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Rapid Responses: Rapid Responses published:
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The Castefields project was not an Evercare project and was not run by UnitedHealth Group
- Richard Smith (17 November 2006)
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Failure to evaluate puts services at risk
- S. Michael Crawford (17 November 2006)
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Peer review - an expensive, arbitrary lottery
- JK Anand (18 November 2006)
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Re: The Castefields project was not an Evercare project and was not run by UnitedHealth Group
- David Black (21 November 2006)
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Error in editorial
- David A Black (5 January 2007)
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Frustration, disappointment and unmet need!
- Clive E Bowman (10 January 2007)
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Community Matrons can work
- Alexander Williams (12 January 2007)
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Richard Smith, Chief executive UnitedHealth Europe, London SW1P 1SB
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David Black's editorial says: "Supporting this information were data from an Evercare pilot in Castlefields in the UK, run by UnitedHealth Group, that had not been subjected to peer review." The Castlefields project was not an Evercare pilot and was not run by UnitedHealth Group, and the practice would probably be upset by any suggestion that it was. It's an individual practice--that of David Colin- Thomé, the "primary care czar." As far as I know, however, it’s true that its data have not been peer reviewed, but, “so what?” As I’ve long argued, peer review is not a guarantee of quality but an arbitrary, expensive, error prone lottery. (1) The Castlefields project is often presented as the British alternative to Evercare--but it was actually developed from a Seattle scheme. Richard Smith 1. Smith R. Peer review: a flawed process at the heart of science and journals. In: Smith R, The trouble with medical journals. London: RSM Press, 2006. Competing interests: I am the chief executive of UnitedHealth Europe, the company that ran the Evercare pilots |
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S. Michael Crawford, Consultant Medical Oncologist Airedale General Hospital, Skipton Road, Steeton, Keighley, West Yorkshire. BD20 6TD
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Black's editorial discusses the article by Gravelle et al[1] very fairly. We do not know if the Evercare approach avoids admissions to hospital, thereby saving money. When a new approach to the diagnosis or treatment of a condition is developed, especially if it involves a new drug, it is expected to be properly evaluated in carefully designed studies. The randomised controlled trial is the optimal method. Its widespread introduction into the NHS depends on it being approved by the National Institute for Health and Clinical Excellence. The principle of managed care is being introduced into the NHS without this evaluation. More to the point, the assumption that it and other strategies to avoid or shorten admissions must be successful is used to justify the rapid attrition of capacity in NHS hospitals, especially in general hospitals, which is happening in response to shortfalls in funding. This diminution of capacity means that patients, or doctors and other professionals acting on patients' behalf, must compete more intensely for resources. Since there is no umpire for this competition the shrinking of the NHS increases inequity. Managed care may be valuable to the NHS as well as appreciated by those who receive it. It may, in the end, reduce the number of beds required. These points must be properly tested; wards must only be closed when they are demonstrably redundant. 1 Gravelle H, Dusheiko M, Sheaff R, Sargent P, Boaden R, Pickard S, et al. Impact of case management (Evercare) on frail elderly patients. 1: Controlled before and after analysis of quantitative outcome data. BMJ 2006 doi: 10.1136/bmj.39020.413310.55. Competing interests: None declared |
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JK Anand, Retired N/A
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As the former Editor of the BMJ says - peer review is an expensive, arbitrary lottery. Why then do the "Quality Journals" - the BMJ, the Lancet,et al continue to waste money? I should add that although I published a bit in peer-reviewed journals, I no longer have an interest in the matter. (Dr Aranson will be pleased that I did not say "in the issue". Please see the issue dated 18 Nov, 2006, page 2006. Dr JK Anand Retired. Competing interests: None declared |
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David Black, Consultant Geriatrician Queen Marys Hopital Sidcup
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Richard Smith is quite correct, and the points about Castlefields being anything to do with Evercare or UHG were not in my original editorial. They were added during sub-editing, but is is my fault for missing the error in the final version. Appologies to Richard Smith and David Colin-Thome Competing interests: None declared |
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David A Black, consultant physician Queen marys Hospital, Sidcup, Kent DA14 6LT
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Please note that the editorial contains an error. The Castlefields project was not run by the United Heathcare Group. This was mistakenly added by the subediting team at the BMJ, not the author. Competing interests: None declared |
