November | 2017 | Becky Malby

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In Part One we addressed everything you need to know about appointment systems to manage demand, from knowing what your demand actually is, through to types of appointments, triage, GP variation and skill mix. This gets you to the point where you definitely have enough appointments with the right range of professionals to meet demand. The next step is how to reduce demand and for this blog we are going to focus on reducing demand in Primary Care and from primary to secondary care.

Put simply the answer is based on collaboration and being ‘in it together’; partnership between people and professionals, moving away from the dependency model that has pervaded the NHS since its inception to an asset based approach with opportunities, possibilities and personal and community resources and resilience.

Reducing Demand in Primary Care

So far we have been concentrating on managing demand. Doing all primary care can to best support people that need their services, including tackling the unmet need (the people that haven’t been able to get a GP appointment). But there is a more fundamental option that Primary care needs to embrace – reducing demand.

Our data for two CCGs across our demo practices (11 in total) showed this:

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Note: Unmet demand did not include missed calls

In one CCG:

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This seems a common pattern. So lets assume as in our previous blog that this can be better managed, the next issue is to consider whether some of this 40% really need a primary care appointment at all? This is not a judgement on people’s ability to choose the best service or them, but a reflection of the damage the dependency model in our public services has done to communities’ resilience.

There are two immediate ways to reduce demand

MINOR AILMENTS & CONCERNS

The first approach is to reduce demand from minor ailments that can be driven by providing open access walk-in service so people know that can access an appointment if their symptoms don’t go away (i.e. reducing the ‘just in case’ appointments). See this from Robin Lane Health and Wellbeing Centre where they introduced the Walk In clinic in 2012.

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Another addition is to provide education and advice. Better Care Together has produced a series of films that give advice and tips to people at home to manage their conditions, from back pain to inhaler technique; Public Health Wales has produced these on living with diabetes

2. SELF-CARE AND RESILIENT COMMUNITIES

Now to the more knotty issue. The needs that seem to create the most frustration with GPs, but require the most significant change in professional attitudes – reducing demand where the presenting need is for reassurance, living with chronic conditions, social isolation and loneliness, and a range of mental health conditions responsive to self-care, by facilitating people and communities to support each other.

The latter is a fundamental shift in thinking from people who have needs in a deficit model, that need fixing – recipients of services; to people as coproducers of their health and wellbeing bringing the wealth of relational and talent assets to improve people’s self-esteem, coping strategies, resilience skills, friendships and personal resources (Foot & Hopkins 2009 p.7)

Some of the most powerful influences on behaviour change are family and neighbours, and a collective sense of selfesteem, helping people believe that it is possible to take actions to improve health and well-being. (Foot an Hopkins 2009 p9)

There has been progress in some parts of the NHS and Social Care in taking an asset based approach and working with communities to develop personal and community resilience.

For example in Leeds their Asset Based Community Development in Leeds (Kretzmann & McKnight 1993) is a key part of the Best Council Plan 2017-18 build capacity within communities to offer support to people with care and support needs.The small sparks fund has catalysed significant projects and new supportive community activities in the City, with community connectors being a vital asset in helping vulnerable people live well.

The Carnforth Community is working on Self-Care through a whole range of co-produced initiatives. helping people to care for themselves.

The best documented in terms of impact is Altogether Better working with Practice and Community Champions across the UK with significant effect (Evaluation Report 2015 p4)

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Since this publication Altogether Better has spread to Dorset, London and is working with our London Primary Care Academy practices.

Nesta’s ‘People-Powered Health’ project looked at how to apply the ideas behind co- production to long-term conditions – one of the most expensive, least successful aspects of NHS work. Nesta’s calculations, based on a range of studies, were that People-Powered Health along these lines could cut NHS costs by at least 7 per cent and maybe up to a fifth (NESTA 2013) the initiatives ranged from full coproduction to peer support. Our report on Volunteering in the NHS (Boyle, Crilly, Malby 2017) showed that volunteers make a difference to:

Patient outcomes and experience
Resources (demands on health and care system)
Workforce (providing additional capacity, and substitution)
Organisational (culture and staff satisfaction)
Community resilience
Volunteer’s own wellbeing

Although the term volunteer does not best fit the emerging potential and capacity of people to gift their time. We produced a chart to show the types of roles that citizens are taking in the NHS (P16)

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Our report showed that whilst there are a plethora of projects and programmes which are popular locally, make sense to local communities, and in common sense terms must reduce demand, there is little systematic evaluation of the impact of these at scale in terms of the wider impact in the NHS. They are marginal to the mainstream of the NHS and will stay that way without evidence of the potential. In our view there is enough tantalising evidence to say that this is how the Primary Care can work with communities to reduce demand.

Reducing Demand from Primary Care to Secondary Care

In Morecambe Bay, introducing phone and video links (The advice and guidance service) with consultants of the 2,441 ‘conversations’ begun by GPs with hospital specialists, 1,675 (72%) of patients were managed under the care of their local GP from the 6 months April to October 2017. Previously these patients would have been referred to hospital for an outpatient appointment. It also ensures that those people needing to go to outpatients can have a full work up in advance. See the video here

Another scheme allowing people with minor eye conditions to see a local optometrist avoided 1,600 unnecessary referrals in its first 18 weeks (The Economist 2017) . In the first two months of the new service seeing patients in the community rather than hospital, almost 1000 people were been seen at their local opticians for a variety of conditions/ treatments, rising from 30 to 300 per month. You can read about this here

In my previous blog on Care Homes we identified the significant impact GPs working with Care Homes can have cutting admissions to secondary care by 20%. The Health 100 Service in Havering secured a reduction of 35% (95% confidence interval, 6% to 55%) in emergency admissions. Also, total bed days following emergency admission fell by 53% (Sherlaw-Johnson et al 2018).

And finally the Health Foundation found that for older people, having continuity of care reduced admissions to secondary care “…if patients saw their most frequently seen GP two more times out of every 10 consultations, this would be associated with a 6% decrease in admissions.”(Deeny et al 2017 p1), which if Primary Care put in place the appointment model described in Part One they would be able to do.