Website of the Department of Health

1) Table of emergency admissions by ambulatory care sensitive condition 2003/04 (Source NHS Institute)

2) Case studies

The Dudley PCTs have developed new care-closer-to-home pathways for patients, by redesigning clinical roles. The project shows how clinicians can be engaged in service redesign and how better patient education and information about services can influence changes in behaviour.

Health and social care workers have been brought together to provide high quality care in a seamless way.  Improved information about services and better patient education has led to patients making more informed choices about their care.

In July of 2003, the PCT's professional executive committee chair (a GP), the Director of Quality and Nursing and a senior team manager in Social Services spent three days speaking to clinicians and patients in Dudley Hospital about the ways that they could work together to ensure that the patients received appropriate care at all times. 

The reaction was overwhelming. Two main issues emerged. Firstly that clinician to clinician communication needed to be improved to ensure that patients had a seamless transfer through their whole episode of care. Secondly , although local services had been developed to prevent unnecessary hospital admission, this had not been communicated to front line clinicians in a way that maximised their use.

The team developed an action plan for the health and social care community which included a whole system clinical development programme leading to the development of a new model of care for Dudley.

This model provides a way forward for every health and social care economy in the country to use evidenced based care, coupled with innovative ways of using staff, to provide the best care for patients in a way that ensures that there is proper clinical engagement.

Benefits:

The Adam Practice in Dorset developed a primary care Echo service with cross-PCT coverage in the Poole area covering a population of over 170,000 (Echo is an in house testing echocardiology service for congestive heart failure diagnosis).  A GPswSI runs the service with support from a qualified medical technical officer and a service manager/clerk.  Each Echo costs about a quarter of the cost of a secondary care referral, which offsets the initial start-up cost fairly rapidly.

GP Dr Liddiard, who runs the scheme with a clinical assistant in cardiology, says: 'There are some real benefits for patients in running a primary care Echo service, with more patients having Echos and more people needing treatment being found.  Treatment can be changed appropriately and cardiology time can be saved for patients with more sever morbidity.

Central Cornwall PCT has taken a whole system approach to the management of long-term conditions.  Community matrons are working alongside GPs in the EPIC practices.  The GPs and their teams have been able to rapidly access services via the community matron who has a workstation within the practice and access to the patients records.  Practices report far greater co-ordination of care and access to services.  They particularly value the monitoring role of their elderly patients.

Using a benefits realisation format they have been able to demonstrate a reduction in emergency admissions of 457 across Cornwall, the facilitation of 84 early discharges, reduced GP visit s in and out of hours, and increased patient satisfaction, generating savings of £975,000.

The Sharma practice near Grimsby had a high proportion of housebound patients on its chronic disease register.  A nurse practitioner has the role of visiting and monitoring these conditions and may also undertake acute visits for the same cohort of patients.  The nurse has also developed relationships with colleagues in community nursing and social services.  Direct access for the nurse to step up care has been negotiated operating alongside a rigorous system of examining data on emergency admissions.  This allows targeted and focussed intervention on those frequently admitted.  For COPD the patient admission rates have been cut by 87 per cent, with none of those patients being admitted through A&E.

In 18 months a practice within the Forest of Dean has achieved a reduction in hospital admissions of 50 per cent (real figures 37 down to 17).  The practice has introduced a regime of treating patients who report the first signs of an exacerbation by treating with steroids and antibiotics.  Patients are also given an emergency supply to take at home if needed and agree a self-management plan.

3) Reducing repeat admissions was a key priority in the 2004 NHS Improvement Plan.  The NHS is working towards a target of reducing emergency bed days by 5 per cent by 2008 through improved care in primary and community settings. Improved proactive care of patients has resulted in two per cent fewer Emergency Bed Days during 2004/05 has already released over £200m for additional patient treatments.  Last year, the Department overhauled the way in which the NHS cares for people with long term conditions with better monitoring and management of people closer to home, backed up by the recruitment of 3000 community matrons.  The recent White Paper announced a fundamental shift in expenditure from spending on hospitals to spending on care closer to home and on preventative services. It recognised that same procedure in primary care can cost as little as one-third compared to secondary care.   There are over 15 million people in England living with a long term condition.

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