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Managing ACSCs: how can avoidable hospital admissions be reduced?


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    Nigel Edwards

One of the most significant benefits of the UK’s primary care based system is that it keeps patients away from unnecessary admission to hospital. However, our data briefing on ambulatory care-sensitive conditions suggests that it may not be succeeding in its gatekeeping role.

In a high proportion of admissions for these conditions, primary care or other ambulatory care interventions could have prevented admission. Some infections are vaccine-preventable, and some chronic diseases – particularly in respiratory medicine, diabetes and cardiology – could be better-managed, but there is no one obvious intervention that seems to make a difference.

This problem has been known about for some time – John Billings of New York University started writing about it in the 1980s – and the intervening period does not seem to have produced very many breakthrough ideas. General improvements in care, in particular, self-care, and improved access to responsive primary care can help. Some of the developments in improving chronic disease management, particularly in COPD, diabetes and heart failure seem to offer more promise.

Direct access telephone lines, advice from pharmacists, single points of access, and primary care in the A&E department look intuitively appealing as methods for dealing with the problem, but the evidence that they work at the scale required or are cost effective seems hard to come by. This leads to another surprising finding. The scale of savings available is rather small, even if very ambitious assumptions are made about the level of improvement that is achievable and about the relative costs of alternative models (the savings are gross rather than net). Given the deeply entrenched social, behavioural and economic factors, and the scale of improvement that some NHS services require, the high end of the savings estimates may be very optimistic. In addition, much of this saving is spread across several hundred hospital sites and can only be realised by either reducing overheads or by diverting the money into additional activity in the hospital – which may not be required.

This means that the measures to reduce ambulatory care-sensitive admissions have to be cheap and, because of their diverse nature, relatively generic.  A striking feature of a number of the attempts to reduce admissions over the past decade is how much they have relied on relatively small and often quite specialist services, with narrow referral criteria that were not always co-ordinated with other services and often had limited hours of availability. Other elements of the system have not been aligned with the objective of reducing hospital use either – out-of-hours services are not measured on their reduced referral to hospital, nursing homes are not regulated on their reduced use of the A&E department.

Preventing admission is the right thing to do. Admission to hospital may treat the immediate problem but over 35 per cent of older people admitted to hospital are discharged in a poorer functional state than when they were admitted and so there are good health, as well as economic, reasons for avoiding admission.

Rather than inventing new initiatives a better option might be a radical simplification of the existing complex web of services and initiatives to ensure that the basics of primary care work are supported by high-quality ambulance services, nursing homes that do their job well and good generic community-based nursing that can manage chronic disease, administer intravenous drugs at home and respond when and where required.