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Archive for the ‘Demand management’ Category

Well, does it? Here’s the evidence. You can see on the chart the steady reduction in outpatient and inpatient long-waits in the early noughties, followed by the dramatic cut in referral-to-treatment long-waits from 2007 to 2009.

GP referrals are used to indicate the level of demand, and they rise in two steps over the period. The first step doesn’t line up with the long-wait events, but the second step does coincide quite nicely with the achievement of 18 weeks.

Although it doesn’t look like much on the chart, the increase from mid-2007 is a 22 per cent step up in GP referrals over two years, which is not to be sneezed at (but hardly represents a spiralling out of control). Was it caused by the improvement in waiting times? Who knows; this is perhaps one for the health economists (who have various views on the subject).

Data sources: RTT data, inpatient and outpatient waits, GP referrals (recent), GP referrals (older) 

As British schools broke up and everyone headed off for their summer holidays, the Co-operation and Competition Panel (CCP) published their final report on Any Willing Provider. One passage that caught journalists’ and commentators’  eyes was this (para. 91):

The imposition of minimum uniform waiting times at providers [by PCTs] also appears reasonably widespread.

The CCP reported that PCTs claimed two benefits of minimum waiting times.

• more equitable treatment for patients across different providers;
• reduced expenditure for taxpayers.

The CCP criticised the first as “an unfortunate levelling-down”, and the second as a “one-off benefit that cannot be repeated”. In response to the argument that longer waits can save money as patients remove themselves from the list, they said (in a much-reported footnote to page 29):

We understand that patients will “remove themselves from the waiting list” either by dying or by paying for their own treatment at private sector providers, and that there is a relationship between the self-pay market in private healthcare and the length of waiting lists in the NHS. However, research suggests that the effect of increasing waiting times at all hospitals is unlikely to be significant. A 10% reduction in waiting times is associated with an increase in demand of between 1.35% and 2.35%. Assuming increases and decreases in waiting times have a similar effect, it is likely that an increase in waiting times will have a small impact on overall demand for services.

Actually a 2 per cent fall in elective demand sounds like a very useful saving to pocket, in return for a small increase in waiting times from (say) 15 weeks to 16.5 weeks. Unfortunately the CCP do not provide a reference for their statement that “research suggests” this. There is other evidence that waiting times over 10 weeks may deter patients: RAND Europe, City University  and the King’s Fund surveyed patients’ attitudes to waiting times in 2006, and found (in para. 5.3.2):

For waiting times of 8 weeks or less, a change in waiting time is valued as zero. That is to say, on average there is no benefit from reducing the waiting time from referral to treatment below 8 weeks. Once the waiting time reaches 10 weeks, there is, however, a step change where the increases in waiting time are valued negatively (and significantly different from zero). It can be seen that the rate of change is relatively constant, implying that for waits of 10 weeks and above the valuation of waiting time increases approximately linearly.

In other words, patients are unfazed by waiting times under 10 weeks. But when waits are over 10 weeks, every extra week adds the same amount of extra disincentive. Whether this disincentive actually translates into reduced demand, unfortunately, is not something that RAND et al come to any clear conclusion about.

So what about the argument, advanced by the CCP and others, that it is pointless trying to save money by lengthening waiting times, because you only get the savings once? I think most commissioners would respond (as some did to the CCP) that once is better than never, and that if the requirement is 18 weeks then why divert scarce resources towards even-shorter waits for the least-sick patients in the system?

But I think minimum waiting times are objectionable for another reason: they create hopelessness.

Waiting times and waiting lists are not simply the balance of activity and the demand for healthcare. A fair amount of NHS activity is devoted to patients who are stuck in follow-up loops, who attend clinics when the result of their diagnostic test is not in the notes, who are referred to the wrong specialist, or who keep coming back as emergencies because their long term condition is not being managed.

If clinicians and managers can achieve system improvements that drive out this “failure demand” then waiting lists and times would largely disappear in those services. But no clinician or manager is going to bother, if all the benefits of system improvement are going to be instantly confiscated by a minimum waiting time requirement, bluntly imposed by the commissioner.

payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed

For this reason alone, minimum waiting times should not be an operational requirement; payment should not be withheld for short-wait activity, nor should individual patients be deliberately delayed.

