Frequent attenders to A&E departments: a qualitative study of ...

Frequent attenders to A&E departments: a qualitative study of ...

Frequent attenders to A&E departments: a qualitative study of people who repeatedly present with alcohol-related health conditions Tom Parkman, Jo Neale, Ed Day, Colin Drummond 1 Background The term AFA is unclear, contested and potentially pejorative Very little is known about AFAs AFAs do not appear in policy documents and there are few interventions specifically targeted at them In the absence of factual information, AFAs are at risk of stereotyping and/ or misplaced policies and interventions 2 Stereotypes and prejudice

Social categorisation The process whereby a person is not seen as a unique individual, but as a member of a group of people based on common characteristics Stereotyping Beliefs are based on the characteristics of groups of people Linkages are made between individuals, a social category and traits of that category Stereotypes are not necessarily harmful, but can become harmful if inaccurate information is erroneously attributed to a social group Prejudice

Prejudice goes further than stereotyping & includes an emotional component (often negative) Prejudice can can result in individuals being verbally rejected, discriminated against, stigmatised and marginalised from society 3 Presentation aim & methods Aim: To increase understanding of AFAs demographic characteristics, substance use, social circumstances, and patterns of A&E attendance Definition of AFA used: Any patient aged 16 or over who attends any A&E department 10 or

more times within a year or 5 or more times within a 3-month period for an alcoholrelated condition (ISD Scotland, 2011) Methods: In-depth qualitative interviews with 30 AFAs from 6 hospitals in greater London (February June 2015) 4 Demographic characteristics Mean age: 48 years (range = 20 68 years) Gender: 18 males, 12 females Employment status: 28 unemployed, 1 employed, 1 self-employed Income: Employment Support Allowance (ESA), Disability Living

Allowance (DLA), wage for those employed Education: no qualifications (n=9), GCSE (n=12), A-levels (n=5), university degree or higher (n=4) Ethnicity: White British (n = 19), Asian British (n=4), Mixed Race (British) (n=3), European (n=3), Other (n=1) Ever been in prison: n = 6 5 Substance use Alcohol: 29/30 reported many years of heavy drinking Illicit drug use: 20/30 said they had never tried drugs 5/30 reported a history of drug dependence (cocaine, heroin, crack, mephedrone, Valium) 4/30 reported smoking cannabis in the past

1/30 active drug user (IV heroin) 6 Mental health Diagnosed: Depression, bipolar, personality disorder, borderline personality disorder, dementia, agoraphobia, bulimia Undiagnosed: Depression, anxiety, hearing voices, seeing faces Stress-related: Generalised stress, loneliness, boredom Drinking-related: Vascular dementia, cerebral cellular atrophy Self and identity-related: No self-worth, no self-confidence, self-loathing, self-judgement, rejection of alcohol dependent label in favour of binge drinker Memory-related (caused by alcohol abuse): Short & long-term memory problems Emotional instability: Mixed up emotions, anger issues Self-reported explanations: Childhood bereavement, trauma, rape, sexual abuse, physical abuse, family problems, deteriorating health Self-reported consequences: Addiction, suicide attempts, self-harm Drinking always used to self-medicate MH problems

They tell me I'm looking great, I'm putting weight on, I'm looking well. But the faade looks good. We've all got a great faade, but inside sometimes I'm crumbling (Ppt 3; Male) 7 Physical health Alcohol-related: Chronic conditions: Diabetes, liver failure, kidney failure, gastritis, hepatitis, pancreatitis, high blood pressure, incontinence, angina, respiratory problems, stroke, anaemia, heart attacks, peripheral neuropathy Physical trauma: Broken bones (from falling over) General ill-health: Bad teeth, problems with sleeping, malnutrition, weight gain/loss, persistent vomiting, malaise Non alcohol-related: Physical disabilities: Guillain-Barre syndrome, blindness, physical immobility Good health: Feel fine, ok (n=3) Drinking always used to self-medicate physical health problems My liver's failing again. One kidney's packed up, one's working. I've got lung cancer, I've

got pancreatitis, I've got hepatitis, I've got everything you can imagine and I'm terminally ill and I'm going to die soon (Ppt 26; female) 8 Housing circumstances Local authority/ housing association (n = 8) Homeless (n = 6) Hostel, YMCA or sheltered housing (n = 5) Owner occupier (n = 4)

Living with friends/family (n = 3) Private renting (n = 3) Medical centre (n = 1) Participants regularly discussed housing instability as a reason for drinking It [housing] is a big issue for me at the moment. That [house] is where I did all my drinking when it got really bad. I would say thats where it all happened Maybe Ill change my mind. I dont know. But if I was to go home tomorrow, it would just be a bad move on my part. I dont really want to go back there. (Ppt 27; Female) 9 Family and social networks Harmful/no relationships:

Pro drinking/drug using relationships Abusive relationships Relationship breakdown Social isolation Boredom Loneliness Bereavement I could be in a room full of people and still feel really alone. (Ppt 19; Male) Negative or no relationships were reasons for continued drinking Good relationships:

Non-drinking friends and family Perceived positive relationships Abstinent friends and/or family Peers in recovery 10 She does the cooking, everything. She does the gardening, she does the hoovering, cleaning, everything She wont let me do anything. (Ppt 23; Male) A&E attendances Attendances (last 12 months): Mean = 24 (range = 10 84) Admissions (last 12 months): Mean = 5 (range = 0 17) Drink-related reasons: Intoxication, withdrawal, physical health problems, self-harm, overdose, suicide attempts, mental breakdown Every time I call up 999, Im drunk, Im completely drunk and I feel suicidal Every time, I want

to kill myself. (Ppt 28; Female) Non-drink related reasons: Health problems: Pain, neurological problems, asthma attacks Lack of alternative health care: No access to/ availability of GP Social problems: Homelessness, violence Non medical problems: Hypochondria, self-reported fake suicide attempts & overdoses Reasons for returning to A&E: Warmth, safety, always open, provides immediate help, provides companionship, is the preferred service, perceived as providing better care, offers free sandwich/ cup of tea, clothes are washed, referred there by other services, others call an ambulance If I had nowhere else For safety because Im vulnerable. (Ppt 15; Male) Reason for attendance at A&E included drink, and non-drink related reasons 11 Conclusions & implications AFAs have multiple and complex needs AFAs are a very diverse group in terms of their demographic characteristics, drinking and wider substance use, health and social needs, access to

physical and social capital, and patterns of A&E attendance This diversity needs to be highlighted and recognised to: a) prevent stereotyping and labelling, with the attendant risks of harmful prejudice, stigma and discrimination b) ensure policies and services/ interventions are sufficiently flexible and response to individual needs and circumstances c) provide A&E staff with the necessary support, resources and training to enable appropriate referral and/ or care management within emergency departments 12 Thanks for listening Any questions? 13

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