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Rapid Responses: Rapid Responses published:
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NHS/Kaiser comparison
- carl thomson (29 November 2003)
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Waiting to go home. ? too many specialists ?
- Richard F Gunstone (29 November 2003)
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I could have told you what it took 35 clinicians and managers travelling to California to discover
- Margaret E Allen (30 November 2003)
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Urinary Tract Infection
- Hamish McLaren (1 December 2003)
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Not comparing like with like
- Mark L Mallet (2 December 2003)
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Debate about Kaiser needs transparency and hard evidence
- David A Evans (3 December 2003)
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Worried about a new Target!
- Nikhil C Kaushik (3 December 2003)
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NHS/ Kaiser comparison
- John J McMullan (4 December 2003)
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Quality of care, length of stay and readmissions
- Shah Ebrahim, Stephen Frankel, George Davey Smith (4 December 2003)
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Bringing the Kaiser principles to the NHS - Do not throw the baby out with the bath water.
- PADMANABHAN BADRINATH (6 December 2003)
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Improving bed management in the NHS
- Stephen Black, Nathan C. Proudlove (8 December 2003)
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Hospital bed utilisation and deprivation
- Adrian B Drake-Lee (11 December 2003)
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Is co-morbid dementia more prevalent in NHS admissions than Californian?
- Jerry Seymour (16 December 2003)
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Mere pedantry?
- Michael R Lewis (21 December 2003)
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Pursuit of Perfection
- Jacqueline CT Close, Miranda C Jenkins (6 January 2004)
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There is more to care than counting hospital bed days
- Martyn J Parker (23 January 2004)
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Clinician input would have made analysis more convincing
- Rowan H Harwood (2 February 2004)
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Incidence / Prevalence OUGHT to affect bed use
- L S Lewis (11 August 2004)
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carl thomson, semi-retired CA13 0YG
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The great disparity in admissions with angina seems easy to explain. With patients waiting a year for CABG it is a common experience to see waiting list patients repeatedly admitted with chest pain ? unstable angina. Also an NHS feature is the patient who is kept in hospital for an urgent test e.g. exercise ECG, endoscopy, echocardiograph which can be done in a day or three as an in-patient but goes on to the 'n' months waiting list for outpatients if the patient is discharged. A fee for item of service would quickly right this in the NHS. Competing interests: None declared |
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Richard F Gunstone, Retired physician. Lecturer in Medicine Walsgrave Hospital CV2 2DX
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One reason for the delay in discharge of patients from acute beds is the increased number of specialist nurses and therapists who are thought necessary to see the patient before discharge and who work in different hospitals departments rather than the ward. Surely the ward Sister has many of the skills of the tissue viability nurse and the stoma nurse, and a knowledge of nutrition and illness and an understanding of pain and of the analgesics prescribed for the patient to take home? It is even possible that the surgeon or physician caring for the patient might have a role in thse matters.... Competing interests: None declared |
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Margaret E Allen, Physician Assistant East Palo Alto, California
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It took 35 clinicians and managers, travelling to and staying in California, to discover that the NHS can learn from Kaiser's approach to day bed use? I have been a Kaiser patient myself, have recently spent a year working in the NHS, and have now returned to work as a family practice mid- level clincian in the Medicare system in California. I could have told you for a fraction of the cost that beds are managed tightly here, with support from more cost-effective support services, a more practical philosophical life-style approach, and less physician turf protection than in the NHS. Not only is money being wasted on kind but absurd day bed use in the UK (waiting for routine evaluations, doctors not wanting to discharge a patient because of the extra work involved) but on junkets to California, New York, Minnesota, and Louisiana (to name but a few recently investigated US communities). These places have been visited by sincere but, oh I don't know, exploitative NHS staff, looking for solutions to the NHS workforce crisis. Well-trained mid-level providers, such as the inaccurately-named physician assistants, could tap a reservoir of skill and experience available to augment the inadequate NHS workforce. Accessing this group would not take personnel away from nursing, and takes advantage of ethnic and gender diversity. A national programme of training, evaluation, and registration could be set up quite easily, and physician assistants added to the NHS workforce within a relatively short period of time, providing continuity on the wards, and liaison with general practitioners It would be nice to feel that money was being spent on effective, well- documented solutions, rather than all-expenses-paid jaunts to sunny California! Competing interests: None declared |
