Rebecca Rosen: Supply-induced demand in primary care

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Supply induced demand as it relates to

primary care

Dr Rebecca Rosen

Senior Fellow, The Nuffield TrustGP, Ferryview Health Centre, Woolwich

March 18 2014

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Many types of supply induced demand to enjoy

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Factors shaping demand for better access to primary care

1. Increasing complaints and frustration about poor

access to booked GP appointments

2. Unproven assumption that rising A&E numbers

are fuelled by poor access to GPs

3. Public enthusiasm for walk-in clinics but high

cost to CCGs and little impact on A&E use

4. Rising demand for new ways of consulting,

booking and communicating with GPs

5. Interplay between 7/7 hospitals (safety/

efficiency) and 7/7 GPs (convenience/ capacity)

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Multiple unscheduled & scheduled primary care services

Is public confusion fuelling service use?

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Questions for today

• Are we able to measure and monitor how far increased access to general practice and other primary care (scheduled and unscheduled) increases demand?

• In the current policy and financial context, can we make judgements about ‘more appropriate’ and ‘less appropriate’ demand?

• Can we design services in ways which reduces the likelihood of supply induced demand for ‘less appropriate’ need?

• Is it possible to influence people’s perception of when they need professional help and change the way they use services in order to modify the impact of supply induced demand?

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Categories of unscheduled primary care attendance:

Hard working adults – ongoing but tolerable symptoms which could be minor or could herald serious illness. No convenient appointment

Child with fever – ‘viral illness’. Been to WIC/UCC/GP 2 – 3 times in previous week: worried parent

Working mother – called by nursery ‘child has a fever’. Book to have child checked before setting eyes on him/her

Boss (school) require a sick note from day 1

New onset ‘severe’ symptoms

Request for a phone call: I feel a bit sick. Could it be due to the tablets you gave me yesterday?

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Underlying issues (1) : Workforce

• Applications for GP training posts down 15% nationally, 9% in London

• 9 district nurses in training in London due to finish this year

• No figures on number of practice nurses in training but shortage of training posts available

• ?? newly qualified GPs opting to work in unscheduled services for flexibility and higher pay – less admin, less follow up

• Harder to flex workforce numbers for unscheduled or scheduled care – particularly if there are stringent waiting time standards

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‘Two incompatible ideals’ in a system that lacks capacity to meet demand?

(Freeman 2010)

• Mixed research evidence on the impact of advanced access on

continuity

• No impact on continuity by advanced access (Salisbury 2007)

• Decreased continuity with advanced access (Phan and Brown 2009)

• Patients value seeing a GP they know – even if they want rapid access

for urgent problem

• Patients set their own priorities in different clinical situations

• ‘Trade-offs’

• ‘Sacrificing continuity for immediacy’ (Guthrie & Wyke 2006, Boulton et

al 2006, Cowie 2009)

Underlying issues (2) : Balancing access and continuity

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GP perspectives:

• How will new ‘access challenge’ services manage access and continuity?

• What will be the organising logic of new services: what balance between bookable &

unscheduled appts

• Can continuity be preserved across collaborating practices or will there be lots of

‘holding the fort’

• Will they be able to steer working people to extended hours bookable slots

• Current GP workforce will be spread thinner - Need to cover both longer hours and

availability for coordinated MDT working for complexity

• Availability to participate in MDT meetings/planned discussions with other services

• Ability to deliver long appointments to deal with complexity

• Continuity as a route to greater efficiency in general practice

Underlying issues (2) : Balancing access and continuity

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Underlying issues (3) : Realistic or unrealistic expectations

• Ten year narrative of ‘rights and responsibilities’ in the NHS has been skewed in favour of rights and entitlement to access tax funded services

• ‘Tesco’ style 24/7 NHS: Key point about 24/7 hospital to improve safety is mixed with a narrative about convenience / customer service in accessing primary care

• Numerous initiatives to promote self care for minor illness, but with limited impact

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Underlying issues (4): Risk appetite in protocol driven services

• Regulatory and quality standards have important implications for capacity, cost and management

• Is 111 too risk averse?

• Nurse led services tend to be more based on clinical algorithms, so ?? are they more risk averse?.

• Call to change the level of risk aversion in society? (Julia

Neuberger, 2008)

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Audits of 186 children attending six walk in clinics a London GP clinic and weekend opening in Durham Dales

Daily walk in clinic for <16’s, 10am – 1pm

186 patients seen

21 attended with <24 hours of symptoms

6 attended with <48 hours of symptoms (4 marked

appropriate by GPs)

18 used another service within 1 week of WIC attendance

7 used more than 1 other service within 1 week of attendance

(3 appropriately)

Of 186 patients, 27 attended within 48 hours of onset of

mainly minor, self-limiting symptoms. 25 used at least

other service within 1 week of attending the clinic under

investigation

6. What was the reason for attending your practice at the weekend? I became unwell and knew the practice was open 18

It was more convenient for me to attend at the weekend rather than in midweek 74I was passing the practice and saw that it was open 1I was redirected by 111/Emergency Department 7

Other, please state (See Q6 tab) 65

No answer 13

12. If your practice had not been open, where would you have sought medical help or advice Urgent Care Centre 34111 12A&E 9Pharmacy 8Friend or family member 2Waited until the practice was open 104Other, please state below (See Q12 tab) 3No answer 24

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Concluding thoughts

• No right and wrong answers• Workforce pressures will become a significant

constraint on our ability to increase capacity • Little robust evidence on the interplay between

increased rapid and unscheduled access and the ability of patients with chronic complex illness to achieve continuity

• Need for debate on whether it is desirable and/or possible to change patient and public expectations of the NHS