Published: 27/05/2004, Volume II4, No. 5907 Page 24 25

UnitedHealth Group, the company behind the Evercare chronic-disease model of care for older people, is moving into the UK market, and among the high-profile names on board is the BMJ’s editor of 13 years.So why did he choose to go, and has he really ‘signed up with the devil’?

The decision by British Medical Journal editor to join US healthcare company UnitedHealth Group’s new UK business was always going to be controversial. The fact that Dr Richard Smith will be joined by special health adviser to the prime minister and long-time pusher of US ideas Simon Stevens has served to intensify the story. Stir in the increasingly political issue of chronic disease and it takes on even more importance.

Dr Smith’s move was announced last Thursday and he says e-mails were swift to arrive. He has rattled enough cages in his time (from drugs companies and dodgy research to the British Medical Association itself ) to be sanguine about criticism. He refers to a note from well-known academic and critic of managed care Allyson Pollock, who politely suggested ‘that I was signing up with the devil’.

He is keen to defend himself:

‘Obviously I had thought a lot about this before I took the job but I genuinely believe that in order to improve the NHS [then] the more skills, views and competencies, the more likely it is to work, ’ he insists.

‘Here is the NHS anxious to modernise and anxious that if things do not improve quickly, the whole thing could collapse as the middle classes desert. There is a feeling that it will be difficult to do it ourselves with existing resources - and that you need people to help you.’

Dr Smith is not likely to start his new role until the autumn and he stresses that he is still hazy about how he will be working and what he will be selling - ‘we have not decided on a name, we do not have offices’. The only real UK employee is chief operating officer Gail Marcus, who is still based Stateside.

But chronic-disease management is likely to be to the fore.

United is best known here for the nine primary care trust pilots it started last year for the Department of Health, based on its Evercare model - a major part of its US Ovations business that posted revenues of $1.7bn in the last quarter. Evercare uses advanced nurse practitioners to identify and monitor older people, often with multiple chronic diseases, who account for a disproportionate amount of unplanned acute care. Evaluation released a month ago by Manchester University ago was ‘pretty positive’ says Dr Smith. ‘I think they’ve decided to turn it into business because Evercare has gone well, although variably in different trusts. Some of them have taken to it much more easily than others.’

He says Walsall worked best.

Although the company itself has been bullish about rolling out the Evercare model across the UK, Dr Smith downplays the scale involved.


He seems to envisage PCTs calling on United in a consultancy role rather than necessarily outsourcing large parcels of social care.

‘It would be no bad thing if eventually this became embedded in the NHS and United moved onto something else, whether It is data collection and, I suspect, many other possibilities, ’ Dr Smith ponders. ‘I do think It is going to be more about helping with developments rather than providing a massive service. Perhaps It is about capturing it in the form of software that you sell, I am not sure. But it does seem different than something much simpler like setting up a cataract factory.’

‘A start has been made with Evercare and one obvious question is whether it can be spread throughout the NHS, ’ he says.

‘One of my roles is to get to know primary care better than I do at the moment.’ United is already talking to Trent strategic health authority and others in the Midlands and Dr Smith says there have been ‘overtures’ to Wales, Scotland and Northern Ireland, with a longer-term ambition in the rest of Europe.

The question remains why a PCT needs to contract with United rather than developing its own model based on Evercare principles. Dr Smith is too diplomatic to say most would not be up to it, but he does point to the ‘formidable problem’ of collating and updating the necessary population information and training the workforce.

‘It illustrates why a big American company can be helpful in the NHS. We know how fractured the health system is in the US, so United has to deal with enormous complexity and gets rather good at managing that.

The NHS may look like a monolith but we know in reality it is not. A lot of nurses are pretty unfamiliar with collecting data and analysing it, ’ argues Dr Smith.

‘The first problem is just to identify the frail elderly and in most trusts they are not clearly identified - then you work out what their needs are, triggered by their values. The success boils down to them feeling more satisfied.’

Interestingly, research in the US on Evercare, reported by Dr Smith himself last year, suggested that patient satisfaction was not especially affected, although families and carers much preferred it.Also, mortality rates were about the same - although admissions and accident and emergency attendance were halved and overall savings of $90,000 a year were achieved for each nurse employed (Dr Smith says the model assumes about 80 patients per nurse).

The UK pilots have been fairly narrow in scope, studying the very elderly based in their own homes. By contrast, Evercare in the US has tended to focus on nursing homes and Dr Smith sees no reason why that would not be appropriate in the UK in the future. ‘And clearly, although Evercare has been about the elderly, there are 45-year-olds with multiple conditions who would equally benefit from this kind of tightly co-ordinated services.’

The other area that is on United’s immediate radar is data collection - it is currently running a pilot in North Tees PCT - and its Ingenix information arm already has a base in England doing drug trials.Many PCTs lack good, wellrounded information on populations. Dr Smith accepts the crude summary that the service is, in an allusion to the UK health data company, Dr Foster for primary care, adding ‘this is a lot more complicated because constant updating is very important, and quite challenging’.

A cynic would think that Dr Smith and Mr Stevens might have pitched for their new jobs at United but he insists that the company made the approach.

Although there have long been links between the US company and the BMJ Publishing Group, of which Dr Smith is chief executive, he says he only got the initial call from Ovations chief executive Lois Quam (‘a smart, wise woman’) on 5 March.

He says he wrote down 10 reasons to pursue it and 10 reasons not to. ‘I was interested to find that the weighting was really towards moving. I am 52 and I’ve been here a long time - although there is obviously more risk involved. It might not work out at all!’

He went over to visit United in Minneapolis at Easter and says he only knew of Mr Stevens’ parallel recruitment ‘pretty far into the process, and he had other possibilities’, so it wasn’t a factor. And they have quite different jobs.

‘Simon’s got a specific position with the US company, in addition to the UK. I do not see myself in career terms going up much higher but Simon is only 37 so I am sure he probably does. His future might be in the US in the longer term, but I do not think That is going to happen to me.’

He told his employers he was going at the beginning of last week. It must have been something of a shock - he has been with them for 25 years, with 13 years as editor and chief executive.

Since he got the top job, the business has grown annual revenues from£12m to£45m, with various international deals, an impressive online portfolio of ‘knowledge’ products and a student version (‘like BMJ on speed…’, he quips). He also says he is proud of his work with the World Health Organisation in making research available affordably to the developing world. He also recalls fondly favourite topics of the past such as evidencebased care, prison health, the role of the General Medical Council and the link between unemployment and ill health.

His forthright and unpompous style will be much missed. For his part he says he will inevitably miss the weekly platform he has at BMJ, although ‘ironically I may well end up with more time than I have now to actually write’. But he is clearly looking forward to doing rather than just saying. BMJ takes him all over the world on a regular basis, he says, ‘but oddly enough rather than going to places Australia like I did very recently I find rather attractive the idea of going to Walsall and North Tees and really getting into what’s working’.