From April, GPs in England will find themselves at the forefront of the search for the NHS equivalent of the holy grail – a way of reducing the seemingly inexorable rise in unplanned admissions to hospital. A new directed enhanced service (DES) worth £160m will aim to stem the 50% rise in emergency admissions over the past 15 years, with GPs made responsible for identifying and closely managing the 2% of patients on their list identified as being at highest risk of an unscheduled hospital stay.
But many experts are warning the DES is based on evidence that is flimsy at best and say it will have little impact without wider system change; some even claim it could result in an increase in admission rates for other patients. As practices prepare to take on the new DES, are they being handed an impossible mission?
The exact specifications of the DES are still being worked out. But based on information released by NHS England and the BMA, we know it will incentivise GPs to proactively manage their most complex and vulnerable patients through risk profiling, assign a named accountable GP to older and other vulnerable patients and provide ‘timely telephone access’ to relevant providers to support decisions relating to hospital transfer or admission.
Practices will also have to review A&E attendance and unplanned admissions from care home patients and share information with their CCG to improve commissioning decisions. The DES takes the place of the Quality and Productivity domain of the QOF and the discontinued risk-profiling DES from April, and will be worth a sizeable chunk of practice income.
NHS England says the DES is designed to reduce or hold steady the rate of unplanned admissions, although practice pay will not depend on the extent to which this outcome is achieved. A spokesperson told Pulse that an impact assessment was not deemed necessary because the DES was developed with clinical commissioners.
However, there are already doubts over its likely impact; studies of such case-management approaches both in the UK and internationally have found relatively little evidence to support their efficacy in reducing admissions.
Thin evidence base
Professor Martin Roland, professor of health service research at the University of Cambridge and a part-time GP in the city, predicts the DES will make little difference overall and even suggests it could raise unplanned admissions rates among the 98% of patients not included in the scheme. An analysis he published last year in the BMJ showed case management of at-risk patients faced an ‘improbably’ large task to reduce unplanned admissions overall by 10% (see box).
What the evidence says
• A Nuffield Trust pilot in north-west London found no significant reduction in emergency admissions or changes in the wider use of services after better care planning and co-ordination. Researchers said it would take longer for any impact to be seen.
• In a meta-analysis of all 11 published trials of case management in older people to date, including five trials of community-initiated schemes, none showed a fall in unplanned admissions.
• A King’s Fund analysis found little improvement in emergency admissions with case management, but identified improved use of healthcare resources, quality of life and independence, and that patients felt case management gave them improved access.
• Analysis published in the BMJ showed that in order to achieve a 10% reduction in emergency admissions by focusing on 4.5% of the population at highest risk, case management would have to result in 40% of their admissions being avoided – an ‘improbably’ large amount, concluded the authors.
Professor Roland says: ‘This is a perfectly reasonable thing to propose for frail elderly people. The only real problem is that these 2% are not responsible for all that many emergency hospital admissions. It’s therefore very unlikely that this measure on its own will make a great difference to overall rates of emergency admission.
He adds: ‘By focusing attention on one very small group, other admissions might not be avoided.’
In May last year, researchers from the Nuffield Trust and Imperial College London found no significant reduction in emergency admissions or changes in the wider use of services in their evaluation of an integrated care pilot involving 1,236 patients – over-75s and patients with diabetes – that was funded by NHS London and NHS North West London and that started in July 2011.
Similarly, in January last year, UK researchers published a major systematic review and meta-analysis of all published trials to date on the impact of case management on unplanned admissions.
They identified 11 trials of case management in older people, published between 1999 and 2011, although none was conducted in the UK. Of the five trials of community-initiated case management included in the review, none showed a fall in unplanned admissions.
Lead author Dr Sarah Purdy, reader in primary care at the University of Bristol, says while the study concluded case management failed to reduce unplanned admissions, this was likely to be because many of the models used were not intensive enough.
But she is sceptical about the impact the DES will have without significant investment in other parts of the system.
She says: ‘Looking at the enhanced service, on the basic information available, it won’t necessarily be able to give the support that a well-funded, co-ordinated team can.’
Sir John Oldham, a former GP who previously advised the Department of Health on efficiency and productivity in the NHS and now leads the Labour party’s strategy on whole-person care, says there are benefits to be had from case management, but only if the right services are wrapped around it.
Sir John says an ‘integrated team approach’ could improve outcomes and reduce unscheduled admissions and there are ‘increasing examples around the country that have done that’.
However, he adds this might not be the case with the new DES: ‘Where this fails is when an initiative is placed in a box called “case management” and treated in isolation from other system changes that need to happen. Some of the case management evaluated made this basic error and would never work.’
But NHS England insists the DES is essential, citing evidence that shows over-75s make up around 8% of the population but account for around 30% of unplanned admissions – and their emergency admission rate has risen more quickly than that of other age groups.
A spokesperson for NHS England says: ‘In negotiations, it was agreed that a more proactive approach to managing care for older people and for people with complex health conditions is, therefore, likely to have a significant impact in reducing or holding steady the rate of admissions, and that improved access to practices for this cohort of patients is likely to aid in reducing A&E attendances and hospital admissions.’
Some commissioners also support the scheme. Salaried GP Dr Rebecca Rosen, vice-chair of NHS Greenwich CCG and a senior research fellow at the Nuffield Trust, admits the evidence is ‘limited’ for the DES but says it should ‘make a difference to the experience of patients – to get better continuity and a more personal relationship’.
She says: ‘It’s about redesigning the way the whole practice responds to these individuals. I think there is the potential for real benefits and it’s worth trying.’
With millions of pounds invested in this new DES and rising pressure on emergency departments, NHS England will be hoping she is right.