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Clive E Bowman, Medical Director BUPA Care Services, Bridge House, Outwood Lane, Horsforth, Leeds LS18 4UP
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The editorial regarding Case Management for elderly people in the community by Black (1) reflects a frustration and disappointment of the Evercare pilot projects reports in the UK and should not negate the proven benefits of the Evercare approach to the case management for care home residents which are quite a different proposition to the case management of older people in the community at large. The Evercare project in the UK seems to have proved that investment in case management improves quality, drives up costs but does not necessarily improve utilisation as measured by acute hospital admissions. In the US, Evercare has been shown to maintain quality at a reduction of overall health expenditure, particularly in terms of acute bed utilisation for the defined population of care home residents. Understanding and providing for the medical care needs and support of care homes residents remains problematic in the UK, as a typical example I am presently observing a PCT that considers the entitlement to and needs of care home residents to be no different to other older citizens. When this PCT's patients migrate to a care home the PCT is accepting of discontinuities in care incurred when an individuals usual GP chooses to decline to maintain care and then the individual is allocated to another doctor. It is clear that this does not represent any conscious choice by the individual or for that matter the receiving doctor. It is difficult to argue that such discontinuity in care is in the patient’s interests or helpful in the containment of emergency admissions and with no sense of irony the same PCT is concurrently seeking to reduce acute “inappropriate” admissions from care homes. David Black and I wrote an editorial in 1997 entitled “Community institutional care for frail elderly people, time to structure professional responsibility” (2). Whilst there have been isolated pockets of practice development, the healthcare needs of care home residents generally continue to be overlooked, recognition and reform is now long overdue. There can be no doubting that with good proactive approaches to case management, including medical care will have a positive effect not only on the health and life quality of care home residents but also reducing emergency events and transfers to acute hospitals. It is worth noting that for every NHS bed (of all types) there are more than three care homes beds in the UK and that the policy direction for more care to be provided closer to home with a reduction of acute hospital beds utilisation (3) and the well known demographic trends should make the coordinated management of community institutional care beds including medical care a priority now. This would build capabilities and confidence for people receiving long term care but also develop experience and inform development for the various and increasing forms of Intermediate care that health care will increasingly be critical to maintain acute hospital capacity. Yours sincerely Clive Bowman FRCP Black D A Case management for elderly people in the community BMJ 2007;334:3-4 (6 January), doi:10.1136/bmj.39027.550324.47 (published 15 November 2006) David Black and Clive Bowman Community institutional care for frail elderly people BMJ, Aug 1997; 315: 441 – 442 Department of health Our health, our care, our say: a new direction for community services The Stationary Office Cm 6737 January 2006 http://www.dh.gov.uk/PublicationsAndStatistics/Publications /PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanc eArticle/fs/en?CONTENT_ID=4127453&chk=NXIecj Competing interests: Medical Director BUPA Care Homes |
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Alexander Williams, General Practitioner EX41HJ
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In response to Blacks recent editorial(1), I would like to report the success of a Pilot project using a community Matron and domicillary pharmacist in a primary care setting (2). The pilot ran for 9 months and due to its positive outcomes has now been rolled out to all the cluster groups in the Exeter PCT. I am sure that the keys to our success were successful, cross boundary, multi-disciplinary working and the correct identification of the patients that we could help. We initially looked at patients with 2 or more admissions in the preceding 2 years and felt we would have little impact as the illness's were complex and well established,although included these in the caseload. We decided to target those who were emerging with new episodes of illness. Typically these would be frail, elderly women,living alone and on polypharmacy. We used our long term conditions team, including a domicillary pharmacist to rationalise the medication and offered intensive home support from our district nursing team. There was also close liason and good working relationships with social care to enhance support at home. This has emerged into a weekly multi- disciplinary case meeting.As a last resort we could case manage some patients in a local nursing home. We reduced our admission rate by 3% (against a rise of 9% in surrounding practices) and made savings of £275,000 against our commissioning budget. So rather like the Chancellor on budget day i would "commend this to the house" 1.Black DA. Case managmentfor elderly people in the community BMJ 2007;334:3-4 2.Williams A. How i helped make community Matrons a success.Pulse, 21.12.06 p31 Competing interests: None declared |
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