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

2. 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)

3. 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

4. Studies of NHS Direct and NHS111 show that call lines do not appear to alter utilisation http://www.sheffield.ac.uk/scharr/sections/hsr/mcru/reportshttp://www.sheffield.ac.uk/scharr/sections/hsr/mcru/reports. Turner et al. BMJ Open 2013. doi:10.1136/bmjopen-2013-003451 % change in system activity following start of NHS111 in 4 pilot sites relative to control sites

5. Commuter WICs

6. 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%)

7. 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 2009. doi: 10.3399/bjgpo9X473150. Coster et al. BJGP 2009. doi: 10.3399/bjgpo9X473169

8. GP-led Urgent care centres

9. 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 2014. doi: 10.1136/emermed-2013-202410

10. 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 2014. doi: 10.1136/emermed-2013-202410

11. 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 2014. doi: 10.1136/emermed-2013-202410

12. 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

13. 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

14. 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 2000. 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

15. 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.

16. 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

17. Copyright ©2000 BMJ Publishing Group Ltd. Munro, J. et al. BMJ 2000;321:150-153 Impact of NHS Direct on emergency and urgent care services

18. 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

19. 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)659141 (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.