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Hamish McLaren, Consultant Physician Greater Glasgow NHS Board, PO Box 15329, 350 St Vincent St, Glasgow G3 8YZ
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I was interested to see that the diagnosis of "urinary tract infection" features as one of the top 11 reasons for emergency hospital admission. This diagnosis also features in the top twenty reasons for admission to North Glasgow Hospitals but is at variance with clinical experience which suggests that it features rarely as a primary reason for admission. Although some of my DME colleagues would not agree I think the reason for this diagnosis featuring so prominently is that it is a label applied to many old people who are admitted "off their feet". Urine culture is part of the routine work up in these cases and is frequently positive although how much urinary infection has to do with the person's deterioration is debatable. I would suggest that this diagnosis is really a surrogate for unexplained deterioration in elderly people which would also explain the long length of stay (15 days)associated with the label Competing interests: None declared |
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Mark L Mallet, Consultant Physician Royal United Hospital, Bath BA1 3NG
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The analysis by Ham and colleagues appears to be seriously flawed by the inability to distinguish NHS acute hospital bed days from stays in community hospitals and similar facilities. This is particularly relevant to stroke, which contributes most to the overall difference, by having long total lengths of stay. The availablility in the Kaiser system of 'skilled nursing facilities' with access to therapists would presumably equate to stroke rehabilitation facilities in intermediate care in the NHS; it would be good to see what effect the inclusion of these bed days makes to the comparison. Competing interests: None declared |
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David A Evans, SHO, obstetrics and gynaecology Chesterfield and North Derbyshire Royal Hospital NHS Trust, Calow, CHESTERFIELD. S44 5BL
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Editor, The original article by Feacham et al.(1) comparing Kaiser with the National Health Service has attracted much attention, not least from the Department of Health. Constructive debate challenging the infrastructure and process of the NHS is to be welcomed. We should not become complacent or blame shortcomings blindly on lack of resources. I am sure that we have much to learn from each other. However, the authority of the debate is diluted by the way in which the article by Ham et al(2) was published. Firstly, Chris Ham did not declare any competing interests. The DoH, for which he is Strategy Director, is currently running pilots in 7 Primary Care Trusts adapting elements of the Kaiser model. He therefore has a vested interest in showing that the model his team has advocated performs better than the NHS. Secondly, I was surprised that the conclusions of the paper were presented as fact in the summary box “What this study adds”. The paper suggests that Kaiser has accomplished its better acute bed utilisation “through integration of care, active management of patients, the use of intermediate care, self care and medical leadership”. Neither this paper nor Feacham’s have presented any evidence that this is the case: these claims are either speculative or based on their own analysis of the Kaiser system. Whether or not Kaiser actually achieves better bed utilisation and how this is achieved has not been conclusively demonstrated. The presentation of the paper in this way does not promote debate, but weakens it. The influence of such a publication should not be underestimated. The DoH has set up pilots modelled on aspects of the Kaiser system on the basis of Feacham’s flawed article, which was surely only intended to initiate debate. It is important to ensure that unsubstantiated conclusions are not presented as fact, so that we are not fuelling another fruitless political exercise. Unfortunately, the Primary Care Trust pilots will all omit the most significant distinction of the Kaiser system – that it is not run by politicians. 1) Feacham RGA, Sekhri N, White K. Getting more for their dollar: a comparison of the NHS and California’s Kaiser Permanente. BMJ 2002;324:135 -43 2) Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003;327:1257-1260 Competing interests: None declared |
