This new report, based on a workshop in March 2014, sets out to inform the development of 20 pilots (in England) of the Prime Minister’s Challenge Fund, to improve access to primary care. The report focuses on the debate around unintended consequences of extending (e.g. longer opening hours) or broadening (e.g. phone or online consultations) access – will increased access meet unmet need or does it stimulate new demand?
Increases in demand and utilisation risk the opportunity cost of taking resource from where it may offer greater benefit. The report includes discussion of research into induced demand and induced utilisation by Professor Jon Nicholl at ScHARR, University of Sheffield. The research showed that 16% of people attending walk-in clinics and 12% attending urgent care centres would have done nothing if those services were not available. The urgent care centre completed 75% of consultations without onward referral whereas walk-in centres completed only 50%. The key lesson is that additional services may not substitute and therefore increase overall usage; the question should be asked if this additional usage is responding to unmet need or is avoidable.
The report notes that urgent care services cannot always complete the consultation without onward referral, where there are possible underlying causes which need investigations and follow-up, leading to a “safety-netting” approach where urgent symptoms are managed and the patient then referred back to their GP for follow up. This presents a challenge in agreeing what this initial consultation should include and what is needed to ensure timely and effective handover of care.
The report also highlights some issues around the service organisation and patient flow which warrant attention and could be redesigned to manage avoidable attendances/admissions, including, availability of transport services and timing of home visits. There are examples of services targeted at particular patient groups: for example, East Midlands Ambulance Service offers a falls service which enables referral of patients without injuries directly to social services. There may be a need to redesign services, at a system-wide level, to respond to need without inducing additional demand. The report references examples in Denmark and the Netherlands where telephone triage by GPs and nurses has helped to divert patients from services. The role of community pharmacists in supporting minor illnesses through expanding services – for example, medication review – is also covered; however, it is noted that there is requirement for additional qualifications to register as an independent prescriber.
Lessons for commissioners
Although the report is focused specifically on the Prime Minister’s Challenge Fund, the discussion will be of general interest, given current pressures on health systems. Some of the key considerations are:
- Service design which focuses solely on expanding opening hours is likely to spread an already stretched resource more thinly. There is a need to consider a system-wide perspective.
- Workforce pressures in primary care will need to be considered.
- A key challenge will be to manage the combination of short term and long term problems in primary care.
- Patient and public expectations influence their choices. There needs to be effective communication to ensure a clear understanding of what an urgent care centre is and how it differs from other services. Rosen refers to the Yellow Man campaign, which emphasises a clear message repeated over time and in various settings using brands and terminology recognised by the public.
- Linked to this is the growing emphasis on self management and the need to build capacity to support a move towards more self care. The report highlights the importance of incentives: “Until it becomes just as easy and just as helpful to click on a computer icon or load a phone app for self-care advice as it is to attend a clinic, it is unlikely that people will stop using unscheduled primary care”.
- Commissioners will need to be clear about aims and measures of success. The report notes that number of contacts, whilst easy to measure, will not indicate success. Alternative measures, focused on outcomes and to the local context, will give a better indication of value – for example, completed pathways of care and cost-effectiveness. A baseline assessment will be critical and there needs to be recognition that change will take time.
- Patient and staff perspectives should be included in evaluations to understand expectations and experiences. The report notes that this may help to explore different perspectives of what “urgent” means.
- Lastly, a long term view is needed if real improvements are to be achieved and this needs to consider the balance of managing urgent care needs alongside longer term and more complex problems.
Rosen R (2014) Meeting need or fuelling demand: improved access to primary care and supply-induced demand, Nuffield Trust; Available at: http://www.nuffieldtrust.org.uk/publications/meeting-need-or-fuelling-demand.