4. Managing ambulatory care sensitive conditions

What is it?

Ambulatory care sensitive (ACS) conditions are chronic conditions that include congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension. Actively managing patients with ACS conditions – through vaccination; better self-management, disease-management or case-management; or lifestyle interventions – prevents acute exacerbations and reduces the need for emergency hospital admission.

Why is it important?

• Despite admission being largely preventable, a significant proportion of all acute hospital activity is related to ACS conditions. In the East of England region they accounted for 12.2 per cent of all acute hospital admissions in 2006/7 (ERPHO 2009).
• There is significant variation in how effectively ACS conditions are managed – for example, the NHS Atlas of Variation in Healthcare shows a five-fold variation in emergency admission rates for asthma across PCTs in England (after standardising for population characteristics).
• These admissions are costly. The total cost to the NHS in 2005/6 was estimated at £1.3 billion for a core set of 19 ACS conditions.

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.
• Reducing variations in ACS admissions by spreading existing good practice could produce cost savings of £170 to £250 million across England (NHS Institute 2011). This variation-based calculation may significantly underestimate potential savings from managing ACS more effectively 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. This can include a number of elements, such as:

• treatment decisions based on explicit proven guidelines
• case management to support people with complex long-term conditions
• disease management and support for self-management for those with less complex long-term conditions
• telephone health coaching, and other behavioural change programmes, to encourage patient lifestyle change
• easy access to urgent care for those with acute aggravated conditions.

Useful resources

• The NHS Institute estimates the potential to reduce emergency admissions for ambulatory care sensitive conditions at national and local levels and by condition.
• Birmingham Ownhealth is a service that uses specialist care managers to support people with ACS conditions via telephone coaching.
• The King's Fund has developed a risk stratification tool that uses inpatient data to identify patients at risk of re-hospitalisation within a year.

For further information

• Download all ten priorities: Transforming our health care system
• You can also find all the references mentioned here in that version
• Listen to Candace Imison talk through the ten priorites in our audio slideshow