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Nikhil C Kaushik, Consultant Ophthalmic Surgeon North East Wales NHS Trust Hospital, Croesnewydd Road, Wrexham LL13 7TD
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In this study the authours Ham et al have concentrated on people aged 65 and over because older people make the greatest use of acute beds. This is a bold statement but a fact of life. Getting unwell or not remaining as well as one is during youth is what OLD AGE is all about. My fear is that some well meaning policy advisor in the DOH might latch upon this phrase and consider introducing a new Target that might be a part of the next Queens' speach as : ".......government will aim to reduce the number of people over the age of 65 in the UK by 30% during the term of this parliament!" Competing interests: Interested in having an opportunity to serve the elderly with eye problems. |
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John J McMullan, Retired gp, occupational physician HP7 0HU home visits for disability assessments
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The marked differences have various causes. The greater admission rates result from delays in hospital treatment, as Dr Carl Thomson points out in relation to angina and CABG. The longer stay makes greater differences. Both are affected by integration which, the authors say, "enables patients to move easily between hospital and community, or into skilled nursing facilities". Integration was well under way in 1972 when I visited Kaiser during a study of behaviour, health and disablity. The need for integration was recognised from the start of the NHS in 1948 and first steps were taken by the attachment of District (community) Nurses to general practices. A study in Leeds (MacPhail AN, Bradshaw DB. Lancet July 8 1967:89-91) showed in graphic detail the need for good assessments of home circumstances and care from nurses, therapists and support services to allow sucessful early discharge home and avoid repeated readmissions. Now the former 'bed-blocker' has become to-day's yo-yo readmission. Why is our progress so slow? Attitudes change slowly. New medical schools are bringing together scientific cure and community care which rightly overlap. Interprofessioal education has practical difficulties but they can be overcome. If our older teaching hospitals were to bring the education of nurses alongside that of doctors integration could go ahead before another generation elapses. Competing interests: None declared |
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Shah Ebrahim, Professor of Epidemiology of Ageing Department of Social Medicine, University of Bristol, BS8 2PR, Stephen Frankel, George Davey Smith
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Ham and colleagues report that bed-days used for a range of common diagnoses among people aged 65 years and over are substantially higher in the NHS than in United States managed care programmes.[1] They conclude that the NHS can learn from Kaiser Permanente Medical Care Programme’s integrated model. Stroke admissions contribute most to the extra bed-days in the NHS and also show the largest relative differences from the USA comparators used in the analysis. Since admissions for stroke are driven by the incidence of stroke, one would expect countries with a high incidence of stroke to have high admission rates. Comparable incidence rates are not available, but mortality, which serves as a reasonable proxy for incidence, shows that the USA has much lower rates of stroke than the UK; age-adjusted stroke mortality rates in the USA are about 35% and 49% lower at ages 35-74 and 75-84 years respectively.[2] The analysis presented here shows that despite the lower risk of stroke, admission rates for Medicare in California and USA are about 45% higher than the NHS rates, and Kaiser’s rates are broadly similar. It seems likely that the higher Medicare stroke admission rates in the face of lower incidence is due to a higher proportion of re-admissions among US stroke patients that among NHS patients. A considerable proportion of the longer average stay for NHS patients must simply represent the fact that more British patients are admitted only once, rather than repeatedly. Furthermore, the NHS bed-days include days spent in intermediate care beds, but these post-acute bed-days are not included for the US data. Randomised controlled trials of stroke units demonstrate clear benefits in terms of long-term disability and mortality, with none of the trials in a Cochrane systematic review reporting median lengths of stay of less than 13 days.[3] It seems implausible that high quality stroke care is consistent with US managed care stays of only 4 to 6 days. It is perfectly possible to discharge elderly people with strokes (and other conditions) from acute hospitals very rapidly, but if the consequences are a failure to apply effective clinical interventions and rapid re- admissions this hardly constitutes successful management. Ham et al suggest that patients should be “co-providers” of their care. The vision of stroke patients admitted, then readmitted to hospital would be a perfect satire on the “cost is all” view of “saving” the NHS, if it were not clear that this message would be greeted enthusiastically by government. 1. Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente,and the US Medicare programme: analysis of routine data. BMJ 2003;327: 2. Sarti C, Rastenyte D, Cepaitis Z, Tuomilehto J. International trends in mortality from stroke, 1968 to 1994. Stroke 2000;31:1588-1601 3. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software Competing interests: None declared |
