Susan Pickard

Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data

Objectives To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people. Design Practice level before and after analysis of hospital admissions data with control group. Setting Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission. Main outcome measures Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out). Results The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval −5.7% to 38.7%), emergency bed days (increase 19.0%, −5.3% to 43.2%), and mortality (increase 34.4%, −1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged ≥65 effects on the rates of emergency admission (increase 2.5%, −2.1% to 7.0%), emergency bed days (decrease −4.9%, −10.8% to 1.0%), and mortality (increase 5.5%, −3.5% to 14.5%) were also non-significant. Conclusions Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.

User involvement in clinical governance

Objectives To investigate the involvement of users in clinical governance activities within Primary Care Groups (PCGs) and Trusts (PCTs). Drawing on policy and guidance published since 1997, the paper sets out a framework for how users are involved in this agenda, evaluates practice against this standard and suggests why current practice for user involvement in clinical governance is flawed and why this reflects a flaw in the policy design as much as its implementation.

Impacts of case management for frail elderly people: a qualitative study

Objective: To assess the impacts of different forms of case management for people aged over 65 years at risk of unplanned hospital admission, in particular the impacts upon patients, carers and health service organization in English primary care; and, in these respects, compare the Evercare model with alternatives. Methods: Multiple qualitative case studies comparing case management in nine English Primary Care Trusts which piloted the Evercare model of case management and four sites which implemented alternative forms of case management between 2003 and 2005. Data were obtained from 231 interviews with patients, carers and other key informants, and from content analysis of documents and observation of meetings. Results: All the projects established functioning case management services, but none led to major service reorganization or savings elsewhere in the health care system. Many informants reported examples of admissions which case management had prevented, but overall hospital admissions did not significantly change, possibly due to increased case-finding. Patients and carers valued case management for improving access to health care, increasing psychosocial support and improving communication with health professionals. Conclusion: Case management was highly valued by patients and their carers, but there were few major differences in outcomes between Evercare and other models.

The ‘Good Carer’: Moral Practices in Late Modernity

Informal carers in the context of late modernity must negotiate two potentially conflicting discourses. One is associated with a post-traditional and increasingly individualized society characterized by ‘pure’ relationships with an emphasis on authenticity and choice. The other is a more traditional discourse found particularly in current health and social policy which relies explicitly on significant input by family carers. This ar ticle analyses the tensions arising from this paradox, specifically for older carers engaged in long-term care relationships. The first, theoretical, section provides an overview of the ‘subjective turn’ associated with modernity together with the heterogeneous ethics of governmentality associated with liberal rule. The second, empirical, section discusses ‘moral narratives’ drawn from carers’ accounts of caregiving. The conclusion highlights the social contexts in which carers make moral choices and identifies the links between policy normativities on the one hand and inequality and resistance on the other.

Contracts and the Quasi-market in Community Health Services

In the NHS quasi-market, contracts are the crucial mechanism through which purchasers influence providers of health care. Most attention has been given to the commissioning and contracting process in acute hospital services. However, there is another important but neglected sector of health care – community health services (CHS) – in which the specification and implementation of contracts is particularly difficult. In this article, three dimensions of contracting are analysed, illustrated by qualitative evidence from case studies, concerning: the measurement of activity; the estimation of costs and prices; and the monitoring of outcomes and quality. This article argues that community health services are intrinsically problematic within the quasi-market, and suggests that the nature of the services and the system of delivery militate against provider competition. It is argued that CHS have more in common with ‘clans’ and ‘networks’ rather than markets and hierarchies, and that this requires collaborative rather than adversarial relationships between purchasers and providers.

Some National Service Frameworks are more equal than others: Implementing clinical governance for mental health in primary care groups and trusts

This paper reports the findings of a study concerned with the way in which Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) engaged with the Mental Health National Service Framework (NSF) as part of their remit to implement clinical governance. A qualitative multiple case study is reported which used semi-structured interviews and documentary analysis in a purposive sample of 12 PCG-Ts in England. The study found a general awareness of and support for the Mental Health NSF among PCG-Ts. In some localities the NSF acted to reinforce existing local developments in primary care mental health. However, compared to the NSF for Coronary Heart Disease a number of difficulties in responding to the Mental Health NSF were identified. These related to the perceived clinical status and complexity of managing mental health problems at practice level (e.g. familiarity with and competence of General Practitioners (GPs) in managing the conditions), inter-agency working, clinical governance training and the feasibility of producing clear demonstrable mental health outcomes as part of performance management. While the NSF for mental health presents opportunities for establishing the principles of quality assurance and improvement in the area of mental health, it is in danger of being marginalized in the clinical governance agendas of new PCTs, because of an inability to compete on an equal footing with other clinical priorities. While the partial demedicalisation of mental health is increasingly recognised as desirable for policy and therapeutic reasons the corollary is that it is harder to implement non-medicalised forms of care through the essentially medicalised apparatus of clinical governance. In order to deal with the complexities and challenges posed by the mental health agenda targeted support and resources are needed to promote clinical governance developments within primary care organisations.

