Born in the USA, by Seamus Ward

1 Feb 07
US-style healthcare schemes are increasingly being imported into the NHS. But do they work on UK soil? Opinion is sharply divided within the medical profession and beyond. Seamus Ward investigates

02 February 2007

US-style healthcare schemes are increasingly being imported into the NHS. But do they work on UK soil? Opinion is sharply divided within the medical profession and beyond. Seamus Ward investigates

It's been a busy morning for Julie Rae. The community matron has been rushing around Selby, north Yorkshire, visiting patients in their homes. She has a single aim – to keep people with long-term illnesses out of hospital by providing home visits and information, liaising with social care staff and intervening before the patients' health degenerates to the point where they need an emergency admission.

Set up two years ago, the Selby case management scheme concentrates on patients who have frequent, unplanned hospital admissions. Many have heart problems, diabetes or chronic obstructive pulmonary disease (COPD) – respiratory diseases such as emphysema and chronic bronchitis.

This morning's patients included a woman with COPD, whose blood oxygen saturation was monitored to ensure there were no early signs of an acute episode. Another visit was to a man with heart problems whose wife had called Rae last week, worried about what to do if his condition worsened.

'We had a chat but it was mainly about reassuring her and giving them information about who to contact and what to look out for,' Rae says. 'We are trying to get people to the right place at the right time, reducing the length of stay when they are in hospital and giving them information so they know the early signs of an approaching crisis. This helps us step in to prevent an unplanned admission. Case management improves patients' quality of life and I feel empowered because I know who to bring in to support my patients.'

The idea is simple but its origins are closer to New York than York. Case management programmes such as the one operated by Rae and her five colleagues in the Selby and York area have been run in the US for many years. Health insurers and providers see them as a way to keep costs down. Now they are gaining popularity in the NHS, which is due to have 3,000 community matrons running case management programmes by the end of March.

While importing ideas and services from overseas is not new, the NHS appears increasingly to opt for those originating from the US, whether it is the influence of US management consultants such as McKinsey or suggestions that primary care trusts could become more like US health maintenance organisations.

But, as with so many imports from across the pond, the trend has already produced a backlash. Robust criticisms of US-style health care models were recently aired in the British Medical Journal. And health experts are keen to emphasise the differences between the two health systems.

King's Fund health policy director Jennifer Dixon says: 'While I think it's healthy to bring ideas in from the States, it may be dangerous to assume you can just “cut and paste” [them]. Health care here is different historically, culturally and politically.'

There are major differences between the NHS and the US health system, such as funding. While the NHS is tax-funded and largely free at the point of delivery, the US system is insurance based, although there are federal and state programmes that provide health care for elderly people and those on low incomes. While out-of-hospital care is provided by independent clinicians, hospitals are run by for-profit corporations and not-for-profit bodies, including local governments and religious organisations.

There are 47 million people without medical insurance in the US – about a sixth of the population – although there have been some failed attempts to introduce universal coverage. Recently, governor of California Arnold Schwarzenegger launched proposals to introduce universal coverage to the US's most populous state, where almost one in five (6.5 million people) have no medical insurance. Two Democratic contenders for presidential nomination, Hillary Clinton and Barack Obama, have also pledged it.

When the UK's Department of Health established its independent sector treatment programme in 2003, US health care providers appeared to hang back as firms from South Africa and Sweden won contracts for planned NHS surgery. But recently American accents have become more common in the DoH's Richmond House headquarters as US health care providers and health insurance companies seek opportunities in NHS primary and community services.

McKinsey is a major player, although it insists it is not 'flying planeloads of Americans' over to help on its NHS work. Most of its staff may be British but the philosophy of its US parent company is firmly applied in the UK – one principle of which is to say very little about the work it does.

'The NHS has embarked on a massive programme of reform and we are one of a number of different kinds of consultancy that are providing input at different levels,' a spokesman says. 'We are not the sort of firm that makes predictions about how our business will grow.'

McKinsey might be hiding its light under a bushel. As probably the premier management consultant in the NHS, it has worked with the DoH, foundation trust regulator Monitor, aspirant foundation trusts, strategic health authorities and the Connecting for Health IT programme, as well as with primary care trusts on their fitness for purpose reviews. According to a parliamentary written answer from health minister Ivan Lewis last October, the DoH paid McKinsey £240,000 in 2004/05 and £2.865m in 2005/06. In the first six months of this financial year, this had more than tripled to £9.964m.

US involvement in the NHS is causing disquiet among unions but recent concerns have centred on claims that case management does not work. A Manchester University study, published in the British Medical Journal in November, said a £4m pilot of the Evercare case management programme in nine PCTs had not shown reductions in emergency admissions, length of hospital stays or death rates.

