Nurse-led case management: do not believe the hype

The DoH's model for improving the care of those with long-term conditions will push the argument for an increase in case management. But a review by the King's Fund warns there is little evidence this would reduce admissions - or even be cost-effective. Lyn Whitfield reports

Next week, the Department of Health is due to launch its model for improving the care of people with long-term conditions, with an initial focus on case management for those 'most vulnerable' to unplanned admission to acute care.

Indeed the model, a draft of which has been seen by HSJ, promises that the introduction of case management by community matrons will 'play a significant role' in helping health communities meet government targets on reducing emergency bed days.

Yet with exquisite timing, the King's Fund has just published a review of research on case management for older people with long-term conditions (the focus of pilots in England) that raises questions about this claim.

The King's Fund found only 'weak' evidence that case management actually reduces emergency admissions and says there is even less evidence for its cost-effectiveness. It also says 'the review did not find evidence for the superiority of any one model [of case management]'.

This is a very carefully chosen form of words. Becky Rosen, one of the review's three authors, says 'we do not want to be seen as saying there is no evidence for Evercare', the model of nurse-led case management brought to the UK by US insurer UnitedHealth.

Nor does the King's Fund want to be seen to be attacking the model of case management by community matrons being promoted by the NHS. But it does say that case management is not going to be an 'off the shelf' solution to reducing emergency admissions in line with government targets.

Instead it recommends that primary care trusts should be 'given flexibility' to develop their own arrangements.

That is surely controversial enough, given that 3,000 community matrons will be recruited to 'spearhead' case management by March 2007 and PCTs are being told to implement the NHS long-term care model by 2008.

The management of long-term conditions has been moving up the political agenda for some time and has been controversial because the policy proposals developed in the UK are so heavily influenced by US health insurers.

The NHS long-term conditions model draws heavily on the 'pyramid of care' developed by Kaiser Permanente, the California-based health management organisation. Or as one source somewhat sarcastically told HSJ this week: 'Kaiser is about to save us all.' The pyramid can be drawn in various ways, but it essentially divides the population of people living with chronic illnesses and other long-term conditions into three (see diagram, opposite):

A broad base (70 to 80 per cent) with stable conditions and low care needs who can 'self manage'.

A large minority with more complex conditions or care needs who need specialist, disease-specific services.

A small minority with highly complex and/or multiple conditions, who may also have unstable personal circumstances, who need case management.

The NHS long-term conditions model addresses all three groups.

At the base of the pyramid, it locks into the recently published public health white paper, and says selfsupport strategies should be developed.

At the next level, it says health communities should strengthen disease management. But the initial focus is on the apex of the pyramid, the 'most vulnerable' patients, for whom case management by community matrons is prescribed.

As the model says, 'such patients have an intricate mix of health and social care difficulties' and the NHS and social care services have not always been good at meeting them.

A big driver for the new approach is the Treasury's public sector agreement target that the NHS should reduce emergency bed days by 5 per cent in four years.

At an HSJ conference in October, DoH head of primary care Gary Belfield warned this is 'more difficult than it looks' because the year-onyear increase in emergencies means the PSA target 'is really a 12 per cent reduction by 2008'.

The hope is that it will be possible to identify the small proportion of patients who account for a disproportionate number of emergency admissions and bed days and, by applying the case management approach to them, start getting these down.

At a recent conference in London, Birmingham and the Black country strategic health authority chief executive David Nicholson, who is chair of the NHS system reform leadership group, went further: 'There is no doubt that if we do not tackle this issue there will be a real issue with sustaining the services we have got.' He added that unless emergency admissions were tackled, payment by results would suck money into acute care.

However, it is the evidence for such hopes that the King's Fund report questions. Its researchers identified more than 400 reports on case management published over the last eight years, and looked in detail at 19. All of these were research studies, including 'gold standard' randomised controlled trials into health services-led case management for people aged over 65.

The researchers found that only five of these studies, and only two randomised controlled trials, showed a significant reduction in emergency admissions, while the others showed no difference or differences that were not statistically significant.

The researchers did find that most of the 19 studies showed reduced lengths of stay in hospital, but turned up little evidence that case management reduces use of emergency departments or cuts costs.

'The evidence on cost effectiveness is weak, ' says Dr Rosen.

