Shared learning database

Type and Title of Submission


A collaborative care plan to reduce unplanned admissions to secondary care and enhance rapid access care in the community


A collaborative care plan was devised between primary and secondary care in order to provide a rapid access service within the community for people with MS to prevent unplanned admissions. People with Ms had been requesting that emergency care be provided closer to home and reduce the need to be admitted to hospital. The pathway also ensures that the right treatment is provided at the right time to the patient.

Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG8 - Multiple sclerosis

Is the submission industry-sponsored in any way?


Description of submission

Aims and objectives

A partnership with the local acute hospital and General Practitioners (GP's) to develop a care pathway for people with Multiple Sclerosis (MS) to prevent unnecessary hospital admissions through accident and emergency, acute admissions unit and out of hour's service. This would be a rapid response service by the MS Nursing Team to reduce hospital inpatient stays. This is driven by: patient choice, brings care closer to home, reduces costs, increases earlier diagnosis, enhances speciality for MS in the community, reduces infection risks due to decreased hospital stays and user support. People with MS (PwMS) who have received this service have found it effective, efficient, accelerated their recovery and improved the patient journey.


Multiple Sclerosis due to its unpredictability and variability within each person can lead to emergency appointments with General Practitioners and unplanned attendance at secondary care providers. This is particularly apparent when the MS nursing service is unavailable, i.e. out of hours, bank holidays and weekends. The majority of GP's and secondary care providers have a limited knowledge of MS and the management of symptoms or relapses, this has resulted in PwMS being admitted to acute beds with medical needs which could be easily managed within their own home. Locally this can result in unplanned charges of a minimum of 2000 per admission. Not only could the management of these people be improved with reduced costs and reduced admission rates but would improve the PwMS's experience, by maintaining their ability to stay at home reducing infection risks and ensuring the right treatment at the right time. PwMS were keen to improve their journeys and key stakeholders were keen to work together in order to ensure this was carried forward.


The success of the project was also dependent on securing additional funding for the MS Nursing Team to carry out the additional visits and intensive telephone support. Demonstration of the cost benefits of this proposal for a minimum outlay to senior management within the PCT allowed a potential business case to be prepared and presented at a Provider Services commercial meeting during August 2009. The proposal of an additional seven hours of band 6 nursing time was supported and agreed in order to commence a six month pilot in September, at a cost of 3,620 (including additional travel costs) to prevent a predicted ten admissions, costing the PCT a minimum of 20,000, a potential saving of at least 16,000 (figures obtained from Provider Services Finance Department of 2,000 per person per admission of seventy two hours or more to secondary care). All stakeholders were keen to enhance the service and the project has now been secured recurrently, reducing admissions by up to 50 per year, saving significant amounts of money, ensuring best practice and patient satisfaction.

Results and evaluation

At the end of the six months a total of eight admissions were avoided at our secondary care provider and twenty eight were prevented by working with our GP colleagues. This represented a significant cost saving to the PCT in the region of 60,000, coupled with this PwMS were receiving the right care, at the right time, within their own homes. They reported greater satisfaction with the service and improved communication between professionals. Every patient who is treated using the pathway is invited to complete a satisfaction questionnaire and all those returned have stated how much better the new way of working is for them.

Key learning points

This project has highlighted a new way of working within community MS nursing, recognising the need to alter practice to improve patient care and outcomes coupled with the demonstration of the true cost effectiveness and value of community specialist nurses. It is therefore imperative for community based MSSN's to continually explore new ways of service design and delivery which have the ability to demonstrate efficiency, savings and impact which assist in the larger business planning process. Nurses are at the forefront of delivery of care and as such can have a direct affect in making and shaping future policies, becoming clinical leaders in our fields is crucial to the organisation as well as the success of the government's modernisation agenda. Ensuring that all stakeholders are involved and wish to succeed is crucial as well as ensuring that the patient is at the centre of all decisions. This pathway is already being implemented in other areas Nationally with success.

View the supporting material

Contact Details

Name:Debbie Quinn
Job Title:Multiple Sclerosis Specialist Nurse
Organisation:Northamptonshire Healthcare foundation Trust
Address:York House, Isebrook Hospital, Irthlingborough Road
Postcode:NN8 1LP
Phone:01933 235853


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This page was last updated: 25 October 2012

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.