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PADMANABHAN BADRINATH, Specialist Registrar in Public Health Medicine Southend PCT, Harcourt House, Harcourt Avenue, Southend on Sea, SS2 6HE
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Editor, NHS has declared loud and clear that it is a learning organisation and would work more proactively with partners to become a consistent, high commitment, learning organisation (1). In a recent statement (2) the Secretary of State for Health warned the critics who are opposed to learning from a different health care system and emphasised that preparedness to learn and improve is a sign of strength, not of weakness. He also listed the five lessons that the NHS could learn from Kaiser Permanente, USA, and the most relevant lesson being integration of health care provision. We have a tendency to dismiss totally or view with great scepticism any issues being championed by senior NHS managers or politicians assuming that the hidden agenda is to cut costs. In our enthusiasm to safeguard patient care, we should not rush to veto initiatives from other health care systems. One of the criticisms (3) of the paper by Ham et al (BMJ Nov 29) is that no evidence has been presented for the conclusion “that Kaiser has accomplished its better acute bed utilisation “through integration of care, active management of patients, the use of intermediate care, self care and medical leadership”. Ham et al do state in their methods that to understand the reasons for difference in bed days, one of the authors interviewed senior clinical and managerial staff including visits to Kaiser medical facilities. This type of qualitative data is hard to summarise and present in a quantitative manner. However, there is empirical evidence to show that Kaiser’s Chronic Care Programme Management targeting diabetes, hyperlipidemia, asthma and congestive heart failure has reduced emergency department visits. From 1996 to 2000, the emergency department visit rate for Kaiser patients declined from 10 per 100 persistent asthmatics to four (4). In a randomised controlled trail in Kaiser Health Plan’s facility in Pleasanton, California (5) a multidisciplinary outpatient diabetes care management delivered by a diabetes nurse educator, a psychologist, a nutritionist, and a pharmacist in cluster visit settings of 10-18 patients per month for 6 months reduced both inpatient and outpatient utilization. Kaiser is also the market leader in providing and implementing self- management support for patients (6). In the 21st century NHS, we should be open to new ideas and innovations from anywhere including market economies and in the case of Kaiser we should not throw the baby out with the bath water. In our efforts to reject the principles of market economy from the US health care system, we should not refuse to learn the good practices from across the Atlantic, which will ultimately benefit our patients. To quote the Secretary of State “To refuse to learn at all is to commit an institution to steady decline. The NHS is a strong powerful social force in British society. It has the capacity and the strength to learn from the market just as it has the capacity and strength not to copy it". I would like to point out here that Political and Managerial Champions are as important as Clinical Champions to deliver the best possible service to the communities we serve. If we stand by and ignore the opportunities to learn from other systems, then health care historians will blame us for not bringing the best to our clients. References 1.‘Working Together – Learning Together’. A Framework for Life Long Learning in the NHS. http://www.doh.gov.uk/lifelonglearning/ accessed on 6th December 2003. 2.THE NHS MUST LEARN FROM OTHER HEALTHCARE SYSTEMS – REID. DOH press release, Tuesday 4th November 2003. http://www.info.doh.gov.uk/doh/intpress.nsf/page/2003-0423?OpenDocument. accessed on 6th December 2003. 3. Evans DA. Debate about Kaiser needs transparency and hard evidence. BMJ rapid response, 3rd December. http://bmj.bmjjournals.com/cgi/eletters/327/7426/1257#42194 accessed on 6th December. 4. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775-9. 5. Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care. 1999;22:2011-7. Full text free access http://care.diabetesjournals.org/cgi/reprint/22/12/2011.pdf 6. Glasgow RE, Davis CL, Funnell MM, Beck A. Implementing practical interventions to support chronic illness self-management. Jt Comm J Qual Saf. 2003;29:563-74. (The views expressed here are that of the author only and not of his employer or other associated organisations/institutions) Competing interests: The author is a keen believer in some of the principles and methods of health care delivery by Kaiser and has approached the Unit headed by Professor Chris Ham for a letter of support to spend a month in a Kaiser organisation to learn from observation and interaction. |
