Why could US provider Kaiser provide better care at the same cost as the NHS? Why were there so many bed days in the UK? After four years of questions, writes Professor Chris Ham, beacon sites are providing answers
For the past four years an important debate has been raging on what lessons the NHS can learn from Kaiser Permanente, a US organisation that finances and provides healthcare.
The spark was an analysis by Richard Feachem and colleagues, published in the BMJ in 2002, which claimed Kaiser achieved better performance than the NHS at roughly the same cost. It attracted huge interest and argument.
Later, an analysis of hospital use for 11 leading causes of bed day use compared available data for the population aged 65 and over in the NHS, Kaiser and the Medicare population in California. The NHS used three and a half times as many bed days as Kaiser and almost twice the Medicare California standardised rate. Kaiser achieved these results through a combination of relatively low admission rates and much shorter hospital stays. Length of stay varied directly in line with age in the NHS, but not with Kaiser.
But describing differences in healthcare utilisation is not the same as explaining them. How was Kaiser able to provide healthcare to its older members using far fewer bed days? Visits to the US by NHS nurses and NHS managers found a number of factors.
Following the visits, a number of NHS pilot projects were set up, selecting aspects of Kaiser's approach that seemed to have particular relevance to the challenges here.
These beacon sites would not claim to have transformed service provision, even though progress has been made. All three have started to integrate care, focusing on diseases, populations and localities that are local priorities.
A few barriers...
The pilot projects have faced barriers to change. These include government policies that risk further fragmenting care rather than supporting integration. Particularly important in this respect are foundation trusts based on acute hospitals only, payment by results that rewards additional hospital activity, and practice-based commissioning that, in the wrong hands, could accentuate divisions between primary and secondary care.
But local leaders have kept faith with their visions. The Our Health, Our Care, Our Say white paper sets out a direction entirely consistent with the work of the beacon sites. At the heart of this vision is care closer to home through a stronger focus on meeting the needs of people with long-term conditions, thereby avoiding unnecessary hospital admissions.
In the words of one of Kaiser's leaders, the key to achieving successful change is 'momentum rather than speed'. The beacon sites have started to build the momentum required to enable change and improvement to become sustainable.
Plans for the integration of services in Torbay were developed following visits to Kaiser by the primary care trust chief executive and senior staff in 2003. The acute trust was involved early and took part in subsequent study visits. The PCT has also been working with the local authority to integrate health and social care, and a care trust was formed last December.
The common concern has been to achieve much closer integration of organisations and services. Specifically, the care trust and the acute trust have committed themselves to:
- integration of care;
- promotion of supported self-care, particularly in the management of long-term conditions;
- avoidance of unplanned hospital care;
- personal care management for vulnerable people with the most complex needs.
One of the early projects was the North Torquay integrated health and social care centre. The aim is to bring together three practices in new premises, with much closer involvement of social care staff. The plans also involve services that are normally available only at Torbay Hospital, such as outpatient services and some diagnostic facilities. A site for the centre has been identified and, when complete, it will serve a population of 28,000.
North Torquay is an example of work across Torbay to integrate health and social care services in areas known as zones. Five zones have been established, serving populations of between 25,000 and 40,000. In each zone, there is an integrated health and social care team under a single manager. The zones provide a geographical focus for service integration and much of their work is concerned with the needs of older people.
The work of the integrated teams is directed at reducing reliance on unscheduled care. Practices have been encouraged to understand the populations they serve and identify patients most at risk of unplanned admissions, using the local enhanced service provisions of the new general medical services contract. In the event, the incentives did not work as intended and zones used the available resources to invest in district nursing support to identify older people at risk.
Patients most at risk are allocated a case manager and given care plans. These include treatment objectives, planned interventions and recommended actions in the event of a crisis. These plans and related information are kept in yellow folders in patients' homes and are readily available to health and social care staff. The name of the case manager is included in the folders.
One of the most significant projects was a review of community hospitals. Attention focused particularly on Paignton hospital, a 50-bed facility in the process of changing into an active intermediate care service. This involved developing the role of nurses and therapists and establishing closer links with Torbay Hospital and its team of specialists in care of the elderly.
As a consequence, lengths of stay have fallen and more patients have been treated. Paignton Hospital plays an increasing part in reducing pressure on beds at Torbay Hospital by providing a step-down facility. GPs are still involved in providing care but the emphasis now is on GPs with a special interest in care of the elderly working as one full-time equivalent from 9am-5pm, Monday to Friday.
The acute trust has become increasingly involved. The experience of adapting Kaiser's principles has influenced thinking on plans for a new hospital in Torbay. These plans envisage a hospital with 20 per cent fewer beds, based on reductions already achieved (30 beds since 2002-03) and the expectation that further reductions will be realised.
The Northumbria pilot, developed following a visit to Kaiser in 2002, is led by Northumbria Healthcare trust, responsible for three general hospitals and seven community hospitals. Its two main commissioners, North Tyneside PCT and Northumberland Care trust, are key partners.
A priority has been to improve the performance of services in the acute hospitals and strengthen integration with primary care and community health services. A tangible expression of the commitment to integration has been the appointment of a GP as one of the medical directors in the healthcare trust.
Revamping emergency care
An early priority in Northumbria was to reform emergency care. This involved establishing a 'front of house' team - three consultant physicians and two accident and emergency consultants. It operates as the Hospital at Night team after 9pm, and is supported by a single emergency care team of junior doctors. The effect of these changes was to bring consultant input to the shop floor and create a more integrated emergency care service.
