1. © Nuffield Trust Supply induced demand as it relates to primary care Dr Rebecca Rosen Senior Fellow, The Nuffield Trust GP, Ferryview Health Centre, Woolwich March 18 2014

2. © Nuffield Trust Many types of supply induced demand to enjoy

3. © Nuffield Trust 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)

4. © Nuffield Trust Multiple unscheduled & scheduled primary care services Is public confusion fuelling service use?

5. © Nuffield Trust 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?

6. © Nuffield Trust Categories of unscheduled primary care attendance:

7. © Nuffield Trust 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 or scheduled care – particularly if there are stringent waiting time standards

8. © Nuffield Trust ‘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

9. © Nuffield Trust 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 Underlying issues (2) : Balancing access and continuity

10. © Nuffield Trust 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

11. © Nuffield Trust 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)

12. © Nuffield Trust 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 No answer 24

13. © Nuffield Trust 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