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Primary care tsar Dr David Colin-Thome tells Emma Wilkinson about his case management vision

It is a nightmare scenario familiar to every GP: a busy surgery interrupted by a moment of crisis.

Whether it is an elderly woman with COPD who cannot breathe or a 56-year-old man suffering a hypoglycaemic attack, plans have to be dropped and fraught telephone calls made. Too often the patient ends up in hospital.

It was this sort of 'acute crisis' that first led the Government's primary care tsar, Dr David Colin-Thome, to question whether general practice was equipped to meet the needs of its most chronically-ill patients.

Dr Colin-Thome is a consummate politician and his time as a key Government adviser has left him well versed in the art of sugar coating uncomfortable truths. But over his three years as tsar he has alienated some of his fellow GPs with claims that vulnerable patients have been neglected by primary care.

'This is a group of patients we have not been very concerned with in the past and we need to support them in a more systematic way,' he tells Pulse, speaking at the Department of Health last week.

'At the moment probably too many people are being admitted when they don't need to be and kept in longer than they need to be. That resource could be spent on funding in the community.'

It was during a visit to southern California five years ago that Dr Colin-Thome, who still works as a part-time GP in Runcorn, Cheshire, had his eureka moment. He was so impressed by the case management approach taken by US health providers ­ in which specially trained nurses co-ordinated the care of vulnerable elderly patients ­ that he came home determined to replicate the system in his own Castlefields practice.

So successful was he in doing so that 'the Castlefields experience' has entered official Government parlance and become the basis for national policy.

Last week Dr Colin-Thome fronted the launch of the national community matrons scheme, in which 3,000 matrons will manage the long-term care of patients with multiple chronic conditions. It is a long way from the humble beginnings of Dr Colin-Thome's own scheme.

'It began with a social worker based within the surgery to help the GPs focus on some of the social work aspects of their job,' he explains. 'Then we had a nurse who spent half the time as a district nurse and half the time doing case management.'

As the scheme grew, the nurse took on case management full-time. She now looks after more than 50 patients with her salary funded by PMS money ­ an option Dr Colin-Thome has encouraged other practices to consider. 'This fits in brilliantly with practice-based commissioning. The whole point is to get the system to work better.'

The scheme has reduced hospital admissions by 15 per cent and saved £1 million ­ figures endlessly repeated in Government reports, and of which Dr Colin-Thome is palpably proud.

It prompted the department first to sign up US company Evercare to run case management pilots and then to propose community matrons. The matrons are intended to be in place by March 2007 as ministers target a 5 per cent reduction in hospital bed days by March 2008.

PCTs will be free to decide how they implement the scheme but will be encouraged to identify about 20 patients per practice who would benefit from frequent contact with a highly-trained nurse.

But academics and health professionals alike have expressed scepticism about whether the experience of the private and profit-orientated US health care system is transferable to the UK.

The doubters argue UK evidence is lacking and criticise the Government for rolling out active case management nationally before its own pilots have reported back. Final results of the Evercare pilots will not be available until next year.

Dr Colin-Thome is practised at sidestepping some of the more awkward questions about the UK evidence base. He insists the Government was absolutely right to press ahead, and indeed as he reels off a series of studies he says support his case, it is hard to believe his enthusiasm is not genuine.

'If we look at case management there is already a sound management base ­ not just Evercare. There is enough evidence internationally to show it works,' he insists.

Dr Colin-Thome is keen to be seen as a friend of GPs rather than a critic. He stresses that active case management should not be seen as a threat to GPs' generalist role and emphasises the benefits for practice staff as well as patients.

'Now [crisis] happens less often and when it does someone is available to deal with it. As a staff thing it's fantastic. Pressure is enormously reduced.'

The Castlefields experience

How it works

·A nurse, working closely with a social worker, manages

50-60 vulnerable patients over the age of 65.

·Criteria for inclusion in the scheme include multiple chronic conditions, high medication use, frequent hospital admissions or GP consultations and regular contact with social services.

·Nurse monitors patients' health and medication in order to prevent 'crises'. She co-ordinates social and medical services and teaches patients and their families how best

to manage their condition, liaising with the GP where necessary.

Results

·Admissions for older people reduced by 15 per cent

·Average stay fell from 6.2 to 4.3 days

·Total hospital bed days fell by 41 per cent

·Deaths in hospital for cancer patients cut by 50 per cent

·Heart attacks decreased by 50 per cent

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