In this slideshow Dr Rebecca Rosen, Senior Fellow, Nuffield Trust, discusses the concept of supply-induced demand as it relates to primary health care. She discusses the factors driving demand for increased service access and the unclear nature of the relationship between increased access and continuity of care. Dr Rosen 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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Supply induced demand as it relates to primary care
Dr Rebecca Rosen
Senior Fellow, The Nuffield Trust
GP, Ferryview Health Centre, Woolwich
March 18th 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 cf scheduled
care – particularly if there are stringent waiting time standardsWill there be enough GPs and nurses to extend
capacity across a longer working week?

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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
●
What will be the impact on continuity and coordination of extending
hours of access to GP clinics and changing the mix of bookable and
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
To what extent can we re-balance the rights and responsibilities
narrative? How could we do this?

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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)
What part does risk aversion play in stoking
supply induced demand?

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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 74
I was passing the practice and saw that it
was open 1
I 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 34
111 12
A&E 9
Pharmacy 8
Friend or family member 2
Waited until the practice was open 104
Other, please state below (See Q12 tab) 3

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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