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.

1. Supply induced demand
From the Front Line
David Lloyd

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. It’s getting tough to do it all in 10
minutes

4. One way to cope with demand

5. FUNNY OR SAD

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. • 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. • 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. • 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. My Brief
• Put the out of hours point of view
• Confirm that supply induces demand
• Talk about case mix

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. 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. And this is what happened to our list in 2013 9%
rise List 18% of all new patients in Harrow

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. 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. 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. 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. Yellow other
PCTs
Blue Harrow
Green
Ridgeway
Red No GP

19. Overall Patient Experience
(1 patient out of 207 rated care as poor)

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. 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. 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. 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