Having said that, it is surely unrealistic to expect commissioners and trusts to plan activity based on (say) 10 week waits across the board, when their figures say that only 16 weeks is affordable? Or to continue to fund 8 week waits in General Surgery when Orthopaedics is struggling at 22 weeks?

To be sure, planning activity and capacity on the basis of 18 weeks, when the service concerned is currently achieving 10 weeks, is a step backwards. More than that, it is a shame, because those short waits were hard-won, and there is always the worry that letting patients wait is the easy way out for the NHS.

But times are tight. There is a difference between, on the one hand, commissioners using 18 weeks as their planning assumption, and on the other hand imposing 15-week minimum waiting times operationally on a patient by patient basis.

Good planning protects urgent patients

It is worth remembering that good planning, based on realistic assumptions about what is possible with waiting time management, also protects hard-pressed services by releasing resources for them. When long-wait targets are being aggressively pursued, this extra resource may be essential to stop urgent patients being delayed.

This post first appeared at HSJ blogs

We talk about the demand for healthcare all the time, but sometimes the talk is loose. If you hang around NHS offices for long enough you might hear statements like:

• Demand can’t be that high – the contract doesn’t provide that much.
• Last year we did 1,000, add 3% growth in demand, so that makes 1,030 next year.
• I’ve got hips coming out of my ears.

…and so on.

This kind of talk confuses demand and activity. More accurately, we might say things like this:

• Demand is likely to grow, but we don’t know exactly why or by how much.
• The waiting list is the accumulated mismatch between demand and activity.
• If we want to control waiting lists, we have to at least keep up with demand.
• Historic demand is activity plus the growth in the waiting list (adjusted for removals).

This is the sort of thing that is built into good planning models, and it allows us to make other useful distinctions, like:

• recurring activity is the activity required to keep up with demand; and
• non-recurring activity is everything else, and it brings down the waiting list.

So far so good. But behind all this, we are making a big assumption that won’t spring out of a planning model: that all our “demand” represents real work that we need to do. For instance:

• a patient is seen in outpatients by the wrong consultant and has to be rebooked with the right one; is the first appointment “demand”?
• a patient is referred for unnecessary follow-up by a junior who is not confident enough to discharge; is this follow-up “demand”?
• a patient is seen in outpatients, but the necessary test results aren’t ready so they have to be rebooked; is this “demand”?
• a one-stop clinic replaces an outpatient-diagnostic-outpatient sequence; does demand fall by two-thirds?

And on the inpatient side, are any of the following “demand”?

• a patient remains in an acute bed for a couple of days longer than necessary, waiting for a ward round and then drugs;
• a patient arrives for surgery, but is sent home and rebooked because they had toast for breakfast;
• a patient is admitted to avoid breaching the 4 hour A&E target, even though they don’t meet any AEP criteria.

These examples of “demand” are not caused by unmet healthcare needs in the population. Rather, they are artefacts of the system. How much of our total demand is created like this? 3 per cent? 10 per cent? 30 per cent? Do we have the faintest idea?

If it’s a sizeable proportion, and I suspect it probably is, then reducing it could substantially offset the (apparently) growing genuine demand for healthcare. Which would be handy at a time of near-frozen real-terms funding.

The King’s Fund has just published a new report on referral management, and delivered a cold shower to the referral management centres that some PCTs have created to weed and redirect GP referrals. It concludes:

the greater the degree of intervention, the greater the likelihood that the referral management approach does not present value for money.

Or, as one triaging GP put it:

It gets back to individuals making decisions on other people’s decisions.

Not that everything is rosy in the world of GP referrals. When GPs were allowed to review their colleagues’ referral letters they were not shy about saying what they thought:

When we first started, some of the referrals were absolutely appalling, dreadful. Two lines, referrals of two lines, please see this patient with headaches, and we automatically rejected all of those…

and

I mean, I just couldn’t believe my eyes initially, the quality of referrals was just dire

Well, criticisms are always fun to read. But what did work? In the words of the King’s Fund:

A referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective. …

Practice-based commissioning clusters and their successors, the GP commissioning consortia, are the obvious conduit and driver for peer review and audit.