A related priority was to improve 'back of house' care. This involved the differentiation of wards according to the acuity of patients treated. The aim was to concentrate acutely ill patients on wards with senior staff and to use other wards for the treatment and care of patients with less acute needs, but who had a predominantly skilled nursing and therapy need. The trust is working with partners in the health economy to expand back-of-house levels of care to community hospitals and intermediate care.
Improvements to back-of-house care are supported by the use of Interqual, clinically based software supplied by McKesson and widely used in Kaiser hospitals to assess appropriateness of admissions, care levels and length of stay. It showed that initially 23 per cent of patients were at the wrong level of care. Most should have been receiving a lower intensity of care, although some should have been at a more intensive level.
Teams of experienced nurses known as care facilitators have been employed to use these results to actively manage length of stay and facilitate patient discharge and the differentiation of back-of-house care. Although initially the Interqual project encountered resistance from clinicians, this has changed over the last year. Recently Northumbria found that, for most of the common reasons for admission, the average length of stay was less than the national average.
Underpinning this work has been the development of the three acute hospitals in Northumbria as a network. Medical staff work across different sites and can sustain services in the new 96-bed hospital at Hexham that provides care to a population of only 70,000. The trust has also invested in a contact centre, which was seen in action in Kaiser in Atlanta. This provides a single phone number for patients and offers information and a 'choose and book' service until the full direct booking service is available.
Alongside these projects, Northumbria has given priority to strengthening integration between primary care and community services. This has involved a focus on improving quality of care for people with long-term conditions.
An integrated service for people with diabetes has been established in which routine care is done in primary care with specialist outreach from the hospital. Outcomes are at least as good as those achieved in Kaiser. Similar work has been undertaken in chronic obstructive pulmonary disease and is being extended to other long-term conditions. There is more emphasis on self-care, both through the expert patient programme and other related initiatives.
In future, Northumbria will be seeking to exploit the opportunities created by the new general medical services contract and practice-based commissioning. This includes using the new quality and outcomes data and the existing medics data, which has been used for nearly five years as a tool to develop high-quality chronic disease management in Northumberland.
This database will help to focus its efforts in commissioning locally-based community services, targeted at the areas of greatest priority and potential benefit. As this happens, effort is being concentrated on four care streams - urgent care, elective care, family care and long-term conditions - with a view to developing more integrated services through agreed pathways.
This pilot involves Eastern Birmingham PCT, Solihull PCT and Heart of England foundation trust. It was developed following a visit to Kaiser by senior clinicians from the three organisations in 2003. Other managers and clinicians from Birmingham and Solihull have participated in further study visits and the Working Together for Health' programme has emerged out of their collaboration.
Over 90 per cent of Heart of England foundation trust activity is generated by the two PCTs. Its application to Monitor was not based on the assumption that it would increase activity along the lines proposed by other applicants. Rather, its involvement in the programme has led to the assumption that hospital use would stabilise and, in time, become lower volume and more specialised as a result of more integrated working with PCTs.
Quality and leadership
Working Together for Health has focused on two areas of work - improving the quality of care for people with long-term conditions, and development of clinical leadership in partnership with management.
For long-term conditions, particular attention has been given to heart failure, chronic obstructive pulmonary disease, diabetes and chronic kidney disease. Clinical teams from across the health community have undertaken process mapping to understand existing care pathways and agree how these can be improved.
In response to particular challenges in capacity and demand, Eastern Birmingham PCT invested in an intermediate care diabetes team to support primary care in developing the skills and processes to manage the burden of the disease in its most disadvantaged wards. It became the highest performer in its strategic health authority under the quality and outcomes framework in the registration of patients with diabetes, a key requisite of structured care. Dedicated community-based clinics have been developed to support GPs in managing both heart failure and COPD with heart failure, piloting an approach based on group interventions with patients.
Teams of assertive case managers have been appointed to care for the most vulnerable patients with long-term conditions. They work across the hospital-community interface in support of district nursing, providing advanced nurse practitioner advice in the systematic review and intervention with patients at a high risk of multiple admissions, resulting in a significant reduction in hospital admissions.
To support the work on long-term conditions, the Partners in Health Centre was opened last July. The centre, a converted building on a site next to Heartlands Hospital, provides innovative services for patients with long-term conditions. It operates as a neutral space, neither secondary nor primary care, where professionals can collaborate to deliver integrated care. Patients using the centre have access to self-care support and educational programmes.
The orthopaedic triage service has a major presence at the centre. This began as a pilot programme with two practices and has been expanded to cover the whole health community. It offers orthopaedic assessment in primary care by an extended scope physiotherapist for all musculoskeletal conditions where a GP feels an orthopaedic consultation is required. The service includes a mobile clinic and a choice of locations for patients. Waiting times for treatment have been cut significantly and the achievements of the service were recognised in last year's HSJ Awards. Over 70 per cent of all referrals for orthopaedic outpatients are now managed within this service.
Working Together for Health is in the early stages of using Interqual to establish the appropriateness of use of hospital and intermediate care beds and the medical fitness for discharge of patients. Heart of England has trained staff on Interqual and is carrying out initial ward audits with a view to introducing it on a routine basis on the wards during 2006-07.
The second element of work has been a focus on developing the relationships between clinicians in primary and secondary care and a leadership model that emphasises managers and clinicians working together to develop excellence in local services.
This programme has seen the identification of key individuals to develop them as local leaders according to locality and clinical specialty. The management and clinical partnership has been modelled at its most senior level by the partnerships between PCT and acute chief executives, acute medical directors and professional executive committee chairs.
Chris Ham is professor of health policy and management at Birmingham University's Health Services Management Centre.