NHS must proceed with caution on new methods for reducing hospital admissions among older people

The government's approach to helping older people with long-term health conditions stay out of hospital is welcome, but the NHS should proceed with caution in introducing new 'case management' initiatives as evidence on their effectiveness is weak, says a report from The King's Fund published today.

The report examines the evidence behind government moves to get all primary care trusts in England to establish case management programmes by 2008. Case management involves providing tailored-care to people identified as being most at risk of hospital admission and is seen as a key weapon in the battle to reduce emergency hospital bed days by five per cent from 2005. Ministers strongly favour a nurse-led case management approach. One such model is already being piloted in nine primary care trusts and 3,000 community matrons will be recruited to extend this work across the country.

But The King's Fund report, which is based on a review of published evidence on the impact of case management, argues that:

  • There is limited evidence that case management for older people can reduce hospital admissions - the evidence base is weak
  • There are many different ways of organising case management for high-risk patients with long-term conditions, with no strong evidence to support one approach over any other.
  • US approaches, on which much of current England policy is based, may not translate easily to other health systems
  • Evidence for the cost-effectiveness of case management is limited. Further evaluation is needed to establish whether the benefits of providing case management are offset by savings from fewer patients using hospital services.

Co-report author Dr Rebecca Rosen said:

'The NHS is under increasing pressure to introduce case management. Although the evidence is limited, this may well be a useful way of improving care for patients with the most complex health conditions. But it's unlikely that a 'one-size-fits-all' solution to the problem of rising emergency hospital admissions will be appropriate.

'We need primary care trusts to be given genuine flexibility to develop their own arrangements, based on an analysis of local needs. Case management approaches already exist in the UK, together with well developed primary and community care services. Furthermore, we know that about half of the patients most at risk are under 65, and many are likely to need a mixture of medical and social care support not reflected in the current models of nurse-led case management.'

Case-Managing Long-Term Conditions, by Ruth Hutt, Rebecca Rosen and Janet McCauley, argues that primary care trusts need to be clear about the needs of their local patients before deciding how best to develop case management, who should provide it and the range of services that should be in place to ensure it is effective. They must consider whether it is best developed by adapting existing services or whether new arrangements should be put in place, it says. Finally, it urges them to work in close partnership with those providing social care and to ensure they continue to provide services for people with less severe illnesses who nevertheless have significant health and social care needs.

The King's Fund chief executive Niall Dickson said:

'This is not a red light but an amber one. Case management may well have the potential to improve the quality of life of these patients, but our study shows we still have a lot to learn. It remains unclear what contributes to success or failure. With many different ways of providing case management, there is still only limited evidence about which type is the most effective. We urge ministers to think carefully before committing the NHS to any single approach until we have a much clearer understanding of their impact.'

Notes to editors: 

1. For further information or interviews, please contact The King's Fund media and public relations office on 020 7307 2585, or 07831 554927.

2. Case management has been defined as the process of planning, co-ordinating, managing and reviewing the care of an individual. The broad aim is to develop cost-effective and efficient ways of co-ordinating services in order to improve quality of life. There is no single model of case management, and the term is used to describe a range of approaches to improve the organisation and co-ordination of services for people with severe, complex health problems. Many forms of case management already exist in the NHS and new arrangements are emerging.

3. The King's Fund is an independent charitable foundation working for better health, especially in London. We carry out research, policy analysis and development activities, working on our own, in partnerships, and through grants. We are a major resource to people working in health, offering leadership and education courses; seminars and workshops; publications; information and library services; and conference and meeting facilities.