Emergency admissions for diabetes fall by almost 7% in integrated care pilot scheme

Half of the efficiency savings needed to be made in London to help meet the £20bn national NHS target could be made through the integrated care of patients with long term conditions, a pilot study has indicated.

Early findings of the North West London Integrated Care Pilot, which covers a population of 550 000 and provides care to patients with diabetes and frail elderly people, were reported at a conference on high quality healthcare organised by the think tank Reform in London on 16 May.

Hannah Farrah, director of strategy and commissioning development at NHS London, described previous attempts at integrated care in London as “cottage industries.” She said, “We didn’t think that they were having the impact that they really need to have if you are going to change that demand curve of acute services.”

In the northwest London pilot GPs ensure that patients with diabetes have integrated care plans shared electronically with all providers and that care is delivered across different settings. The most complex patients are discussed in monthly case conferences by multidisciplinary groups. The aim of the pilot is to reduce use of emergency services, emergency admissions, and length of stay and to drive down the cost of care of diabetic and elderly patients by 24% over five years.

Although the pilot has yet to be fully evaluated, early signs are that the patient experience is improving, clinicians are leading and learning, and emergency admissions at participating practices have fallen by 6.6%. Farrah said that this was “quite a massive achievement in a short space of time” at a time when emergency admissions at non-participating practices in other areas of London had risen by 0.3%.

“Multiply that up within the pilot to cover the other long term conditions, and across London, and we forecast you can get at about half a billion, which is roughly half of London’s commissioning side of the QIPP [the Quality, Innovation, Prevention, and Productivity framework through which the NHS’s chief executive, David Nicholson, wants the NHS to make £20bn in efficiency savings by 2014-15].”

Farrah said that hospitals that no longer had a demand for services would need to reduce their costs sufficiently to enable money to be taken out of the system and that some of them would have to close. “We have trusts which are already in recurrent deficit. You reduce their income further, you take away some of that growing demand, and they have increasing difficulties,” she said.

“What we have to have is a wider debate about the . . . level of hospital capacity that we have in the system. And we have to convince our public and politicians that they want this change to happen, because at the moment what they hang on to is quite an outmoded form of delivery.”

However, Norman Warner, a former health minister (2003-6), warned the conference that, because many MPs had low majorities, and the number of potential seats would reduce from 650 to 600 in 2015, “this is not a good environment for political bravery.”

David Dalton, chief executive of Salford Royal NHS Foundation Trust, said that a fundamental problem was that hospitals had no incentives to close beds, because although a bed’s closure would save the NHS as a whole an estimated £10 000 (€12 400; $15 800), the same bed could generate £70 000 in income for that particular trust. “We have got to create a system that gives incentives for closing down facilities to liberate that cost and understand the structures of fixed costs and variable costs within our organisations,” he said.

The health secretary, Andrew Lansley, said that the evaluation of a pilot of care closer to home some years ago by the National Primary Care Research and Development Centre in Manchester showed that the best way to deliver care outside of hospital “was not to just hand the service to GPs or indeed community nursing but was for the service to be delivered in a combined effort with the clinical specialists in the hospital [and] to move them [the specialists] into the community.”

He said that the response should be not to treat hospitals as having less work and therefore to simply cut what they did but to respond positively by turning hospital trusts into healthcare trusts, integrate services more effectively, “and in effect build new services which manage patients in the appropriate context.”