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Your recent reports on case management of the vulnerable elderly are overly pessimistic and go considerably beyond the evidence.

You did not make clear that independent research by Picker Institute Europe showed that elderly patients and their carers greatly valued the services provided by case managers. Previously patients had received fragmented, episodic care and had felt lost in the complexities of a health care system designed primarily for dealing with acute illness.

The debate is over whether case management can reduce unplanned admissions to hospital, and a recent review by the King's Fund found there was some evidence to show that it could. The crucial question is less whether it works and more how to make it work best, and many practices are experimenting with different schemes.

The Evercare programme, which we provide, used two unplanned hospital admissions as an entry point to the programme, but it was known that this was not the best method. It was simply all that was possible at the time because of the state of information systems in the NHS.

Better methods, which are already available, will use other information ­ such as clinical condition, numbers of drugs being taken, and use of community and social services.

In order to reduce unplanned admissions to hospital, case management will need to be accompanied by improved commissioning of services, particularly of intermediate care services. Although case management alone is unlikely to be enough, it is still probably one of the best options for solving the important problem of reducing emergency admissions.

Richard Smith

Chief Executive, UnitedHealth Europe

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