Published: 17/02/2005, Volume II5, No. 5943 Page 25

Dr Richard Smith, chief executive, UnitedHealth Europe

Your report on the Evercare pilot seriously misrepresents what I said to your magazine (news, page 7, 10 February). I am distressed that you write that United 'blames low success rate on use of NHS nurses'. I said no such thing. The nurses who worked in the pilots did a remarkable job - as research conducted by Picker Institute Europe showed. You chose not to report these results.

I did say that the experience in the US is that the programme achieves better results if the nurses are employed by Evercare, but whether that would be the case here is unknown - and to suggest that I was blaming nurses for anything is a complete non-sequitur.

Your report also wrongly states that the research from Manchester and Sheffield 'found that' the Evercare pilots 'had cut less than 1 per cent'. It did not. The research has no data on hospital admissions from the Evercare pilots.

Rather the research showed that using two unplanned hospital admissions is an insensitive way of identifying those most at risk of future unplanned hospital admissions.

We know that better methods are needed to identify those most at risk, but the data systems available in the NHS at the time the pilots started did not allow the use of anything more sophisticated.

Ideally it would be possible to use data on number of diseases, medication, use of GP and social services, social circumstances, and the like. UnitedHealth Europe has access to such tools, which are used with 50 million people in the US. The tools are being tested in England.

Data from the US show that overall costs can be brought down by over 30 per cent between year one and two and by about 10 per cent thereafter, but the evidence also shows that the programmes take more than a year to embed and produce maximum benefit.

It is also important that the programmes are intensively managed. Case management is conceptually straightforward but hard to implement. As a recent BMJ editorial said, 'Case management is a tough, difficult job to do well, whose complexity and difficulty is often underestimated.' The important question is not 'Does case management work?' but rather 'How can it be made to work optimally'.