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How US-style proactive care will drive Blair's dream for NHS

US-style schemes aimed at cutting emergency admissions through 'proactive' management of elderly patients with multiple chronic diseases are a key plank of the Government's strategy for primary care ­ Emma Wilkinson reports

Writing in Pulse last week, Tony Blair gave a clear indication of where the Government is coming from in its drive to cut emergency admissions.

The Prime Minister cited figures showing that around 3 per cent of the at-risk elderly account for some 35 per cent of the unplanned hospital admissions for that group.

He also quoted World Health Organisation figures showing incidence of chronic disease in the over-65s will have doubled by 2030.

With the chronically ill currently accounting for up to 80 per cent of GP consultations ­ around 180 million a year ­ the Government's fear is that chronic disease will become the most expensive problem in health care, crippling overstretched hospitals and overloading GPs.

The solution, health officials hope, is the drive launched by Health Secretary John Reid earlier this month to switch the emphasis of the NHS to proactive care.

Pilot schemes are being launched in each of the 28 English strategic health authorities and are likely to differ in the way they operate depending on local needs. But they have a common model in a swathe of US-inspired schemes already running in the UK for some years.

GP prototype

After reading about the fall in emergency admissions reported by a US company five years ago, Dr David Colin Thomé, later appointed the Government's primary care tsar, launched the prototype scheme in his practice in Castlefields, Cheshire.

He hired a nurse to help manage 50 elderly patients in his practice who had multiple chronic diseases or who were frequently admitted to hospital.

After three years his practice had saved the local hospitals £1 million without increasing GP workload.

Other notable achievements were a 15 per cent reduction in hospital admissions for elderly patients, a 31 per cent reduction in average length of stay in hospital, and a 41 per cent reduction in total bed days.

Evercare model

Trials of the Evercare programme run directly by US health care company United Health Group have been under way for up to 10 months in nine PCOs in England and the health care model of Californian health management organisation Kaiser Permanente is being trialled in sites around the country.

Evercare ­ being piloted in Bristol, Luton, Halton, Airedale, Bexley, Walsall, south Gloucestershire and Wandsworth ­ works by employing specially trained nurses to monitor and educate high-risk patients thus preventing problems that could lead to lengthy stays in hospital.

US evaluation of Evercare suggests it has halved numbers of unplanned hospital admissions among the elderly.

Dr Colin Thomé is encouraging all GPs to initiate similar schemes ­ even if they are not involved in the Government's latest initiative.

'We're spreading it out to more sites because the evidence is so strong,' he said. 'It will have a big impact and we're going to keep rolling it out more and more.'

GP concerns

But a GP who contacted Pulse refusing to be named said he was extremely concerned that the Government had already made its mind up about the effectiveness of the schemes.

The GP, who practises in south Gloucestershire, where one of the Evercare pilot schemes is based,

said: 'It worries me enormously that the Government are rolling the scheme out without evaluating it first. It could be a huge waste of money.'

Dr Phil McCarthy, Avon LMC chair and GP in north Bristol, said many GPs were worried that resources for the schemes were being directed away from already overstretched district nursing teams, a situation that the Government has conceded may be a problem.

'We would rather have some money spent on district nursing services and we're seeing cuts to district nursing teams,' said Dr McCarthy.

But Professor Chris Ham, the Department of Health's director of strategy, said the schemes would help the NHS do its job better.

'If it's done well, it's going to have a big impact,' he said. 'A lot of chronic disease management is down to well-run primary care based on the best evidence we have and involving GPs and specialist nurses. Evercare is adding a systematic approach to what's already offered.'

GP expects change for better

Dr Elizabeth Gonzalez is confident that the way patients with chronic diseases are managed will change for the better. Dr Gonzalez, a Birmingham GP involved in one of 10 pilot schemes modelled on the values of US health management organisation Kaiser Permanente (see right), is working with three local PCTs to change the way health care is delivered to patients with chronic obstructive pulmonary disease, heart failure, diabetes, and orthopaedic problems.

'Chronic disease needs to be managed but we're developing an NHS way, not necessarily a Kaiser or Evercare way', said Dr Gonzalez.

Six US principles that will

influence new UK projects

Kaiser Permanente is a US health management organisation that the Government has approached to help improve chronic disease management in the UK.

In February 2003, after a visit to Kaiser, Department of Health officials identified six principles that could be applied to the NHS:

 · An emphasis on integration

 · Giving priority to keeping patients out of hospital

 · Active management of patients

 · An emphasis on self- and shared-care

 · A leading role for doctors

 · More effective use of information

PCOs in Sussex Downs and Weald, Bexhill and Rother, Eastbourne Downs, Blackpool, Northampton, Taunton Deane, Watford and Three Rivers, St Albans and Harpenden, Eastern Birmingham and Solihull have launched projects taking the Kaiser values into account.

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