Published: 03/02/2005, Volume II4, No. 5941 Page 22 23

Ruth Hutt and Rebecca Rosen, the King's Fund

We would like to address the points Dr Richard Smith raises on the King's Fund review of case management (letters, page 20, 6 January).

While it was not a systematic review, we did use a systematic approach to searching for and reviewing papers. The pilots and projects underway in the NHS were not reviewed, as we only included published research. The period of intervention and follow-up in the studies we reviewed varied from three months to three years.

The systematic review Dr Smith describes examined the benefits of home visits for older people undertaken by health visitors, with their focus on surveillance, health promotion, support and prevention of ill health.

They demonstrated no significant reduction in hospital admissions, although they did describe reductions in nursing home admissions and mortality.

Our own review of case management was influenced by emerging policy and focused mainly on services providing more intensive input to patients at high risk of admission. However, our selection criteria led us to include two of the papers in the BMJ systematic review, contrary to Dr Smith's suggestion, so there was clearly some overlap.

We concluded that there is no single model of case management that is best and recommended that PCTs should reflect on their current situation to inform development. Those with established and respected health visitors for older people may choose to go down this route, while those without may target case management on high-risk elders through community matrons.

There is little high quality evidence of the cost-effectiveness of case management. However, we agree with Dr Smith that patient satisfaction or improvements in quality of life are clearly important considerations when trying to attribute a financial value to case management.