The seminar, organised by the National Primary and Care Trust Development Programme (Natpact), in conjunction with the United Health Group Evercare, was held on 10 June.

Chaired by the National Clinical Director for Older People’s Services, Prof Ian Philp, the seminar was attended by a variety of professionals with an interest in the care of older people, GPs, Social Services staff, DoH representatives and a small but select number of geriatricians.

The seminar comprised four parts, a presentation by Prof Robert Kane, Minnesota, entitled Improving Chronic Care in England: The Potential of the Primary Care Trusts, related to the experience and research in the USA, a summary on the progress made by the Evercare team in the 10 pilot sites in England, a report on a ‘home-grown’ precursor project in Halton (Runcorn), and subsequent discussions. Space only allows me to do justice to the first two.

The USA experience and UK pilot studies The key messages Prof Kane sought to put across were that: a) chronic disease (related to an ageing population) is here to stay, so we have to learn to ‘fix it’; b) to achieve this will require significant changes to the traditional health care systems – he described predominant acute care models as ‘baroque/broke’ or more formally as ‘ill suited to chronic disease care’; c) there is evidence to show that better care is possible; and d) the ‘managed care principles’ applied in the USA might work in another context, i.e. the UK.

Prof Robert Kane

There was much in Prof Kane’s presentation that is the very basis of geriatrics, namely, the goal of managing disease to reduce exacerbations; to prevent or minimise the transition from impairment to disability, and to avoid iatrogenic effects. Prof Kane stressed that the more complex a patient’s condition, the greater the need for specialist care and the need for care teams of specialist/non-specialist professionals, breaking away from ‘organ’ focused medicine to a whole systems approach. In addressing alternative ways ahead in the management of chronic conditions, Prof Kane stressed the importance of sharing with the patient, the responsibilities of managing chronic disease - of ‘empowering the patient’.

The intention is to ensure continuous contact with (monitoring of) the patient, but not face to face physician/patient contact, with the goal of promptly identifying any change in the patient’s condition and then ensuring prompt medical intervention. The ultimate goal is both to attend quickly to a patient where there is a change in condition, and to ensure that the physicians focus on those patients who need attention and ideally give these patients more time related to their needs than is currently the case with a 15 minute norm; this will serve the patient better and make better use of the scarce physician time/resource with a consequent reduction of unnecessary hospital admissions.

One has to accept that with chronic disease there will be a decline in the patient’s condition over time; what is important is to establish, in advance, the course of the disease that one might expect, and measure against this the observed development of the patient’s condition, thus enabling any sudden deviation to be identified. It will also serve as a measure of the success in managing the chronic disease.

Against this background Prof Kane stressed the need for a good doctor-patient relationship (patient more likely to follow a regimen where the doctor is liked), the need to train patients to make observations, the requirement for physicians to develop new roles/skills, and a change to the traditional practice of care being administered in a certain specific place. At the same time, what is needed is a seed change from the high profile of the ‘firefighters’, rewarded for acute interventions, to greater recognition of the success of chronic disease management. Nevertheless, Prof Kane acknowledged that the latter is harder to measure, but that one has to make it clear to carers that the long term decline in a patient’s condition does not reflect a lack of success.

Prof Kane dwelt on the need for good information systems and in particular the need to get information on a patient, to a doctor in a way that will attract the doctor’s attention and focus on the relevant information the doctor requires. Prof Kane also drew attention to the ‘amazingly’ bad state of communications, both within hospitals and between hospitals and primary care, on a patient’s medication. The problems of inappropriate medication were also addressed, coupled with the suggestion that there be a ‘pre-programme’ of medication to overcome the risks of drug-interactions.

Looking to the future
Prof Kane advocates, inter alia:

• ‘outcomes accountability (to apply equally to Social Services as to Health Care – both services need to have the same shared goal to ‘provide what the patient lacks’, and to make the partnership succeed)
  
• a role for case management; the development of a strategy to address Primary Care (See Fahey, BMJ, 2003)
  
• an active role for geriatrics consultants in LTC,
  
• Nurse Practitioners and better trained GPs
  
• interdisciplinary team care; and
  
• more consumer education.

