How PSSRU's tradition of service evaluation and development provided a vision for community care reform
I went to PSSRU in 1976 with the specific remit of developing the Kent Community Care Project (KCCP). This work was based on the introduction of budget-holding case managers who would systematically plan and coordinate a full range of flexible and responsive care services for an individual, taking responsibility for ensuring that the overall care network performed in ways that met a person’s needs. The principles of KCCP had been articulated, but the form it should take and how it would work were less clear. So I joined PSSRU to work out the details of implementation.
The KCCP study was carried out in the Isle of Thanet, East Kent, an area where in parts around 40 per cent of the population was over 65. Early results were encouraging in suggesting people could, at reasonable cost, avoid moving into residential and nursing homes, to the benefit of themselves and their families. However, the study numbers were modest and the area was not representative. The Department of Health was interested in the findings and asked us how the strategy could be generalised to the rest of the population. It wanted us to replicate the approach in a more representative district of the country and also look at ways in which there could be more of a joint health and social care approach for making it happen. My job was to do that.
My first contact was with the local authority in Gateshead. They were unbelievably entrepreneurial in terms of using various available funding mechanisms to make things happen. Gateshead was eligible for the Inner Cities Partnership, under the then Department of the Environment, and secured this funding for a three and a half year case management intervention project. Part way through they obtained further Partnership funds for a health element to be added to the study, which gave us a part-time nurse, a part-time physiotherapist and a junior doctor. So Gateshead had a social care case management intervention and a primary care focused health and social care intervention. Our findings, published in journal papers and two books (in 1990 and 2002), showed that case management reduced the need for care home admissions of vulnerable older people and achieved marked improvements in their levels of well-being, at no greater cost to social services.
The second new case management project I initiated was in Darlington where a Care in the Community intervention needed some input on introducing case management to prevent hospital admissions. As before, this was a quasi-experimental study with matched intervention cases and controls. Case managers were put in place to provide alternatives to hospital care. We showed that a high quality case management service targeted correctly achieved improvements in the well-being of older people, a lower level of carer stress compared with patients in long-stay hospital care and was cost effective compared with hospital care.
Our work had a demonstrable impact on policy, with the Gateshead and Darlington projects (as well as KCCP) being cited in the 1989 Caring for People White Paper. Unfortunately, while the approach was taken up as guidance in the policy, the ways in which case management was implemented in practice were largely not how the research had shown it would work. So there was disjuncture between evidence shaping policy and how that policy was actually rolled out. This is a common problem – people pick up a piece of evidence but do it their own way, perhaps for a different population, so it does not work.
My third case management initiative – the Lewisham Case Management Scheme – had its roots in my earlier clinical work when I used to worry enormously about people with dementia and how they should be supported in the community. In the Gateshead study we had found, to my surprise, that one of the subgroups that showed distinctly beneficial outcomes were people with dementia and their carers, which I had not expected. It was agreed that we would work with Guy’s and St Thomas’ Hospital to put case managers into one of their community mental health teams to work with older people, using their other teams as controls, funded by the Sainsbury Foundation. The study showed some really beneficial outcomes for older people and their carers at a similar cost to normal practice. This work is one of the few examples of intensive case management in dementia care in this country and it was cited in the 2009 National Dementia Strategy and used by the French in their 2010 Alzheimer’s strategy.
Overall, PSSRU’s case management work has provided a vision of what case management ought to be. But I’m not sure the work has had the degree of impact it could or should have done (though it has been influential abroad, especially in Australia). In the 1990s, case management was seen in England as the panacea: at one point it seemed that all service users had to have it, but clearly not everybody needed it, so it was not a good use of resources to provide a diluted version to all. There was a focus on roll-out without any concern about being faithful to the model and the evidence. Different local authorities did their own thing, with many just rebadging what they had been doing. This was inevitably followed by a degree of disenchantment. Then the policy of personalisation and devolved budgets came along. In practice, personal budgets are sometimes not dissimilar to the model of case management with devolved budgets; some frail users do not want to manage their budget themselves so more recent guidance allows for some budgets to be managed by care managers. But what you do not see today is a situation where case managers are encouraged to be creative and flexible in arranging a personalised care package.
The lesson for the future is about fidelity to the principles of the case management model, while being flexible and creative about how to achieve the outcomes. It’s about enabling care managers to carry out proper assessments of people’s needs and to use flexible budgets to do things that are outside a narrow range of prescribed activities. At the same time the organisation has to accept the viability and legitimacy of risk and to be more supportive of their staff taking a non-traditional approach.
Interviewed by Teresa Poole
Professor David Challis joined the Kent branch of PSSRU in 1976, where he was Assistant Director leading the unit’s work on multi-disciplinary approaches to case management. In 1996 he moved to set up and run a new branch of PSSRU at the University of Manchester and remains Director as well as Professor of Community Care Research. Since 2009 Professor Challis has also been an Associate Director of the NIHR School of Social Care Research. Here he describes his pioneering work extending the implementation of case management following the original Kent Community Care Project.