Published: 14/10/2004, Volume II4, No. 5927 Page 5 6

The Department of Health is warning primary care trusts that the target to reduce emergency bed days by 5 per cent by 2008 is far tougher than it appears.

The warning came at an HSJ conference, when DoH head of primary care Gary Belfield said that, taking account of the trend of increasing emergency admissions, the 5 per cent target actually equates to a 12 per cent reduction in bed days over three years.

He told delegates that the Treasury originally wanted a 30 per cent reduction in emergency bed days. But he explained that the 5 per cent target set by the government's public sector agreements in July was deceptive: 'We know that year-on-year emergencies are growing. Therefore 5 per cent based on where we think emergencies are projected to go is really a 12 per cent reduction by 2008, which is much more difficult.'

Mr Belfield urged primary care trusts to act quickly to achieve success against the target: 'We can't really wait for a year or two to see how to do it, we need to be running with this from next year because 12 per cent is a big target.'

In August, the DoH set milestones for PCTs to reduce emergency bed days by 1 per cent by March 2006 and 3 per cent by March 2007.

Mr Belfield said the government would publish its model for managing long term conditions within weeks. This will be central to cutting emergency bed days. The new model will attempt to anglicise US approaches to the management of chronic disease, with an initial emphasis on case-managing the estimated 250,000 people with long-term conditions (LTCs) who are intensive users of hospital services.

Mr Belfield told the conference on managing LTCs that the model aimed to give the NHS 'direction without being too prescriptive'. But he said that it would come without central funding or pilots.

Mr Belfield said: 'We are really keen to say these are the principles, but actually it is much more about interpreting this locally.' But he stressed, 'there'll be no extra money for this' and 'no pilots' - except perhaps for self-care, where the DoH is keen to learn from the private sector. And he insisted that success on freeing up emergency bed days was the key to releasing resources back to the rest of the system which could be invested in new ways of managing LTCs.

'In many ways the resource is out there and therefore we need to do things differently. Beds will be released and it is very much a local decision on how these beds are used... how the money is fed into the system.'

He said achieving the total target on emergency bed days would 'free up 5,700 hospital beds' - the equivalent of '10 district general hospitals'.Around 2,500 of the estimated 17.5 million people with LTCs are being admitted into hospital inappropriately, he claimed.

He also told delegates that although the government will encourage private sector involvement, there will be no national procurement of private sector capacity. 'As of today... there is going to be no national procurement for long-term conditions in the way we did for diagnostic and treatment centres...Procuring, say, Evercare nationally just wouldn't work because we are keen to get things working locally.'

Mr Belfield also admitted that by including private sector model Evercare in all its roadshows, the DoH 'probably unwittingly gave out a message that this is all about Evercare'.

'Evercare is good, but it is not the only way.'

Speaking at the same conference, primary care clinical director Dr David Colin-Thomé stressed that Evercare was more limited in its scope than the models being explored by the DoH. He said Evercare had 'been escalated to the level of Hoover or Jacuzzi where the trade name is describing a much more general process'.

But he added: 'It is just one methodology which focuses very much on people over 65, whereas care management or case management will actually apply to people with single diseases who are younger, but who have problems.'

Dr Colin-Thomé cautioned that the current evaluation of the Evercare pilots 'will not have the spectacular results', seen in the US 'because this is early days and it takes quite a lot of time to become embedded in a system'.

Mr Belfield said the NHS must move away from treating episodes of care to thinking 'systematically'.

He said the NHS should start with case management of high intensive users, but over five years roll out the principles more widely.

He also stressed that 'unless we work closely with our social care colleagues', and do it as 'a whole system' - and that includes patient partnerships, voluntary and social care - 'we will fail spectacularly'.

Dr Colin-Thomé later suggested that this could extend to cross-sector funding. 'We maybe need to give some health money to social care...rather than paying for inappropriate clinical interventions.'

But Mr Belfield admitted that while the DoH is 'looking at how integration can work for health and social care, we are not quite there on that yet'.

Other areas where 'we haven't got the answers yet' included payment by results, on which guidance is expected within weeks, 'the big issue of commissioning capacity and capability', and the impact of foundation hospitals and the choice agenda.