The Evercare pilots had already attracted controversy. In 2004, the scheme's owners, US giant United Health, appointed former Number 10 health policy adviser Simon Stevens as its vice-president and head of European operations. The Evercare pilots ran between 2003 and 2005 but before they had ended, then-health secretary John Reid announced the creation of the community matron posts. Although the NHS has been told not to follow any single case management model, Martin Roland, a co-author of the BMJ study, insists the community matron initiative is based on the same principles as the Evercare pilots – and without radical changes, it will have the same outcome.

Roland, a professor and director of the National Primary Care Research and Development Centre at Manchester University, says that NHS intermediate care for patients well enough to be discharged from hospital but unable to look after themselves must be expanded, and there must also be greater community matron involvement in planning patient discharges from hospital.

'Community matrons work a standard working week so half the week isn't covered. During that time, patients have to rely on GP out-of-hours services, which are not well set up to keep an eye on people at home,' he adds. 'It would be naïve to think that something as complex as emergency admissions would be amenable to a simple change such as the introduction of community matrons. Case management is beneficial in some situations and for some groups of patients, but it is quite difficult to generalise.'

Unsurprisingly, the criticism of Evercare has drawn a bullish response from United Health. Richard Smith, United Health Europe chief executive and former editor of the BMJ, says Roland's study was flawed in a number of ways. One of Smith's chief objections is that patients in the study had been on the programme for an average of eight months when evidence from the US indicates a minimum of 18 months is required to see the full benefits.

'Our own evaluation shows patients and carers like it a lot as it makes their lives a lot easier. We believe 16 features need to be in place for it to work effectively, including a good system for identifying patients most at risk; this wasn't in the pilots as the data wasn't available. There also needs to be 24-hour cover and intermediate care. If you have 12 of those features in place you won't get three-quarters of the benefits; you will probably get about 30%,' says Smith.

Health minister Rosie Winterton backs Evercare and insists the NHS is adapting to get the most from case management. 'Services are recognising many of the issues raised in the BMJ report, including the impact of information and the need for integration across services to improve the management and reduce admission of people with long-term conditions,' she says.

Luton Teaching PCT, one of the original pilots, says the Evercare system is reducing unplanned hospital admissions. Although it has taken two years for the benefits to emerge, Luton believes it has cut around 900 unplanned admissions a year – a saving of about £3m at a cost of just under £1m – and the PCT plans to expand the service.

As Luton's experience shows, the Manchester study does not mean case management is dead in the UK. Joe Farrington-Douglas, research fellow in health and social care at the Institute for Public Policy Research, says: 'Fundamentally, the concept of a health system that prevents people getting sick, rather than one that acts as a safety net providing emergency medical care, dates back to the origins of the NHS.'

Demographics are changing, with people living longer and surviving for 20, 30 or even 40 years with chronic diseases. 'Health needs are changing and will be defined less by acute episodes of hospital care. It is unconscionable from an economic and human dignity point of view to continue with a model that is based on sending people to hospital,' Farrington-Douglas adds.

Last month, the IPPR provoked a row when it insisted the NHS needed fewer beds as more care should take place outside hospital. But if wards are to be closed, appropriate community services must be provided and many believe case management can drive that process forward.

'Proactively trying to identify people before their condition gets worse is the only game in town. Emergency admissions should be treated as a failure in the system rather than a success,' Farrington-Douglas says.

In all probability, US health care firms are playing the long game when it comes to developing their NHS business. The aim is to win contracts in primary and community care, with the likes of McKinsey bidding for a contract to support PCT commissioning. In the future, PCTs might be split into commissioning and provider arms – a recent paper by the Reform think-tank called for this – and US firms are interested in playing a role in both.

Later this year the DoH will launch pilots of Life Check, a health questionnaire that will be targeted initially at babies in their first year; children; and 50-year-olds. Patients will be given tailored advice on how they can become healthier and avoid health problems. The initiative has been developed with the help of a number of secondees from US health insurer Humana. The firm has expertise both in using lifestyle questionnaires to assess patients' risk of developing diseases and in providing personal disease prevention programmes.

The NHS does not have a huge amount of expertise in these areas, including case management, despite the creation of community matrons. For providers, winning any potential future contracts for care of elderly people and those with long-term conditions would be a huge prize.

United's Smith admits as much. 'In the US, people are introduced into the programme and we know how much money we get per head. That is at risk if we don't improve the quality of their care and reduce unplanned hospital admissions. We would like that to happen here. The average PCT would have about 500 patients at risk and they could commission us to provide a programme for these patients.' But, he adds: 'It's up to us to improve the quality of their care and reduce unplanned admissions. Otherwise, we would not benefit financially.' This goal, he concedes, is 'some way off'.

US firms are here for the duration, and intent on developing the special NHS relationship. As one former DoH insider told PF: 'Commercial organisations do not get involved in these programmes for the good of their health. They realise they are in the best position to get the spin-off benefits.'

But, as ever, it all depends on the outcomes – whatever works.

PFfeb2007

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