In other words, don’t second-guess the referring GPs; but do work at a doctor-to-doctor level on improving their referral skills. This makes perfect sense. At the time of referral, nobody knows the patient’s condition better than the referring GP. If some GPs aren’t very good at referrals, then the problem is unlikely to be solved by inserting a layer of second-guessers (who have only the inadequate referral letters to base their decisions on). As the King’s Fund says:

any intervention to manage referrals cannot look at the referral in isolation but needs to understand the context in which it is being made

So full marks for the King’s Fund report, then? Very nearly. My slight disagreement is when they say:

any referral management strategy needs to include a robust means of managing the inherent risks at the point when clinical responsibility for a patient is handed over from one clinician to another (so-called clinical hand-offs)

I would argue that they accept the concept of the “clinical hand-off” too readily. Referrals should not be fire-and-forget, rather the GP should remain available as the patient’s advisor after the referral has been made. After all, patients must give their informed consent to every step of their treatment, and both the consultant and the GP have a role to play in informing them.

Whether they want to be or not, GPs are commissioners. Every time they refer a patient, they are committing resources to them.

But not all GPs see themselves as commissioners. After all, isn’t commissioning a complex process of planning, analysing, monitoring, and contract management? PCTs employ whole departments to do that, so why would a GP want to take it on? And if they did, how could they do it well?

There are plenty of compelling reasons why things would be better if GPs (and other practice clinicians) did take a more active role in commissioning. After all, who else could do the job better? On the commissioning side, only they know the patient well enough and have the skill and knowledge to make the right clinical judgement.

When looking for ways to improve GP commissioning, the debate has tended to focus on incentives or, more narrowly, how money can be used to reward GPs for referring within a budget. But there is more to effective commissioning than just meeting a budget (clinical quality immediately springs to mind). And there is more to raising performance than financial reward; the three main factors being ability, motivation, and opportunity (the “AMO model“). So how can we use this broader approach to develop better GP commissioning?

Let’s start with ability, which is built of things like skill, reasoning and perception. We can’t easily improve all of these (improving skill and reasoning is a challenge), but we can improve perception because it depends on the information available to a GP.

A commissioning GP needs easily-accessible information that is up-to-date, accurate, and specific to their own referrals, so that they can monitor their referral spend and keep on top of it. In the past an information analyst would have been needed to crunch the numbers, but new web-based systems (like Mede) can now deliver digestible information and alerts from the SUS datasets directly to GPs.

GP commissioners also benefit from support from a real human, and this is where PCTs can provide a bank manager service: challenging overspends, spotting unusual activity on the account, and advising alternative courses of action.

Next: opportunity. To what extent do GPs have the clinical discretion to change referral patterns and adapt to budgetary constraints? The answer has got to be “some discretion”, at least, simply because clinical need is a grey area in which human judgements must be made. Beyond that, we are into the practicalities: are alternative pathways available?

Obviously an available pathway must physically exist as a service. Not only that, but GPs need to be able to refer to it, so there must be a contract in place with the PCT. Also, it is only worth using an alternative pathway if it provides suitable clinical quality (so GPs need the assurance of good clinical governance processes) at a lower cost (so the price needs to be directly comparable with the on-tariff alternative). PCTs can help here by providing pathway management support to make GPs aware of the alternative pathways available and help them weigh their merits.

Finally let’s look at motivation. Certainly money into the GP’s or practice’s bank account is going to motivate, and this can be formulated in more ways than the Fundholding approach of simply allowing practices to “keep the change” if they come in under budget. For instance, one or more budgetary ceilings can be set, and practices awarded a modest percentage of the underspend against each ceiling. Non-financial forms of encouragement include status (a consortium leadership, a new pathway directorship, a thought leader), and simple recognition and praise.

