news in focus

Published: 29/07/2004, Volume II4, No. 5916 Page 12 13

In order to achieve cuts in emergency bed days, the public service agreement on chronic-disease management demands improved care in primary and community settings. And as Jeremy Davies shows in the second of our series on the four PSAs, to achieve the target different components of the service must learn to work together

The selection of chronic-disease management as one of the four public service agreements has finally secured its place at the heart of government health policy.

The target calls on the NHS to improve health outcomes for people with longer-term conditions by offering a personalised care plan for vulnerable people at most risk. The target also demands a 5 per cent reduction in emergency bed days by 2008 through improved care in primary care and community settings for people with longer-term conditions.

A leaked version of the PSA targets suggested that the Department of Health had been planning to set the target at 10 per cent (news, pages 3-5, 10 June).The DoH refused to comment on why the target has been halved.

National primary care director Dr David Colin-Thomé says it is important that targets are 'achievable rather than just possible'.

He stresses that the 5 per cent reduction is in emergency bed days across the board, rather than just in those relating to the most vulnerable patients highlighted by the first half of the PSA target.

And he points out that it must be achieved in the context of rising emergency admissions, which means the service will have to run faster just to keep still, let alone reduce the level of emergency care.

Attendance and admissions at accident and emergency departments have risen steadily recently (news, page 5, 15 July), with an increase in admissions of almost 10 per cent in the last quarter of last year compared with the equivalent period a year earlier.

So how should the NHS go about meeting its new goal?

Primary care trusts and the providers from whom they commission acute care must be clear that both elements of the target - personalised care plans and cutting bed days - are two sides of the same coin, says Dr Colin-Thomé.

'Setting a target that crosses primary and secondary care makes certain that we look at the whole system rather than just shortterm fixes.You could probably get some way towards meeting the target by reconfiguring staff in casualty, for example. That may be something well worth doing, but it wouldn't be enough.

He explains: 'What's needed is a cultural shift whereby the service goes out looking for problems to nip them in the bud before they become more serious at a later stage. Focusing on the patient's pathway and improving their quality of life must be the driver, and That is what makes it so radical.'

Although Dr Colin-Thomé stresses that PCTs will be free to decide how best to go about developing this new approach, it is clear that US-style managed care is the solution many are likely to opt for.

Since April 2003, nine PCTs have been piloting a modified version of the Evercare case management approach through a£5m project run jointly by the DoH and Ovations, part of UnitedHealth Group.

A full evaluation of the project is expected at the end of the year, but the DoH has already said that early results are promising.Under the Evercare approach, senior nurses actively seek out patients who have had an unplanned hospital admission twice or more in the past year, and then review and manage their care intensively to minimise the chances of further admissions.

Evercare's interim study, published in May, reported that this high-risk population represented just 3 per cent of people over 65 years of age, but was responsible for 35 per cent of unplanned hospital admissions for all people over 65 years of age in participating PCTs.Many high-risk patients were not actively being managed by the system.

Bristol North PCT Evercare project lead Martin Howard says detailed figures on the effects of the new approach will not be available until later this year when the evaluation team will publish hospital admission data from before and during the pilots, and cross-reference this to GP practice data to examine what treatment the 'high-risk' patients have received and where. But he estimates that the project will have achieved 30 per cent cuts in emergency bed days and lengths of stay.

Rolling out Evercare and similar case-management programmes is likely to be central to the NHS's success or otherwise in meeting the PSA target. Nine PCTs have been piloting an approach developed by the Kaiser Permanente group, and London's Haringey teaching PCT is working with Pfizer Health Solutions.

The commercial opportunities around chronic-disease management are unclear although there have been suggestions that strategic health authorities have held talks with private providers to discuss signing PCTs up to managedcare programmes en masse.And the Evercare lead manager at one of the pilot PCTs suggests there will be a pressing need for management consultancy, especially around nurse training and data management: 'When we started this I just couldn't believe how big and complex an agenda we were tackling, and I do not think it would have been possible without the support we received from outside.

It is an all or nothing approach.'

The DoH estimates that, overall, 10 per cent of patients account for 55 per cent of hospital inpatient stays.

It has already announced a target for the NHS to recruit 3,000 community matrons, based in primary care settings and acting as 'human search engines', to identify and advocate on behalf of patients with long-term conditions, by 2008; But Dr Richard Lewis, a visiting fellow at the King's Fund who has researched US-style managed care, cautions against getting too carried away with the case-management approach. He suggests that a focus on meeting the new target by concentrating on the tiny minority of 'high-risk' patients could divert PCTs from the wider chronic-disease management agenda.

'If I have an anxiety about this, It is that case management could start to be seen as a 'magic bullet', when in fact There is no such thing.

Focusing on the most high-risk patients relies on the idea that historic utilisation can predict patients' use of the NHS in the future. You may actually only be able to predict about 40 per cent of future utilisation in this way, so if you're not extremely confident about how you're case finding, you could be diverting resources to the wrong cohort of patients.'

'And there are a lot of other people with chronic disease whose conditions could at any point worsen and bring them to the tip of the triangle, ' he adds. 'The system needs to work a lot better for them, too, or you're just storing up more problems for the future.'

Better management of chronic disease at a lower level must be an equally urgent goal for PCTs and should be assisted to some degree by developments such as the rollout of the expert patient programme, and the quality and outcomes framework that forms part of the new GP contract.

Under the framework, GP practices now have financial incentives to improve the data they hold about patients with chronic disease, and to manage them more systematically.

But bringing all these initiatives together and persuading acute trusts to assist diversions of investment from secondary to primary and community-based services may be a major challenge for PCTs.

Ongoing misaligned incentives in the financial flows system are unlikely to help. Ipswich Hospital chief executive Paul Forden, who is currently on secondment to Norfolk and Norwich Hospital trust and sits on the DoH's financial flows project board, admits that 'at the moment hospitals get paid according to the number of patients they treat, irrespective of what they do'.

'So PCTs can find it difficult to remove any money from the secondary care system if they do things differently.'

Under the payment by results formula the establishment of tariffs for admitted patient 'spells' provides a strong incentive for PCTs to reconfigure services where this reduces the volume of admissions - for example by establishing minor injury units to reduce the volume of A&E attendances. But the current national tariffs are not compatible with service reconfigurations that reduce average length of stay. A hospital might get paid twice as much for keeping a patient for five days as it would for four, for example.

Amendments to the system will allow commissioners to 'unbundle' episodes of care into components that can potentially be provided in alternative settings.

But until this becomes available the best the DoH can offer is to let PCTs adjust the national tariff for an admitted patient if a service redesign has a significant impact on length of stay.

Such issues should not get in the way of reform though, says Dr Colin-Thomé. 'Let's not get too bogged down in technicalities, ' he says. 'If you do not refer the patient, or they do not refer themselves, you're not having to pay the hospital anything anyway.'