To improve and provide personalised care for patients with long-term, complex conditions and to provide appropriate patient treatment pathways for them, Dudley Beacon and Castle primary care trust recruited three assertive case managers and one nurse consultant.

The case managers built up a caseload of patients who were repeatedly attending the Dudley Group of Hospitals emergency department and were having regular, unscheduled emergency admissions.

The nurse consultant teamed up with the PCT's IT and information department to design a system to capture the referral assessments and contacts that were going to be made.

The web-based system was developed at each stage with the case managers. The information department benchmarked admission rates, recording percentages of short and average length of stay for emergency general medicine.

The case managers worked with the information department to identify the patients appropriate for case management. Through working with GPs and being present at the local trust's emergency assessment unit, the case managers were able to begin to provide care for these patients.

As the caseloads were built up, the information department began to build individual patient profiles for each of the patients being case managed. This enabled the tracking of each patient's treatments across the health economy.

From these analyses it is clear that many patients who have had a series of historical emergency treatments in the acute provider were not returning to secondary care once taken onto a caseload. This was identifiable not only from the statistics but also from videoed patient stories.

As case managers were also facilitating early discharge (patients with long-term conditions were typically staying beyond the designated 'trim points'), the average length of stay was analysed and showed consistent month-on-month reductions through the 2005-06 financial year.

The PCT's excess bed-days budget was significantly underspent for the year. The only increases in the average length of stay were in August and January because of case management resource issues. This identification has enabled the PCT to learn from these resource trends, and identify and correct them for the following financial year.

Increased partnership working between Dudley Group of Hospitals trust and the PCT has led to many additional information flows. On a daily basis, the PCT is able to identify all of its patients in secondary care.

When this data is grouped with inpatient admissions, outpatients and accident and emergency data, along with the live case management system, it provides a very powerful analytical tool to support the case managers and to provide an evidence base.

Daniel Ray is head of information at Dudley Beacon and Castle primary care trust, daniel.ray@dudley.nhs.uk