Health economic evaluation of the Lothian high demand service

Reducing ‘avoidable unscheduled attendances and admissions to hospital’ is recognized as one of the eight key areas of improvement NHS Scotland’s 'Shifting the Balance of Care Improvement Framework'. The Improvement Framework identifies a variety of approaches to achieve shifts in the balance of care, two elements of which include the identification of patients who are most at risk of hospital admission, and the development of patient care plans.  Such care plans are built on the understanding that a substantial proportion of individuals who arrive in A&E Departments, or have other forms of unplanned hospital admissions, do not require, or want, acute hospital care, suggesting that it may be possible to reduce acute care costs by providing alternative approaches to acute care. Furthermore, a small number of individuals account for a large proportion of such hospital admissions (often termed “high demand” patients). In 2014, NHS Lothian initiated a service to identify and manage “high demand” patients, by implementing a system of Anticipatory Care Plans (ACPs) amongst those at high risk of future hospital admission. We conducted a comparative before-and-after study of hospital admissions, emergency department visits, length of hospital stay and hospital costs, to estimate the overall service impact.  

Outcome and Translation

The results suggest that introduction of ACPs led to a statistically significant reduction in the number of unplanned hospital admissions and emergency department (ED) visits. There was also an associated reduction in length of hospital stay for unplanned admissions, and lower hospital costs for ED visits and inpatient care. These outcomes suggest that ACPs are a promising intervention to consider if hospitals wish to reduce the number of unplanned hospital admissions. The findings have been highlighted in the Chief Medical Officer for Scotlands’ Annual Report in 2019.

HERU researchers involved in this research project: Paul McNamee and Attakrit Leckcivilize

External collaborators: R. Steel (NHS Lothian)


McNamee, P., Leckcivilize, A., Cooper, C. and Steel, R. (2018) 'Can Anticipatory Care Plans (ACPs) reduce unplanned hospital admissions?', 6th Annual Research Symposium: Evidence for Integration, COSLA Conference Centre, Edinburgh, 24 April 2018.