MANAGING THE DEMAND Dr Gerry Beattie Dr Gerry Beattie 19 th May th May 2010

Demand management - definition Actions taken by primary care/trusts and/ or GP practices to moderate the demand for health care services Actions taken by primary care/trusts and/ or GP practices to moderate the demand for health care services Hospital demand management refers to actions taken to moderate the rate of referrals of patients to hospitals Hospital demand management refers to actions taken to moderate the rate of referrals of patients to hospitals NHS Evidence NHS Evidence

Demand Demand is not a given – it can be influenced Demand is not a given – it can be influenced Demand is constantly changing Demand is constantly changing As waiting times come down demand may rise As waiting times come down demand may rise In some main specialities demand is rising In some main specialities demand is rising eg. ENT, neurosurgery, urology eg. ENT, neurosurgery, urology

To manage demand - The interface between primary and secondary care needs to be managed The interface between primary and secondary care needs to be managed There is a need to assume a corporate ownership of patient pathways through primary and secondary care There is a need to assume a corporate ownership of patient pathways through primary and secondary care

Demand It’s all very well saving 10 pence in the pound, but perhaps what’s more important is who spends the 90 pence Kings Fund Kings Fund

Management and demand at the interface between primary and secondary care. Angela Coulter, Director of Policy and Review, King’s Fund British Medical Journal (1998) Vol 316,

Why do GPs refer ? Diagnosis Diagnosis Investigation Investigation Advice on treatment Advice on treatment 2 nd opinion 2 nd opinion Reassurance for the patient Reassurance for the patient

Continued ; Sharing the load or risk of treating a difficult or demanding patient Sharing the load or risk of treating a difficult or demanding patient Deterioration in the GP/patient relationship leading to a desire to involve someone else in the management of the problem Deterioration in the GP/patient relationship leading to a desire to involve someone else in the management of the problem Fear of litigation Fear of litigation Direct request from patient or relative Direct request from patient or relative

‘Collating information and feedback are important first steps in the understanding of patterns of demand ‘ Coulter

Appropriate referrals Necessary Necessary Timely Timely Cost effective Cost effective Effective Effective

What’s referred most - Joint pain Joint pain Hearing problems Hearing problems Abdominal pain Abdominal pain Back pain Back pain Breast lumps Breast lumps Varicose veins Varicose veins Visual problems Visual problems Menorrhagia Menorrhagia

Continued Sterilisation / vasectomy Sterilisation / vasectomy Skin conditions Skin conditions Depression Depression Termination of pregnancy Termination of pregnancy Tonsils Tonsils Otitis media Otitis media Cataracts Cataracts

Managing Demand 1. Knowing demand and flexing capacity 2. Advice only referrals 3. Ref help 4. Speciality GPs 5. Direct access

1. Knowing demand and flexing capacity Gynaecology – unclear what the demand was in terms of numbers and case mix Gynaecology – unclear what the demand was in terms of numbers and case mix Waiting time for GOPD was 16 weeks Waiting time for GOPD was 16 weeks 6 entry points into the system all with separate booking systems – NRIE, WGH, SJH, LCTC, Roodlands, Liberton 6 entry points into the system all with separate booking systems – NRIE, WGH, SJH, LCTC, Roodlands, Liberton Inequity of access and double slotting Inequity of access and double slotting

Centralised Booking Referrals redirected on SCI Gateway to one central office in NRIE. Referrals redirected on SCI Gateway to one central office in NRIE. Patients seen by most appropriate person at the most appropriate site. Patients seen by most appropriate person at the most appropriate site. Ability to respond to pressures and better utilise specialist clinics with more effective use of capacity. Ability to respond to pressures and better utilise specialist clinics with more effective use of capacity. Waiting time for GOPD approximately 6 weeks across Lothian without additional capacity. Waiting time for GOPD approximately 6 weeks across Lothian without additional capacity. Prospective capacity modelling tool Prospective capacity modelling tool

Audit of referrals

DNA’s Sterilisation requests Sterilisation requests Menorrhagia Menorrhagia Pelvic pain Pelvic pain But approximately 70% of DNAs are return patients But approximately 70% of DNAs are return patients Grad e ↓ Pathway → Gra de ↓ Pathway → Gra de ↓

DNA Rate

2. Advice only referrals Examples in various specialities that this works well eg dermatology Examples in various specialities that this works well eg dermatology SCI gateway ‘advice only’ referrals being developed and piloted in gynaecology SCI gateway ‘advice only’ referrals being developed and piloted in gynaecology Ultimately linked to TRAK Ultimately linked to TRAK Demand needs to be monitored closely Demand needs to be monitored closely Manpower needs to be in place in secondary care to deal with such referrals Manpower needs to be in place in secondary care to deal with such referrals

3. Ref help On line referral support On line referral support Perceived as ‘user unfriendly’ at present Perceived as ‘user unfriendly’ at present Services need to take ownership Services need to take ownership Use as a shop window with up-to-date referral help and advice Use as a shop window with up-to-date referral help and advice

4. Speciality GPs Identify GPs with speciality interest to work with secondary care Identify GPs with speciality interest to work with secondary care Protocol and pathway development Protocol and pathway development Focus for information dissemination and feedback in both directions Focus for information dissemination and feedback in both directions Develop educational initiatives Develop educational initiatives Consolidate links between primary and secondary care Consolidate links between primary and secondary care

5. Primary Care Access Removing access restrictions and jointly redesigning primary/secondary care interface processes can improve the whole patient journey Removing access restrictions and jointly redesigning primary/secondary care interface processes can improve the whole patient journey

Primary Care Access Expand the range of diagnostic tests available in primary care Expand the range of diagnostic tests available in primary care Direct access bookable slots in secondary care Direct access bookable slots in secondary care Reduce referrals to secondary care and enhance local care Reduce referrals to secondary care and enhance local care

Primary Care Access Echocardiography Echocardiography Ambulatory BP recording Ambulatory BP recording 24 hour tapes 24 hour tapes Full pulmonary function testing Full pulmonary function testing CT/MRIs of knees, chest, neck, abdomen CT/MRIs of knees, chest, neck, abdomen

MRI lumbar spine – the Tayside experience (April – Sept 2009) GP-OP-MRI-OP vs Direct access GP-MRI 34% GP-OP-MRI-OP vs Direct access GP-MRI 34% GP-MRI-OP 66% GP-MRI-OP 66% GP to OP to MRI to OP - 24 weeks GP to OP to MRI to OP - 24 weeks GP to MRI to OP - 12 weeks GP to MRI to OP - 12 weeks Out patient attendances dropped by 66% Out patient attendances dropped by 66%

Questions ?