Induced demand for and utilisation of the emergency and urgent care system Jon Nicholl ScHARR, Sheffield

Induced demand and utilisation for face-to-face services 1. First contacts for new problems (demand) (affected by accessibility) 2.Further contacts for the same problem (utilisation) (affected by appropriateness of first contact)

Induced demand and utilisation by call lines Call lines could alter demand and utilisation of existing services, for example by o Increasing demand by advising some people who would have looked after themselves to make f-to-f contact, or o Reducing utilisation by sending people to the right place first time, and reducing the need for further contacts for the same problem

Studies of NHS Direct and NHS111 show that call lines do not appear to alter utilisation Turner et al. BMJ Open doi: /bmjopen % change in system activity following start of NHS111 in 4 pilot sites relative to control sites

Commuter WICs

Induced demand by commuter WICs Self-reported pre-consultation intentions in patients attending 6 privately managed, Dr staffed, commuter walk-in centres Pre-consultation intentions ( What would you have done if the WIC had not been available?) N (%) ED139 (11.7) GP631 (53.2) Other228 (19.2) Self/nothing189 (15.9) Total1187(100.0%)

Induced potential utilisation by commuter WICs Self-reported post-consultation plans in patients attending 6 privately managed, Dr staffed, commuter walk-in centres Pre-consultation intentions ( What would you have done if the WIC had not been available?) N (%) Post-consultation plans N (%) ED139 (11.7)74 (5.0) GP631 (53.2)368 (25.0) Other228 (19.2)295 (20.0) Self/nothing189 (15.9)737 (50.0) Total1187(100.0%)1474 (100.0%) O’Cathain et al. BJGP doi: /bjgpo9X Coster et al. BJGP doi: /bjgpo9X473169

GP-led Urgent care centres

Induced demand by GP-led urgent care centres Self-reported pre-consultation intentions in patients attending two privately managed, Dr staffed, urgent care centres Pre-consultation intentions ( What would you have done if the GP-WIC had not been available?) N (%) ED202 (23.2) GP340 (39.0) Other226 (25.9) Self/nothing103 (11.8) Total871 (100.0%) Arain et al. EMJ doi: /emermed

Induced potential utilisation by GP-led urgent care centres Self-reported post-consultation plans in patients attending two privately managed, Dr staffed, urgent care centres Pre-consultation intentions ( What would you have done if the GP-WIC had not been available?) N (%) Post-consultation plans N (%) ED202 (23.2)38 (4.4) GP340 (39.0)146 (16.7) Other226 (25.9)30 (3.4) Self/nothing103 (11.8)659 (75.5) Total871 (100.0%)873 (100.0%) Arain et al. EMJ doi: /emermed

Induced utilisation by GP-led urgent care centres Self-reported 4 wk post-consultation use of other services by patients attending two privately managed, Dr staffed, urgent care centres Pre-consultation intentions ( What would you have done if the GP-WIC had not been available?) N (%) Post-consultation plans N (%) Actual use of services post-consultation N (%) ED202 (23.2)38 (4.4)14 (5.6) GP340 (39.0)146 (16.7)73 (29.3) Other226 (25.9)30 (3.4)21 (8.8) Self/nothing103 (11.8)659 (75.5)141 (56.2) Total871 (100.0%)873 (100.0%)249 (100.0) Arain et al. EMJ doi: /emermed

Estimating the volume of induced utilisation Call lines don’t appear to change demand or utilisation Demand: 12-16% of patients attending walk-in urgent care centres said that they would not have made any contact if the service hadn’t been available Utilisation: 30-35% of patients who use walk-in urgent care centres go on to contact their GP or an ED

Estimating the volume of induced urgent care first attenders at type 3 EDs In 2012/13 there were 6.6m type 3 ED contacts There were an unknown N of type 3 ED minor injury unit attendances in 1994/5

Estimating the volume of induced utilisation MIUs began to be introduced in the 1990s GP and nurse-led walk-in centres began to be introduced in Assuming about 1/3 rd of type 3 ED attendances are to MIUs, the WICs and UCCs may induce about 0.5m new contacts each year 1.5m follow-on contacts

Big uncertainties Small studies not designed to answer this question Response rates Reliability of reported intentions The volume of MIU attendances which may induce relatively little additional utilisation The longer term effects of call lines when they have bedded-in.

Big uncertainties Small studies not designed to answer this question Response rates Reliability of reported intentions The volume of MIU attendances which may induce relatively little additional utilisation The longer term effects of call lines when they have bedded-in. Thank you

Copyright ©2000 BMJ Publishing Group Ltd. Munro, J. et al. BMJ 2000;321: Impact of NHS Direct on emergency and urgent care services

Intentions and outcomes in 249 patients attending two GP-WICs What would you have done if the GP-WIC had not been available? Intention to use other services after consultation Outcome ED202 (23.2)3814 (5.6) GP340 (39.0)14673 (29.3) Self/nothing103 (11.8)659- GP-WIC-8141 (56.2) Other226 (25.9)2221 (8.8) Total871 (100.0%)873 (100.0%)249 (100.0) We know that the 23.2% who said they would have gone to ED exaggerates the true proportion. So

Intentions and outcomes in patients attending two GP-WICs What would you have done if the GP-WIC had not been available? Intention to use other services after consultation Outcome ED202 (23.2)3814 (5.6) GP340 (39.0)14673 (29.3) Other226 (25.9)3021 (8.8) Self/nothing103 (11.8) (56.2) Total871 (100.0%)873 (100.0%)249 (100.0) We know that the 23.2% who said they would have gone to ED exaggerates the true proportion who would have gone to ED. So, other intentions are likely to be unreliable.