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Stephen Black, Principal Consultant PA Consulting, 123 Buckingham Palace Road, London. SW1W 9SR, Nathan C. Proudlove
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The comparison of the bed utilization in the NHS vs. Kaiser Permanente(1) suggests the NHS could improve drastically its management of beds. However the analysis leaves open the possibility that it could be expensive for the NHS in effort and money to reach the levels of efficiency at Kaiser. But we already have a body of direct evidence from other statistics within the NHS that suggest very large improvements are possible and likely to be cheap to implement. These statistics are reinforced by the early results of some modelling exercises we are currently conducting that focus on the impact of key practices in how hospitals manage beds. We know, for example, that length of stay (LOS) varies a great deal in different hospitals (and for reasons not readily explained by demographics or differences in specialisations). We also know that within most hospitals the expected length of stay varies by around one day depending on which day you arrive(2) (a pattern with no conceivable clinical justification). Our models (which build a picture of hourly bed utilization given known patterns of emergency arrivals - which are somewhat random, elective arrivals - which are at least in principle subject to management control, and discharges - which are definitely under management control) suggest that the observed variations are largely due to the widespread practice of not discharging many patients at weekends. Given a hospital with a length of stay of about 7 days (about average), the consequence of not discharging patients on Saturday and Sunday is to waste at least 30% of the effective bed capacity. Active management of discharges and planned arrivals is key to making gains in bed management, but the evidence we have suggests that few hospitals make any attempt to manage either: in many trusts elective “planned” arrivals are more variable than (and uncoordinated with) emergency arrivals. Discharge during weekends requires either consultants to run discharge rounds or to set criteria for nurse-led discharges. Neither of these is an expensive change. We know that large improvements are possible and not just theoretical, as some hospitals have achieved them by applying active management to the arrival and discharge processes. The converse is also true: with no active management, adding more beds often reduces performance (throughput goes down, LOS goes up). We know how to improve bed management in the NHS and it is not expensive. The biggest barrier is not a lack of resources but a deep- rooted unwillingness to change working practices for the benefit of patients. 1. Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. Br Med J 2003;327:1257-1260. 2. Audit Commission. Acute hospital portfolio: bed management - review of national findings. London: Audit Commission; 2003. Competing interests: None declared |
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Adrian B Drake-Lee, Consultant ENT Surgeon University Hospital Birmingham B15 2TH
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How are we to reconcile two recent BMJ articles? The first examined bed stay in the state of California - one of the most affluent economies in the world (1). The second looked at guidelines for deprived patients in the UK (2). Smith stated in an editorial that there were four different methods to fund health care (3). One extreme was in the UK where one provider covers the whole population with state sponsored care. The opposite was found in the USA, which has non-compulsory health care insurance with many providers, where the poor may not be covered. The UK provides health care, irrespective of affluence, but deprived patients need special consideration. Any model of health care must include these patients if it is to be relevant to the UK. We must start with a bottom-up approach for planning and analysis of service. Universal figures for whole or selected populations are misleading as they examine neither social implications nor allow subgroup analysis where variations of practice occur. Deprivation can be measured. It is possible to determine the suitability of each patient and family for reduced post-operative stay. Guidelines such as those of the College of Surgeons of England for day case surgery include consideration of social conditions (5). Using a patient-centred approach, we built a model for extending day case surgery to children undergoing tonsillectomy (6). Over 95% of patients in the most affluent quintile were suitable for day case care, whereas only 55% of the least deprived were. Various factors were built into the model. The risks of postoperative complications were modeled from audit and literature review. The general health of the patient was measured by the American Society of Anesthetists (ASA) grade. The demographics of the population included the distance from the hospital, car ownership and number of adults resident. When the model is applied to aging adults, the proportion found to be medically unsuitable will be higher than in normal children (2%). Orthopaedic surgeons at the Royal Orthopaedic Hospital in Birmingham use a similar approach. They have developed a community service for adults following major joint replacement. Patients who are grade ASA I or II, and have appropriate social conditions for community care have a stay of only four days (70% of adults, personal communication). This is similar to that seen in California. The remainder require longer hospital stay. Practice varies within the UK and members of medical teams should take their social and medical responsibilities seriously to provide safe patient-centred care. I note that there were no additional funds for the California project and this sounds remarkably like a politician’s comment! 