A 'Third Way' for lay involvement: what evidence so far?

Aims and objectives This article considers evidence regarding lay involvement in the NHS, following the White Paper’s commitment to rebuild public confidence in an NHS ‘accountable to patients and open to the public and shaped by their views’. It looks at two aspects of lay involvement: the lay board member’s involvement in primary care group (PCG) decision‐making and the engagement of the PCG with the wider public.

Moving specialist care into the community: an initial evaluation

Objectives: To assess the likely impact on patients and local health economies of shifting specialist care from hospitals to the community in 30 demonstration sites in England. Methods: The evaluation comprised: interviews with service providers at 30 sites, supplemented by interviews with commissioners, GPs and hospital doctors at 12 sites; economic case studies in six sites; and patient surveys at 30 sites plus at nine conventional outpatient services. Outcomes comprised: staff views of service organization and development, impact on primary and secondary care, and benefits for patients; cost per consultation and cost per patient in new services compared to estimates of the price of services if undertaken by hospitals; patients’ views of waiting time, access, quality (technical and interpersonal), coordination and satisfaction. Results: New services required high initial investment in staff, premises and equipment, and the support of hospital consultants. Most new services were added to existing hospital services so expanded capacity. Patient reported waiting times (6.7 versus 10.1 weeks; p = 0.001); technical quality of care (96.2 versus 94.5; p < 0.001), overall satisfaction (88.2 versus 85.4; p = 0.04); and access (72.2 versus 65.8; p = 0.001) were significantly better for new compared to conventional services but there was no significant difference in coordination or interpersonal quality of care. Some service providers expressed concerns about service quality. New services dealt with less complex conditions and undercut the price tariff applied to hospitals thus providing a cost saving to commissioners. There was some concern that expansion of new services might destabilize hospitals. Conclusions: Moving specialist care into the community can improve patient access, particularly when new services are added to existing hospital services. Wider impacts on health care quality, capacity and cost merit closer scrutiny before rollout.

Public service responsiveness to users’ demands and needs: theory, practice and primary healthcare in England

Analyses and policy statements about publicly funded services frequently distinguish ‘demands’ from ‘needs’. The distinction has been challenged, calling into question the coherence of formulating welfare policy and evaluating public services in terms of needs. This paper explicates the conceptual distinction between demands and needs in terms of derived demand and information asymmetry. ‘Needs’ can be defined as ‘rational demands’, where ‘rational’ means ‘consistent and evidence–based’, and ‘demands’ as ‘desires’ rather than ‘effective (i.e. economic) demand’. On that basis, practical demand management in needs–based public services would require: 1. Knowledge of users’ demands for services; 2. Content analyses of users’ demands to identify any misinformed demands; 3. Conversion of any misinformed demands into evidence–based specifications of needs; 4. Formulating coherent, evidence–based demands on behalf of users who cannot to do so themselves. A study of English NHS Primary Care Groups explores the problems which authorities responsible for publicly funded services face in undertaking these activities. Demand management receives low priority in terms of the incentives and intellectual resources applied to it. Needs assessment has higher priority but is regarded as a branch of evidence–based professional practice, controlled by professionals rather than responsive to users. This separation tends to defeat the purposes of needs–based public services.

Frail bodies: geriatric medicine and the constitution of the fourth age

Clinical discourses of frailty are central both to the construction of the social category of the fourth age and to the role and identity of hospital geriatric medicine. However, the influence of such clinical discourses is not just from science to the social sphere and nor do these discourses have their source in a putative truth of the old body but emerge from an interplay between physiological facts, discourses of governmentality, productive processes associated with late modern capitalism and the professional ambitions of geriatric medicine. The article explores this interplay in the two key discourses of frailty that have emerged in the clinical literature during the past 15 years, that of the phenotype and the accumulation of deficits, respectively. Outlining the development of the discourse of senescence from its origins to the more recent emergence of a nosological category of frailty the article explores how these key discourses capture the older body according to particular sets of norms. These norms link physiological understanding with broader discourses of governmentality, including the professional project of geriatric medicine. In particular, metaphorical representations in the discourses of frailty convey key cultural and clinical assumptions concerning both older bodies and old age more generally.