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Experts warn new DES is unlikely to reduce unplanned admissions



Exclusive The new directed enhanced service (DES) to prevent unplanned admissions due to be introduced from April in England it is unlikely to have any impact on avoidable emergency admissions, and may raise them in other areas, claim experts.

Researchers said the evidence shows case management as proposed in the DES is unlikely to reduce unscheduled admissions, without significant improvements in other areas of the NHS.

The new DES will require practices to maintain a case management register of the 2% of patients on their list identified as being most at risk of an unscheduled hospital admission. Each patient on the register will have a ‘named GP’, responsible for providing them with a personalised care plan and overseeing their care.

NHS England said the enhanced service was drawn up with the help of clinical commissioners and is designed to reduce or at least prevent any further rise in the rate of unplanned admissions. But experts say studies of such case-management approaches in the UK and internationally have shown little evidence of any benefit.

Professor Martin Roland, RAND professor of health service research at the University of Cambridge and a part-time GP in the city, recently reported in the BMJ that case-management of at-risk patients would be unlikely to make a meaningful impact on admissions.

Professor Roland explained to Pulse that while a proactive case management approach seems sensible, many emergency admissions happen among patients who may not be picked up through risk profiling and who may lose out as a result of the focus on the risk register.

Professor Roland said: ‘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.

‘And it’s also possible that, by focusing attention on one very small group, other admissions might not be avoided.’

Professor Roland added: ‘We really don’t know what difference this sort of multifaceted intervention will make. It’s a crying shame not to evaluate it, for example by staggering the introduction to a random half of the country so that one could see whether it was having any effect. As it is, we probably won’t know.’

Most recently, a study reported in May last year by the Nuffield Trust and Imperial College London revealed there was no reduction in emergency admissions in the first year of an integrated care pilot involving case management of over-75s and patients with diabetes.

Earlier in the year a large meta-analysis found no reduction in unplanned admissions with trials of community-based case-management programmes. Lead author Dr Sarah Purdy, reader in primary care at the University of Bristol, told Pulse the study ‘fairly conclusively’ showed case management did not work and although a more intensive, multidisciplinary approach could be more successful, this would not necessarily be available under the new DES.

She said: ‘The sort of case management [such as those] based on community matrons, who often have a very large case load and are not be able to give each patient a huge amount of support, may not be as successful as the sort with much more intensive input with a multidisciplinary team, for example with access to a specialist, GP, physiotherapist and occupational therapist, with a specialist nurse co-ordinating everything.’

Dr Purdy added: ‘Looking at the enhanced service, on the basic information available, it won’t necessarily be able to give that support with a well-funded, coordinated team can.’