1. Ham C, York N, Sutch S, Shaw R. Hospital bed utilization in the HNS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ. 2003; 327: 1257- 1260 2. Aldrich R, Kemp L, Stewart J et al. Using socioeconomic evidence in clinical guidelines. BMJ. 2003; 327: 1283-1285 3. Smith R. The future of health care systems. 1997; 314: 1495-1496 4. Anon. Guidelines for Day Surgery. Royal College of Surgeons of England. 1992. 5. Drake-Lee A, Harris S. Social conditions and paediatric day case tonsillectomy. Journal of Health Service Research and Policy. 1999; 4: 101- 105 Competing interests: None declared |
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Jerry Seymour, Consultant in Old Age Psychiatry Nether Edge Hospital S11 9BF
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Ham et al(1) have replicated data suggesting that bed day use is three times longer in the NHS than in the Californian health maintenance organisation Kaiser Permanente, for a variety of medical conditions in over 65s. However, they have not apparently controlled for great old age or psychiatric co-morbidity (particularly dementia), which are both major causes of delayed discharge in older people(2). This may undermine their broad conclusion that the NHS could learn from Kaiser Permanente, for two reasons. Firstly, patients with dementia are likely to be excluded by health maintenance organisations. Secondly, Ham et al have not specified the age profile of the over 65s; dementia is an age sensitive condition, rare at age 65, doubling in prevalence every 5 years thereafter. If there were more very elderly people with co-morbidity admitted to hospital in the NHS than in California, the populations are not strictly comparable. There is an obvious problem with delayed discharge of elderly people in the NHS. The solution may lie not in Californian methods of health care, but in improving hospital and community dementia care in the UK. Yours sincerely JERRY SEYMOUR
(1) Ham, C., York, N., Sutch, S., Shaw, R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme : analysis of routine data. BMJ 2003; 327 : 1257-60. (2) Holmes, J., Butley, K., Cameron, I. Between two stools : Psychiatric services for older people in General Hospitals. Report of a UK Survey. University of Leeds, 2002 Competing interests: None declared |
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Michael R Lewis, Principal in General Practice Welshpool Medical Centre, Powys, SY21 7ER
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Dear Editor, Chris Ham et al state both in their abstract and the body of their paper that the NHS can learn from Kaiser Permanente's methods. This implies that these methods are transferable to the NHS with benefit. They provide no evidence for this assertion, nor was it one of the study's objectives. Should the BMJ be more careful about 'spin', especially in papers with roots in the Department of Health? Yours faithfully, Michael Lewis GP Principal Competing interests: none. Reference. 1.Ham C, York N, Shaw R, Sutch S. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003; 327:1257-60. Competing interests: None declared |
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Jacqueline CT Close, Consultant Geriatrician King's College Hospital, East Dulwich Grove, London, SE22 8PT, Miranda C Jenkins
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Ham and colleagues are to be congratulated on triggering healthy debate on utilisatrion of beds in the NHS. Whilst the data is lacking in quality comparators, it is clear that Kaiser Permanente manage their acute hospital beds more efficiently. So why do we seem reluctant to learn from others who may be doing better? Should the response not be – how can we do better? Are some of the inefficiencies and waste we see in our current system merely a reflection of how we are electing to practice – clinicians and managers working within artificial organisational and professional boundaries whilst patients are “packaged and posted” between different parts of a system which fails to allow vital information to flow seamlessly with the individual. Pursuing Perfection is a programme being led by the Institute of Health Care Improvement (IHI) in Boston, USA. 4 UK sites are currently working with the NHS Modernisation Agency and the IHI to challenge our current thinking by setting ambitious goals for services extending across organisations and providing real time objective measurement of improvement. Lambeth and Southwark represent one health and social care community which has committed itself to this pursuit of perfection. 