As well as encouraging GP commissioners, the PCT needs to be careful not to discourage them with upsets like frequent rule changes, unfair rewards, or failing to support GPs in disputes with providers.

So we have lots of possibilities for improving GP commissioning: information systems and bank-manager support to improve ability; financial and non-financial rewards to improve motivation; and alternative pathways with attractive contracts and assured quality to improve opportunity.

Would I prescribe any particular combination of all these things? No, because every situation is different, and nobody knows exactly what will work best in each case. It would be much better for PCTs and GPs to invent their own approaches together, trying things out, making mistakes, and constantly improving. Partly because that is a good way to solve a complex problem. But also because the satisfaction of problem solved and a job well done is itself a powerful motivator.

Who can manage the demand for healthcare? GPs can. But who else?

Most of the NHS’s work starts with a referral from a GP. That simple fact leads to GPs being described as the “gatekeepers of the NHS” and asked, one way or another, to take responsibility for managing (i.e. restraining) demand and solving all the NHS’s financial woes.

As financial pressures grow, the calls on GPs to restrain referrals and costs will become louder. But how much should GPs take on? Could the temptations to enrich themselves in unethical ways become too strong? And is there a more interesting way to achieve the same objectives, that involve patients and other players more?

Let’s start from where we are now, with GPs having some limited ability to influence the patient pathway and its cost. What makes it limited? Because referrals are fire-and-forget: when a patient has been referred to a consultant, the consultant “owns” the patient, and the consultant has the discretion to make tertiary referrals, keep the patient in bed, prescribe drugs… in short to spend the commissioner’s money on the patient largely as the consultant sees fit (and often to the advantage of the Trust that employs the consultant).

Certainly there are good clinical reasons for this arrangement. But in no other industry would a customer let its suppliers order work from themselves at the customer’s expense.

GPs do sometimes have powers to interrupt the patient pathway using Prior Approval schemes. These can allow commissioners to withhold payment for work that was not approved in advance, either explicitly or by being part of an approved pathway. But Prior Approval schemes have to be agreed with the provider before they can be written into the contract, and a cash-strapped Trust may not welcome a potential loss of valuable excess bed day payments.

So should GPs be given power over the whole patient pathway from end to end, to interrupt consultant-led care, and pull patients out of acute hospitals for transfer to lower-cost providers? Not so fast. Apart from the good clinical reasons mentioned above, it would generate great resistance and ill-will between GPs and consultants: the very people who most need to work co-operatively together if financial control is to be devolved successfully to the front line. So is this line of thinking all a dead end?

No, wait. We’re forgetting somebody. I don’t mean to be unhelpful, but what about the patient?*

The patient (or, if incapable, the patient’s representative) needs to give informed consent at every step along the pathway. Patients are not usually familiar with all the consultants available, their special interests, or the waiting times, infection risks, and other quality standards at each provider. So they need to be informed by healthcare professionals whose judgement they can trust. That certainly includes their consultant, if they are under a consultant’s care. But it surely also includes their GP, no matter whose care they are under?

Now an answer is starting to emerge. If GPs were more available to inform and advise patients at all stages of the patient pathway, even when they are lying in a hospital bed, then patients could manage their own pathways more effectively. Most would choose lower-intensity care closer to home if they could, which aligns well with the preferences of their GP when finances are also considered. It also neatly blunts the potential for a (hypothetical) unscrupulous GP to make money simply by delaying referral, as the patient would be unlikely to agree, and hospital consultants would be involved in the clinical governance process for reviewing the pathways they are using.

This means more work for GPs, and that would cost money of course. But who could be better placed to judge the merits of that trade-off, than the commissioning GPs themselves? Putting patients in control of their own pathways, with guidance at every step from their GPs, is an idea worth trying.

*(“What about the patient?” is a fun game to play in NHS management meetings. If the discussion starts veering off in a direction you don’t like, lean forward and very earnestly ask “what about the patient?”. It stops the discussion stone dead, everybody takes turns to make politically-correct statements about patients, and nobody will have the courage to get back on-topic. Warning: doesn’t work against practising clinicians.)