The next stage review has again highlighted the opportunities for providing elements of urgent and chronic care outside the acute inpatient setting.

Recent guidance from the Royal College of Physicians on ambulatory care and the NHS Institute for Innovation and Improvement’s directory of ambulatory emergency care has pointed to a range of conditions that could, with responsive community based services, reduce the burden on hospitals.

The guidance provides a useful basis for categorising patients with urgent or chronic care needs. Based on these definitions, a medium to large acute trust could expect more than 40 per cent of emergency admissions to fall into these two categories. Spending upwards of£35m with an average per admission of around£1,300 would not be atypical.

Reforming the pathway

This Data Briefing is based on work to assess the opportunity for reforming the patient pathway. The NHS Institute suggests a range of the proportion of patients who could possibly be cared for outside of an acute hospital. This work was to analyse the patient records for a trust in more detail to see if a realistic segmentation could be achieved.

After adjusting for case-mix complexity, many of the conditions still fall within the range proposed by the institute (see first chart), which reinforces the proposition for emergency ambulatory care.

Ultimately there is no substitute for clinically validating the criteria for a model that manages patients efficiently and anticipates the need for intervention. In estimating the scope for change, a word of caution: adjusting for case-mix relies heavily on accurate diagnosis and transcription to the electronic patient record. The quality and depth of coding is notoriously variable.

High potential

Using the example of the medium to large provider, just over 40 per cent of the subset of emergency admissions defined by the directory could be classified as having high potential for ambulatory care (second chart). Of those, 17 per cent represents patients with chronic or complex illness which could be managed in primary care (third chart). The remainder are admissions for urgent care, a minority of which ended up staying overnight. All of them could potentially avoid any hospital admission with better access to assessment and diagnostic services.

This amount of activity equates to£7m-£8m of the£35m total spend on emergency admission for a medium sized provider.