1 year down the line we are already starting to see significant improvements locally: - reduction in LOS for elective knee replacement from 11 days to 5 days (the ambition is day case joint replacement) - reduction in LOS for all COPD patients from 14.4 days to 6 days - improvement in quality of prescribing for older people using a national audit tool from 81% to 98% on a composite measure of 5 quality prescribing indicators - reduction in A&E attendance and hospital admission for older people who are actively case managed in primary care - reduction in readmission rates for older people - active involvement of patients in the management of their own disease and in the redesign of local services Much of the success to date has been through providing clinical teams with time and space to improve their own services and arming them with tried and tested improvement techniques to help achieve goals that are jointly set by patients and clinicians. Teams are actively encouraged to learn from others nationally and internationally and create local context to information gathered. Timely access to data displayed in an easily digestible format has proved invaluable. Gone are the days for us when we invest time and energy defending mediocre services. So much can be achieved by learning from others who are doing better. Why shouldn’t we strive to deliver the best care for our patients. Competing interests: None declared |
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Martyn J Parker, Orthopaedic Research Fellow Peterborough District Hospital, Peterborough, PE67NJ
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I am only able to comment on the validity of this article in relationship to hip fracture patients. The article implies that improvements in NHS care to these patients would occur it their length of stay was similar to the mean of 5 days for those in the Kaiser scheme in comparison to the 27 days in a NHS hospital for hip fracture patients. The low length of stay for the Kaiser patients is achieved by transferring almost all hip fracture patients to step down facilities, which are not classified as ‘hospital stay’. The contrasts with the majority of the NHS patients being discharged directly home. Dose these utilisations of step down facilities improve the outcome for hip fracture patients or reduce costs? There is very little published material on the topic. Fitzgerald, Moore and Dittus 1988, reported a mean hospital stay of 10 days in the USA, with 49% of hip fracture patients being transferred to step down facilities and 39% of these patients still being there six months later. Comparison on costs for hip fracture care is even more difficult to achieve. A cost of hip fracture care of 17,500 US dollars was quoted in 1997 (Brinsky et al 1997). This compares with our estimate of around 5000 UK pounds in 1993. These figures are only rough estimates and until more carefully conducted studies are undertaken regarding the outcomes and costs for hip fracture care between the different health systems or models of care, it is inappropriate to suggest that shorter hospital stays are the better way to manage hip fracture patients. References Brainsky A, Glick H, Lydick E, Epstein R, Fox KM, Hawkes W et al. The economic cost of hip fractures in community-dwelling older adults: a prospective study. J Am Ger Soc 1997;45:281-287. Fitzgerald JF, Moore PS, Dittus RS. The care of elderly patients with hip fracture: changes since implementation of the prospective payment system. N Engl J Med 1988;319:1392-1397. Hollingworth W, Todd C, Parker MJ, Roberts JA, Williams R. Cost analysis of early discharge after hip fracture. Br Med J 1993;307:903-6. Competing interests: None declared |
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Rowan H Harwood, consultant geriatrician QMC Nottingham NG7 2UH
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There is plenty wrong with UK health and social services. Maybe we do have something to learn from Kaiser. But I was not wholly convinced by the analysis of Ham et al. 1. If mean length of stay for stroke and hip fracture, really was 4-5 days under Kaiser, one of 2 things must be happening. Either the care was grossly deficient, or, more likely, patients were being transferred to 'intermediate care' or nursing home beds when in the UK they would have been rehabilitated in hospital. But a UK nursing home would not be recognisable to the a Californian facilities performing this function. They are often large facilities with have their own therapy and medical staff. What in the UK we would call a 'hospital'. This is simply a matter of definitions and organisation, not philosophy. One reason we could not emulate the US is that we struggle to find adequate medical, nursing and therapy staff for these patients, and dispersing them would bring dis- economies of scale that we could not afford. 2. The reason that patients wait in NHS beds is not because we do not know how to plan discharges. The first problem is the ongoing problems with arranging community home care support packages and institutional care for those who need them. Over the 8 years I have been a consultant I have seen social workers withdrawn from multi-disciplinary meetings on both acute and rehabilitation wards, and a 48h notice period for home care swell into a fortnight to get an allocated social worker and a further fortnight to assemble the required package. 