Prof Kane perceives the PCTs as ‘positive managed care models’ with the capacity to overcome adverse incentives and merge disease and case management. In discussing the use of case management in the USA , Prof Kane warns of the dangers of attracting only the ‘sicker clients’, which distorts the overall cost of care.

Prof Kane devoted some time to the financial aspects, emphasising that one should look at the longer term effects of change rather than short term pressures. He believes this change in focus will result in a more cost effective outcome (albeit that this is expressed in American terms of ‘profit’). He identifies the fact that there will be a redistribution of finance between secondary and primary care, and between the health sector and Social Services, i.e. ‘spending in one area yields savings in another’.

UK Evercare pilot sites Marcia Smith, on behalf of the United Health Group, explained the purpose of the 17 month pilot scheme in England, starting from 1 April 2003. Nine of the sites focus on the high risk older people and improving the care pathway, while one site focuses on the capacity for planning, with the outcome being formally evaluated by the National Care Research & Evaluation Centre of the University of Manchester. The goal of Evercare is to offer a system that will ‘optimise primary care of older people and, in the process, reduce avoidable admissions to secondary care.

The principles of the programme are:

• individualised whole person approach (function, independence, comfort, quality of life)
  
• primary care the central organisation for all care
  
• care provided in the least invasive manner
  
• adverse effects of polypharmacy avoided
  
• decisions based on data

Focus of the programme including preliminary results in England
Patient related objectives:

• To identify those people most at risk and monitor outcomes. There is no set way of doing this; they started in England by identifying people over 65, who had been in hospital (emergency admissions), and ascertained that on the data provided by the PCTs, 2-3% of the over 65’s age group accounted for 30% of the hospital admissions the previous year. It was intended to identify other high risk patients that the GPs would know about.
• Collaborative partnership GPs and qualified nurses. Thirty-six nurses have been hired and are being trained in their new role, which includes a more clinical focus, i.e. taking patients’ histories, effecting physical examinations and reporting abnormalities to the GP, communicating across the health care system (not just vertically), and acting as the patients’ champion. This is seen as a collaborative venture with the GPs, who have embraced the concept with varying degrees of enthusiasm, some very supportive, others less so and some ‘may be’.
• Routine education and training for the nurses (a week at a time) is in place, supported by US nurses. Eventually the initial 36 will themselves, become trainers. The response from the nurses under training has been favourable, with the nurses welcoming a more proactive role and the greater clinical involvement.
• Facilitating fast track care in community and hospital, proactive management of high risk caseload, and systematic tools/processes. There will be 60 -70 patients per nurse; nurses will initially spend 5 hours making a patient assessment and developing a care plan to be checked by the GP. Patients will be expected to ‘phone the nurse in the event that there is a change in their condition; in the case of those patients deemed most vulnerable the nurse will contact the patient if there is no call from the patient. Thus a hospital admission, for example, pneumonia will be seen as a failure of the system, as one would expect this to be ‘picked up’ before it becomes critical. Medication will be checked and the patient’s choices will be reviewed as the chronic nature of the disease progresses.

What the studies show so far
Marcia Smith summed up the lessons learned to date.

• ‘speed is possible in the NHS’
  
• resistance has come from ‘predictable entities’
  
• population–based data is available but has not been analysed
  
• nursing values and philosophies are closely aligned between UK and USA
  
• the interest in training needs has been larger than was anticipated
  
• progress made has been proportional to the PCT resource invested

Was the UK there first? Chronic Care Management in Runcorn
Jayne Penny spoke with great enthusiasm on what was clearly a precursor to the Evercare system, an initiative undertaken in Halton by (then Fundholding) GPs in which, as a nurse, she had played a pivotal role. It comprised a system of targeting patients and funds, making assessments and a case plan, interventions as necessary, and an evaluation of the outcomes. Ms Penny cited two case studies of what was adjudged a success, attracting interest from other areas of England. The results were reduced hospital admissions, shorter lengths of stay, closer working with Social Services and between Primary and Secondary Care, and improved patient access to services. Jayne drew attention to the subsequent fit with the NSF in terms of patient centred care, Intermediate Care and the promotion of healthy living

Richard Lynham
BGS Administrative Director