Headlines: November 30th, 2004

The National Health Service is being warned today to be cautious in introducing new ‘case management’ initiatives in helping older people with long-term health conditions stay out of hospital. The advice comes in a report from the King’s Fund, which says evidence on the effectiveness of such measures is weak.The report studies the evidence behind government moves to get all Primary Care Trusts in England to establish case management programmes by 2008. Case management, it explains, involves providing tailored-care to those people seen to be at most at risk of hospital admission. It is an important weapon in efforts to cut emergency hospital bed days by five per cent from next year. Ministers favour a nurse-led case management approach and one such scheme is already being piloted in nine primary care trusts. Three thousand community matrons will be recruited to extend this work across the country.

The King’s Fund report is based on a review of published evidence on the impact of case management. It claims that there is only limited evidence that case management for older people can reduce hospital admissions and it says that the evidence base is weak. It goes on to say that there are many different ways of organising case management for high-risk patients with long-term conditions, but there is no strong evidence to support one approach over any other.

The authors warn, too, that approaches used in the United States, on which much of current policy in England is based, may not translate easily to other health systems and that evidence for the cost-effectiveness of case management is also limited. They call for further evaluation to establish whether the benefits of providing case management are offset by savings from fewer patients using hospital services.

“Case-Managing Long-Term Conditions”, by Ruth Hutt, Rebecca Rosen and Janet McCauley, argues that care trusts need to be clear about the needs of local patients before deciding how to develop case management, planning who should provide it and agreeing the range of services that should be in place to make sure it is effective. It urges the trusts to work in close partnership with organisations providing social care and to ensure they continue to provide services for people with less severe illnesses but who still have significant health and social care needs.

One of the report’s authors, Dr Rebecca Rosen, said the NHS was under pressure to introduce case management and, though the evidence was limited, this might be a useful way of improving care for patients with the most complex health conditions, but a ‘one-size-fits-all’ solution to the problem of rising emergency hospital admissions was unlikely to be appropriate. “We need primary care trusts to be given genuine flexibility to develop their own arrangements, based on an analysis of local needs,” she said.