3. A further problem is with the assumption that most people want to go home. They do, but perhaps 10-20% do not. My rehabilitation philosophy is that we try to maximise abilities to give people choices (about returning home) that they would not otherwise have. However, a significant minority, or their families, have little desire to try. The assumption that institutional care will necessarily be arranged from hospital in these cases (and there are scant alternatives)is very wasteful of hospital beds. Some families are also very tardy in looking for institutional care places when requested to find them. In neither case do NHS staff have any authority or sanction to speed the process up. 4. We know that in-patient stroke unit care (and to an extent specialist hip fracture rehabilitation) is highly effective in improving outcomes. Intermediate care models (often without specialist medical support) have not been tested in the same way. We evaluated the Nottingham Early Discharge and Rehabiltiation service by randomised controlled trial (Age and Ageing, in press). It was highly successful. But despite us having a stake in developing the service, as well as trying to recruit for the trial, we found that only a few per cent of elderly patients were suitable. We have also evaluated residential home rehabilitation - outcomes were similar but length of stay was greatly increased in the residential home participants. Do we believe in evidence-based policy or not? Ham et als analysis looks rather naive. Were they unaware of the differences of definition, or effect of 'politically driven' secular expectations? What did the 35 clinicians and managers who were sent to look at Kaiser have to say? Their views are not systematically reported. To an extent the NHS has evolved to adapt to some of the peculiar pressures placed upon it (not least staffing and funding constraints). There may be quick wins to be had in sorting out Social Services responsiveness, but we won't shift the public's expectation of a hospital bed on demand too quickly. I worry that someone as senior and authoritative as Chris Ham may assume that structural change along the lines of Kaiser will solve the NHSs problems. It wouldn't, it would make things even worse. Competing interests: None declared |
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L S Lewis, GP / Medical Adviser Surgery, Newport, Pembrokeshire, SA42 0TJ
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Ham et al, in a detailed and thorough effort to
compare like-with-like and avoid bias, have certainly caused me to see what I
can learn from Kaiser ! I happen to
believe that NHS doctors feel that they 'share' a stake in the NHS, but
their efforts are more 'compartmented' than integrated.. Already considerable incentives to keep
people out of hospital (eg: NO BEDS ! , GP quality payments, etc. ) would be
further enhanced by local PCT empowerment of 'GP purchasing' , using a
neo-fundholding model, under a system
of NHS Tariffs ( an idea I proposed to Chris Ham 10 years ago ! ). It is not that primary and secondary
care have to be 'integrated' (some hope
! ) , but rather that one 'purchasing' power overseeing the whole
patient-pathway provides the efficiency Kaiser seems to have. In the paper, I noticed that the sum total of bed-days used for all 4 heart conditions
(Coronary bypass, MI, heart failure, Angina)
is much the same per 100,000 population under both systems, although
under Kaiser it appears that this usage comprises more frequent admission, for
shorter stays. Acknowledging that
unseen bed-usage differences ( beds 'outside' each system , eg. private or
intermediate-care) might bias, Ham shows, at least for 'within-system'
bed-usage, that average bed-days used per 100,000 population, for
each of 11 'health-needs', is very much less under Kaiser, than under the NHS. Professor Shah Ebrahim , in his 'Rapid Response ' , said
"Since admissions for stroke are driven by the incidence of stroke,
one would expect countries with a high incidence of stroke to have high
admission rates. Comparable incidence rates are not available, but mortality,
which serves as a reasonable proxy for incidence, shows that the USA has much
lower rates of stroke than the UK; age-adjusted stroke mortality rates in the
USA are about 35% and 49% lower at ages 35-74 and 75-84 years respectively.[2]
". This set me thinking that
significant 'incidence' and 'prevalence' differences between the two healthcare
systems might introduce bias which fundamentally undermines the paper's
conclusion.. Incidence
Bias :- What if there
are only half as many strokes in the Kaiser population, in the period ? The comparison between each system's bed-usage-per-stroke could show a reversed position. Prevalence
Bias :- What
if the number of over-65's with
ischaemic heart disease is twice as high in the NHS as it is in Kaiser ?
This could mean that bed usage
per ischaemic person in the NHS would be half that of Kaiser. Is it possible to incorporate Incidence / Prevalence
comparisons into a re-analysis ? Yours sincerely, Dr L S Lewis Surgery Newport Pembrokeshire Competing interests: I work for the NHS |
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