David Lloyd: Supply induced demand

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Dr David Lloyd of the Ridgeway Surgery in Harrow gives a GP’s perspective on supply-induced demand in health care. Dr Lloyd spoke at the event: Supply induced demand as it relates to general practice (http://www.nuffieldtrust.org.uk/talks/supply-induced-demand-it-relates-general-practice) in March 2014.

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David Lloyd: Supply induced demand

  1. 1. Supply induced demand From the Front Line David Lloyd
  2. 2. Disclaimer • A personal view – I am pretty experienced at Unscheduled Care – I have worked in all types of OOH setting • PCC-appointment only • UCC –front of A/E • WIC beside hospital • Nurse Led • Doctor Led
  3. 3. It’s getting tough to do it all in 10 minutes
  4. 4. One way to cope with demand
  5. 5. FUNNY OR SAD
  6. 6. • A woman sees me on Sunday morning in the polyclinic/8-8/Sunday surgery for a self limiting illness • She found my consultation less than perfect • So goes to A/E • She is told she will have to wait 3.5 hours to be seen and takes a seat
  7. 7. • While waiting she rings Harmoni and fixes an appointment to be seen OOH • She walks round the corner to the OOH base • And meets me again doing my evening shift • Surprised she emerges with the same advice • And goes back to wait in the A/E
  8. 8. • A junior doctor, less experienced does a CXR and bloods • 4 hours later she is discharged from A/E with the same diagnosis after review by a senior team member • She leaves with the advice to see her own GP the next day • So she takes an emergency appointment with her GP the next day • Who happens to be me
  9. 9. • We chat and laugh about our Sunday and I begin to understand the pressures she lives with and she begins to understand the pressures of being a GP • She is a relatively new patient and GP2GP has not yet deposited her notes into my PC • But a week later there is still no sign of the Harmoni email from her attendance or an A/E report • It’s then that I realise that she has used 3 different spellings of her name and generated 3 different sets of notes only one of which has her NHS number
  10. 10. My Brief • Put the out of hours point of view • Confirm that supply induces demand • Talk about case mix
  11. 11. Alex WIC Monthly attendance since opening Monthly Attendence 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Total 1362 1775 1500 1766 1870 2099 2245 2185 2145 2656 2825 3108 2926 3089 2783 3077 3483 3397 4341 3927 3359 4052 4382 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 2009 2010 2011
  12. 12. We were shut down at the end of 2012 • We still open for 8 hours on Saturday and Sunday • Something about money • And supply induced demand! • But we kept the clinic open as an ordinary surgery • And have our last appointment at 7.30 pm M- F
  13. 13. And this is what happened to our list in 2013 9% rise List 18% of all new patients in Harrow
  14. 14. 0 5000 10000 15000 20000 25000 30000 35000 January March May July September November January March May July September November January March May July September November January March May July September November January March May July September November January March May July 2006 2007 2008 2009 2010 2011 Sum of advice Sum of Pcc Sum of HV Sum of Alex Sum of total Harmoni Figures
  15. 15. Referral Rate to A/E Years Date Ref A/E Total % 2009 Jun 4 1362 0.3% Jul 13 1775 0.7% Aug 10 1500 0.7% Sep 5 1766 0.3% Oct 8 1870 0.4% Nov 9 2099 0.4% Dec 11 2245 0.5% 2010 Jan 14 2185 0.6% Feb 21 2145 1.0% Mar 11 2656 0.4% Apr 17 2825 0.6% May 34 3108 1.1% Jun 26 2926 0.9% Jul 16 3089 0.5% Aug 17 2783 0.6% Sep 21 3077 0.7% Oct 27 3483 0.8% Nov 21 3397 0.6% Dec 56 4341 1.3% 2011 Jan 55 3927 1.4% Feb 30 3359 0.9% Mar 47 4052 1.2% Apr 41 4382 0.9% May 24 2393 1.0% Grand Total 538 66745 0.8% % 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% Jun Aug O ct Dec Feb Apr Jun Aug O ct Dec Feb Apr
  16. 16. Top Conditions treated Wound Care 59 Wound dressing 44 Flu symptoms 34 Vomiting 26 travel advice 25 Sore throat 23 blood sample 22 Swine flu 22 Abdominal pain 21 hayfever 21 Foreign Travel Advice 19 Blood test 17 Upper Respiritory Tract infection 17 Insect bite 15 Back pain 14 Cough 14 Diarrhoea 13 dysuria 13 Possible Swine flu 13 upper respiratory tract infection 13 Hot/feverish 12 Knee pain 12 (blank) 12
  17. 17. A man walked into the clinic with a lump in his testicle • The tumour is a classical seminoma that infiltrates extensively into rete testes. The tumour infiltrates into the tunica albuginea but is not invading tunica vaginalis No yolk sac, embryonal or trophoblast differentiation is seen. • And so did 2 others with the same thing • Young men do not consult their GP • They may be from Eastern Europe • And may work 7 days a week to make ends meet
  18. 18. Yellow other PCTs Blue Harrow Green Ridgeway Red No GP
  19. 19. Overall Patient Experience (1 patient out of 207 rated care as poor)
  20. 20. Equity • The Haves – Know the system – Know the words • “difficulty breathing” • “chest pain” – Have the technology • Email • Text • Mobile numbers (I promise I’ll never use it) • Doctor Google – Have friends • You must know my best friend Clare Gerada • The Have Nots – English is their 3rd or 4th language – Can’t use the telephone and be understood – Are not used to having a GP rather than a hospital – May have to move from flat to flat – Or NFA • “sofa surfing” – Have no internet access (nowadays makes homework impossible)
  21. 21. Equity • So do you have a system designed around the haves or the have nots? • Does it always need to be a doctor? • I would argue yes • The key is to sort in one hit • And that means your best person at the Front end • Death by assessment
  22. 22. Supply v demand in a rationed system • If we accept that we cannot provide everything to everyone • How do we divide the resources? • If people choose to use a walk in centre at a time convenient to them rather than see a GP or nurse, is that wrong? • Rather than talk about double paying, make the WIC and GP and OOH/111 the same organisation and give them one budget
  23. 23. In conclusion • Is there supply induced demand? – Yes and no • Can we change or alter the pattern of access? – Yes for the usual suspects – No for the ever changing population mix in London • The solution – One budget – Local emergent strategies

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