Supply induced demand

From the Front Line

David Lloyd

Disclaimer

• A personal view – I am pretty experienced at Unscheduled Care – I have worked in all types of OOH setting

• PCC-appointment only • UCC –front of A/E • WIC beside hospital • Nurse Led • Doctor Led

It’s getting tough to do it all in 10 minutes

One way to cope with demand

FUNNY OR SAD

• A woman sees me on Sunday morning in the polyclinic/8-8/Sunday surgery for a self limiting illness

• She found my consultation less than perfect

• So goes to A/E

• She is told she will have to wait 3.5 hours to be seen and takes a seat

• While waiting she rings Harmoni and fixes an appointment to be seen OOH

• She walks round the corner to the OOH base

• And meets me again doing my evening shift

• Surprised she emerges with the same advice

• And goes back to wait in the A/E

• A junior doctor, less experienced does a CXR and bloods

• 4 hours later she is discharged from A/E with the same diagnosis after review by a senior team member

• She leaves with the advice to see her own GP the next day

• So she takes an emergency appointment with her GP the next day

• Who happens to be me

• We chat and laugh about our Sunday and I begin to understand the pressures she lives with and she begins to understand the pressures of being a GP

• She is a relatively new patient and GP2GP has not yet deposited her notes into my PC

• But a week later there is still no sign of the Harmoni email from her attendance or an A/E report

• It’s then that I realise that she has used 3 different spellings of her name and generated 3 different sets of notes only one of which has her NHS number

My Brief

• Put the out of hours point of view

• Confirm that supply induces demand

• Talk about case mix

Alex WIC Monthly attendance since opening

Monthly Attendence

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Total 1362 1775 1500 1766 1870 2099 2245 2185 2145 2656 2825 3108 2926 3089 2783 3077 3483 3397 4341 3927 3359 4052 4382

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

2009 2010 2011

We were shut down at the end of 2012

• We still open for 8 hours on Saturday and Sunday

• Something about money

• And supply induced demand!

• But we kept the clinic open as an ordinary surgery

• And have our last appointment at 7.30 pm M-F

And this is what happened to our list in 2013 9% rise List 18% of all new patients in Harrow

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2006 2007 2008 2009 2010 2011

Sum of advice Sum of Pcc Sum of HV Sum of Alex Sum of total

Harmoni Figures

Referral Rate to A/E Years Date Ref A/E Total %

2009 Jun 4 1362 0.3%

Jul 13 1775 0.7%

Aug 10 1500 0.7%

Sep 5 1766 0.3%

Oct 8 1870 0.4%

Nov 9 2099 0.4%

Dec 11 2245 0.5%

2010 Jan 14 2185 0.6%

Feb 21 2145 1.0%

Mar 11 2656 0.4%

Apr 17 2825 0.6%

May 34 3108 1.1%

Jun 26 2926 0.9%

Jul 16 3089 0.5%

Aug 17 2783 0.6%

Sep 21 3077 0.7%

Oct 27 3483 0.8%

Nov 21 3397 0.6%

Dec 56 4341 1.3%

2011 Jan 55 3927 1.4%

Feb 30 3359 0.9%

Mar 47 4052 1.2%

Apr 41 4382 0.9%

May 24 2393 1.0%

Grand Total 538 66745 0.8%

%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

Jun

Aug O

ctDec

Feb Apr

Jun

Aug O

ctDec

Feb Apr

Top Conditions treated

Presenting Complaint Total

Wound Care 59

Wound dressing 44

Flu symptoms 34

Vomiting 26

travel advice 25

Sore throat 23

blood sample 22

Swine flu 22

Abdominal pain 21

hayfever 21

Foreign Travel Advice 19

Blood test 17

Upper Respiritory Tract infection 17

Insect bite 15

Back pain 14

Cough 14

Diarrhoea 13

dysuria 13

Possible Swine flu 13

upper respiratory tract infection 13

Hot/feverish 12

Knee pain 12

(blank) 12

Earache 11

urinary tract infection 11

Asthma 10

Rash 10

Viral Infection 10

A man walked into the clinic with a lump in his testicle

• The tumour is a classical seminoma that infiltrates extensively into rete testes. The tumour infiltrates into the tunica albuginea but is not invading tunica vaginalis No yolk sac, embryonal or trophoblast differentiation is seen.

• And so did 2 others with the same thing

• Young men do not consult their GP

• They may be from Eastern Europe

• And may work 7 days a week to make ends meet

Yellow other PCTs

Blue Harrow

Green Ridgeway

Red No GP

Overall Patient Experience

(1 patient out of 207 rated care as poor)

Equity

• The Haves – Know the system – Know the words

• “difficulty breathing” • “chest pain”

– Have the technology • Email • Text • Mobile numbers (I promise

I’ll never use it) • Doctor Google

– Have friends • You must know my best

friend Clare Gerada

• The Have Nots – English is their 3rd or 4th

language – Can’t use the telephone

and be understood – Are not used to having a

GP rather than a hospital – May have to move from

flat to flat – Or NFA

• “sofa surfing”

– Have no internet access (nowadays makes homework impossible)

Equity

• So do you have a system designed around the haves or the have nots?

• Does it always need to be a doctor?

• I would argue yes

• The key is to sort in one hit

• And that means your best person at the Front end

• Death by assessment

Supply v demand in a rationed system

• If we accept that we cannot provide everything to everyone

• How do we divide the resources?

• If people choose to use a walk in centre at a time convenient to them rather than see a GP or nurse, is that wrong?

• Rather than talk about double paying, make the WIC and GP and OOH/111 the same organisation and give them one budget

In conclusion

• Is there supply induced demand? – Yes and no

• Can we change or alter the pattern of access? – Yes for the usual suspects

– No for the ever changing population mix in London

• The solution – One budget

– Local emergent strategies