Supply induced demand as it relates to
primary care
Dr Rebecca Rosen
Senior Fellow, The Nuffield Trust
GP, 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
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modify the impact of supply induced demand?
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
Boss (school) require a
sick note from day 1
Working mother – called by nursery ‘child
has a fever’. Book to have child checked
before setting eyes on him/her
New onset
‘severe’ symptoms
Child with fever – ‘viral illness’.
Been to WIC/UCC/GP 2 – 3 times
in previous week: worried parent
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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Underlying issues (2) : Balancing access
and continuity
‘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)
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Underlying issues (2) : Balancing access
and continuity
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
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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
It was more convenient for me to attend
at the weekend rather than in midweek
I was passing the practice and saw that it
was open
I was redirected by 111/Emergency
Department
18
74
1
7
Other, please state (See Q6 tab)
65
No answer
12. If your practice had not been open,
where would you have sought medical
help or advice
Urgent Care Centre
111
A&E
Pharmacy
Friend or family member
Waited until the practice was open
Other, please state below (See Q12
tab)
13
34
12
9
8
2
104
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3
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
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