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A faulty production line

Case management has no effect on outcomes or costs, find researchers

A new study has cast further doubt on the impact of the unplanned admissions DES by concluding that case management only marginally increases patient satisfaction while having no impact on the cost of secondary care.

The DES, which was renewed for this year’s GP contract, is aimed at reducing unscheduled admissions to hospital of vulnerable patients by closely managing their care but now University of Manchester researchers say all the evidence points to this work being largely in vain.

The team studied 37 papers reviewing the impact of case management pilots focused on patients over 75 with long-term conditions, putting them through systematic review and meta-analysis, and finding no advantage over usual care in terms of overall costs, mortality or use of secondary care services, either in the short (up to a year) or longer term.

There was a small improvement in patient satisfaction both in the short and long term and a suggestion of improvement in patients’ self-reported health status at one year, although the study authors said this was only a ‘clinically trivial’ effect.

Presenting their research, which has been accepted for publication in PLoS ONE, lead author Jonathan Stokes said that ‘the focus on high-risk groups may never alleviate the system pressures alone’, highlighting instead the ‘need for a variety of models to integrate care, taking place across the whole health system and not solely at service delivery’.

Speaking at the recent Society for Academic Primary Care annual conference, he said: ‘Case management has been promoted as a way of reducing health system pressures, but the evidence identified by this review does not… support this promotion.’

GP experts said the findings trigger further questions over the rationale behind the Government’s avoiding unplanned admissions DES, introduced in last year’s GP contract.

The DES, which pays GPs to create a register of their most ‘at risk’ patients, and assign them a lead GP who oversees their written care plan for ongoing management, was renewed for 2015/16 despite warnings from GP experts it is unlikely to work and a rise in unplanned admissions in 2014/15.

Professor Martin Roland, professor of health services research at the University of Cambridge, said the study ‘confirms experience in England of experiments like Evercare and the Integrated Care Pilots, that case management of frail older people is unlikely to reduce hospital admissions’.

He added that this showed the unplanned admissions DES – like earlier schemes including QOF quality and productivity domain indicators – were ‘never likely to impact on emergency admissions even it if improved care for some vulnerable patient groups’.

Dr Richard Vautrey, deputy chair of the GPC, said more work would be needed to research the impact of the unplanned admissions DES specifically, but said that ‘when studies of the DES are done they are unlikely to show a reduction in overall costs as this group of people have complex needs and they will inevitably need hospital care at appropriate times’. 

He added: ‘This research also shows that there is evidence of a rise in patient satisfaction with case management, suggesting patients in this group welcome the attention that clinical teams give them and I suspect that that will be the case with the work done relating to the DES too.’

This year’s LMCs’ conference voted to get the scheme scrapped next year, citing the lack of evidence for the scheme and its failure to reduce hospital pressures in the first year, and warning it was distracting GPs from other vital work and putting them ‘in medico-legal danger’.

Readers' comments (14)

  • Time for the next pilot?
    On second thoughts, if somebody has this fancy of 'piloting' maybe he/she should have joined the RAF instead of conducting costly experiments in the NHS

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  • Shocking!

    The Admissions DES was a waste of time? No-one could have predicted that...

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  • Not a waste of time "there is evidence of a rise in patient satisfaction"-so that's all right then!

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  • So, like, I'm just a simple GP. Is this saying that care plans have been a load of bullsh*t all along? That someone somewhere has pushed us into wasting a great deal of our time on a pointless exercise? Who's going to be punished for it? In this Orwellian world we live in, I'm guessing that it'll be working GPs rather than the ivory towers clique.

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  • Case management - odd to see how it will really stop admissions - there is always a need for urgent, technical assessments that can never be done in primary care. Same with 7 day working - pointless unless supported by lab, x-ray, primary care teams, secondary care teams - and at what enormous cost? How much could be saved by sacking this "department of pointless ideas"?

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  • "How much could be saved by sacking this "department of pointless ideas"?"

    Very little actually, since we're essentially doing this work for free (by trying to earn back money they've taken off us already)

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  • Vinci Ho

    See , I just love these f*c*ing Newspeak language of DoH and NHSE (and of course Darth Vader and Agent Hunt)
    Case management
    Care plan
    Challenge fund
    Success regime
    Very good way to divert from the question, ' who should be the one providing the truth and real answers?'

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  • The Government, desperately trying to find ways of providing healthcare on the cheap.

    Yes, another useless idea. What will the next one be?

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  • There's something deeply sinister about a scheme designed to keep the sickest/most vulnerable 2% of the population from going into hospital when they're acutely ill. I trust that those practices which had the sense to choose not to participate (not mine, unfortunately) will be given back the money that was deducted from their income. With interest.

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  • I've said several times that it is ridiculous to spend time on the high risk patients. The study in Nairn (Scotland) showed a supposed benefit, but all that happened was a regression to the mean, i.e. high risk patients are found by looking for frequent flyers, therefore, by chance alone, they are less likely to "fly" back into hospital.

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