4. Managing ambulatory care sensitive conditions

What is it?

Ambulatory care sensitive (ACS) conditions are chronic conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management, such as vaccination; better self-management, disease management or case management; or lifestyle interventions. Examples include congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension.

Why is it important?

  • Despite admission being largely preventable, a significant proportion of all acute hospital activity is related to ACS conditions. In England ACS conditions accounted for 15.9 per cent of all emergency hospital admissions in 2009/10 (Tian et al 2012).
  • There is significant variation in how effectively ACS conditions are managed – emergency admissions per head may vary more than two-fold between local authority areas after adjusting for the differences in age, gender and deprivation (Tian et al 2012).
  • These admissions are costly. The total cost to the NHS in 2009/10 was estimated at £1.42 billion for a core set of 19 ACS conditions (Tian et al 2012).

What is the impact?

  • Maintaining wellness and independence in the community prevents deterioration in conditions and therefore results in better health outcomes.
  • Emergency admissions to hospital are distressing, so better management that keeps people well and out of hospital should lead to a better patient experience.
  • According to The King's Fund estimates, emergency admissions for ACS conditions could be reduced by between 8 and 18 per cent simply by tackling variations in care and spreading existing good practice. This would result in savings of between £96 million and £238 million (Tian et al 2012). This calculation may significantly underestimate potential savings as admission rates in all areas are significantly above what should be achievable.

How to do it

Early identification of ACS patients is crucial if their management is to be successful. GPs are well placed to do this through the use of risk stratification tools and clinical decision support software within GP practices. Some progress can be made through relatively simple measures such as expanding vaccination, where available, to prevent the onset of a condition. For other ACS conditions (chronic and acute aggravated conditions), commissioners will need to encourage active disease management.

A previous review of evidence (Purdy 2010) suggests that the following evidence-based interventions for avoidable admissions should be implemented and evaluated locally:

  • disease management and support for self-management for those with long-term conditions
  • telephone health coaching
  • other behavioural change programmes to encourage patient lifestyle change.

The review also suggested that improvements in the quality of primary and secondary care are needed, for example:

  • increase continuity of care with GP
  • ensure local, out-of-hours primary care arrangements are effective
  • for those with acute aggravated conditions, ensure there is easy access to urgent care
  • conduct early senior review in A&E, and implement structured discharge planning.

Useful resources

For further information