioritising the sickest. A small minority make high use of the service, which raises clinical and operational concerns. Multidisciplinary ‘case management’ approaches combining emergency, primary and social care have been introduced in some areas but evidence about effectiveness is lacking.AimTo evaluate effectiveness, safety and costs of case management for people frequently calling emergency ambulance services.DesignA mixed-methods ‘natural experiment’, evaluating anonymised linked routine outcomes for intervention (‘case management’) and control (‘usual care’) patient cohorts within participating ambulance services, and qualitative data.Cohorts met criteria for ‘Frequent Callers’ designation; we assessed effects of case management within 6 months on processes, outcomes, safety and costs. The primary outcome combined indicators on mortality, emergency hospital admission, emergency department attendance and emergency ambulance call.Focus groups and interviews elicited views of service providers on acceptability, successes and challenges of case management; interviews with service users examined their experiences.SettingFour United Kingdom ambulance services each with one intervention and one control area.ParticipantsNatural experiment: adults meeting criteria for ‘frequent caller’ classification by ambulance services during 2018.Service providers: service commissioners; emergency and non-acute health and social care providers.Service users: adults with experience of calling emergency ambulance services frequently.InterventionsUsual care comprised within-service management, typically involving: patient and general practitioner letters; call centre flags invoking care plans; escalation to other services, including police.Intervention care comprised usual care with optional ‘case management’ referral to cross-service multidisciplinary team to review and plan care for selected patients.ResultsWe found no differences in intervention (n = 550) and control (n = 633) patients in the primary outcome (adjusted odds ratio: 1.159; 95% confidence interval: 0.595 to 2.255) or its components. Nearly all patients recorded at least one outcome (95.6% intervention; 94.9% control). Mortality was high (10.5% intervention; 14.1% control). Less than 25% of calls resulted in conveyance (24.3% intervention; 22.3% control). The most common reasons for calling were ‘fall’ (6.5%), ‘sick person’ (5.2%) and acute coronary syndrome (4.7%).Case management models varied highly in provision, resourcing, leadership and implementation costs. We found no differences in costs per patient of healthcare resource utilisation (adjusted difference: £243.57; 95% confidence interval: −£1972.93 to £1485.79).Service providers (n = 31) recognised a range of drivers for frequent calling, with some categories of need more amenable to case management than others. Some service users (n = 15) reported deep-seated and complex needs for which appropriate support may not have been available when needed.ConclusionsPeople who called frequently had a high risk of death and emergency healthcare utilisation at 6 months and were a heterogeneous group. Case management may work for some, but we did not find effects on emergency healthcare utilisation or mortality across the population.LimitationsThis retrospective study provided limited options in selecting control areas, or in meeting recruitment targets. Data quality was variable. Arranging patient interviews proved challenging.Future researchThis should prospectively evaluate different forms of case management; improve data collection; and include patients fully in qualitative components.
published_date	2025-10-01T05:32:36Z
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score	11.453573

Strategies to manage emergency ambulance telephone callers with sustained high needs: the STRETCHED mixed-methods evaluation with linked data

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