'We have said that and it is in line with other reviews that have been conducted. But all the big US [health management] companies are doing this, so they must think they are going to get a good bang for their buck, because they are hardheaded corporations.' Perhaps the more alarming finding, therefore, is that although the original research studies from the US and Europe looked at different models of case management, 'none leaped out as being more effective than any other'.

The NHS long-term conditions model is not completely prescriptive. For example, it says that health and social care organisations should work together to identify the 'most vulnerable patients', using a range of criteria.

However, the draft NHS longterm conditions model seen by HSJ says that once patients have been identified, it is community matrons who should take on the case management role.

It says community matrons may 'come from a variety of nursing backgrounds' and work from a variety of settings, but they should work with patients and carers to draw up care plans and then act as a 'fixed point', co-ordinating the services to deliver them.

This is plainly influenced by US work. Yet the King's Fund report says: 'American models of case management. . . differ in context from the target populations of current NHS policy'.

In particular, it points out that key US studies often cited as evidence of the effectiveness of case management actually relate to case management in nursing homes. And it points out that the UK has a strong tradition of primary and community care that is unknown in many parts of the US.

Dr Rosen says there are lessons the UK can learn from the US: 'We can learn how to do this [care for those with long-term conditions] more rigorously. We have got a lot of this stuff, but it is not producing the results that it might do, ' she says.

But she also believes that it is important for local health communities to build on what they have already got. '[Case management] is not a golden bullet. It does have a contribution to make, ' she says.

Others are more scathing. 'The NHS has bought the idea that it is possible to have someone come in, pick off a few patients and save a lot of money, ' says one. 'It will not happen.' The NHS long-term conditions model will certainly pose challenges for bodies overseeing and commissioning care. Identifying which patients to target will require a huge amount of data and sophisticated software to analyse it.

Community matrons will have to be put in place. One HSJ source says their role is very different from that of the district nurse, but PCTs may not realise how different or may have no choice about redploying existing staff, given recruitment difficulties.

Planning and funding the sophisticated packages of care needed to support care plans may tax PCTs struggling with their current commissioning load.

And while the NHS long-term conditions model emphasises the benefits of employing it (better care for patients, reduced emergency admissions) it is not clear that it comes with any sticks (more money or penalties for not doing it).

Long Term Medical Conditions Alliance chief executive David Pink says: 'There is a danger with the pyramid that it could be used by health service planners to focus resources and attention on the worst patients - and I mean the worst patients from the health planners' point of view.

'If the framework just focuses on the top of the pyramid, it will not only be unjust and unfair in terms of focusing on just trying to pull down bed days and not the quality of life of patients, but it will also act as a perverse incentive to people in the system like GPs, and to individuals themselves, as it will reward them for being more ill.

'It is our hope and expectation that the framework will give just as much attention to the rest of the pyramid as well.

Paul Farmer, director of public affairs for mental health charity Rethink, wants to see early intervention, but feels case management could have a lot to offer people with mental health problems, particularly those with long-standing conditions, who often have physical problems as well.

The challenge, he says, will be for the DoH to persuade the increasingly devolved NHS to translate a policy imperative into action.

One lever may be that almost everyone agrees this is good for patients.

All the studies in the King's Fund review reported that the case management improved 'functionality' or prevented deterioration, while Mr Nicholson earlier this month stressed that it could help to reduce health inequalities.

Dr Rosen is unconvinced that the model offers such hope. 'But, ' she adds, 'if I was a patient and I had a person with a strong personal interest in me, I would be delighted.'

Case Managing Long Term Conditions: what impact does it have in the treatment of older people?

www. kingsfund. org. uk

LONG-TERM CONDITIONS: WHAT THE NHS MODEL WILL LOOK LIKE

LEVEL 3

Case management for patients with complex, long-term conditions and high-intensity needs:

Health and social care organisations should develop ways of identifying these patients.

The community matron role should be developed.

The community matron should work with patients and carers to draw up a care plan setting out their needs.

The community matron should co-ordinate the different professionals needed to deliver the plan.

LEVEL 2

Disease management for patients with a single condition or range of problems that threaten their health:

Primary care trusts and wider health communities should identify these patients.

PCTs and practices should develop and extend disease-based protocols and ensure that multi-agency teams deliver against them.

There should be regular recall and reassessment of patients.

LEVEL 1

Supporting self care for patients with stable conditions . Health and social care organisations should understand self care, develop generic selfcare stills, deliver the expert patient programme and education patients about specific conditions.