Induced demand for and utilisation of the emergency and urgent care system

Jon NichollScHARR, Sheffield

Induced demand and utilisation for face-to-face services

1. First contacts for new problems (demand) (affected by accessibility)

2. Further contacts for the same problem (utilisation) (affected by appropriateness of first contact)

Induced demand and utilisation by call lines

• Call lines could alter demand and utilisation of existing services, for example byo Increasing demand by advising some people who would

have looked after themselves to make f-to-f contact, oro Reducing utilisation by sending people to the right place

first time, and reducing the need for further contacts for the same problem

Studies of NHS Direct and NHS111 show that call lines do not appear to alter utilisation

http://www.sheffield.ac.uk/scharr/sections/hsr/mcru/reports. Turner et al. BMJ Open 2013. doi:10.1136/bmjopen-2013-003451

% change in system activity following start of NHS111 in 4 pilot sites relative to control sites

Commuter WICs

Induced demand by commuter WICs

Self-reported pre-consultation intentions in patients attending 6 privately managed, Dr staffed, commuter walk-in centres

Pre-consultation intentions (What would you have done if the WIC had not been available?)N (%)

ED 139 (11.7)

GP 631 (53.2)

Other 228 (19.2)

Self/nothing 189 (15.9)

Total 1187(100.0%)

Induced potential utilisation by commuter WICs

Self-reported post-consultation plans in patients attending 6 privately managed, Dr staffed, commuter walk-in centres

Pre-consultation intentions (What would you have done if the WIC had not been available?)N (%)

Post-consultation plans

N (%)

ED 139 (11.7) 74 (5.0)

GP 631 (53.2) 368 (25.0)

Other 228 (19.2) 295 (20.0)

Self/nothing 189 (15.9) 737 (50.0)

Total 1187(100.0%) 1474 (100.0%)

O’Cathain et al. BJGP 2009. doi: 10.3399/bjgpo9X473150. Coster et al. BJGP 2009. doi: 10.3399/bjgpo9X473169

GP-led Urgent care centres

Induced demand by GP-led urgent care centres

Self-reported pre-consultation intentions in patients attending two privately managed, Dr staffed, urgent care centres

Pre-consultation intentions (What would you have done if the GP-WIC had not been available?)N (%)

ED 202 (23.2)

GP 340 (39.0)

Other 226 (25.9)

Self/nothing 103 (11.8)

Total 871 (100.0%)

Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410

Induced potential utilisation by GP-led urgent care centres

Self-reported post-consultation plans in patients attending two privately managed, Dr staffed, urgent care centres

Pre-consultation intentions (What would you have done if the GP-WIC had not been available?)N (%)

Post-consultation plans

N (%)

ED 202 (23.2) 38 (4.4)

GP 340 (39.0) 146 (16.7)

Other 226 (25.9) 30 (3.4)

Self/nothing 103 (11.8) 659 (75.5)

Total 871 (100.0%) 873 (100.0%)

Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410

Induced utilisation by GP-led urgent care centres

Self-reported 4 wk post-consultation use of other services by patients attending two privately managed, Dr staffed, urgent care centres

Pre-consultation intentions (What would you have done if the GP-WIC had not been available?)N (%)

Post-consultation plans

N (%)

Actual use of services post-consultation

N (%)

ED 202 (23.2) 38 (4.4) 14 (5.6)

GP 340 (39.0) 146 (16.7) 73 (29.3)

Other 226 (25.9) 30 (3.4) 21 (8.8)

Self/nothing 103 (11.8) 659 (75.5) 141 (56.2)

Total 871 (100.0%) 873 (100.0%) 249 (100.0)

Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410

Estimating the volume of induced utilisation

• Call lines don’t appear to change demand or utilisation

• Demand: 12-16% of patients attending walk-in urgent care centres said that they would not have made any contact if the service hadn’t been available

• Utilisation: 30-35% of patients who use walk-in urgent care centres go on to contact their GP or an ED

Estimating the volume of induced urgent carefirst attenders at type 3 EDs

In 2012/13 there were 6.6m type 3 ED contacts

There were an unknown N of type 3 ED minor injury unit attendances in 1994/5

Estimating the volume of induced utilisation

• MIUs began to be introduced in the 1990s

• GP and nurse-led walk-in centres began to be introduced in 2000.

• Assuming about 1/3rd of type 3 ED attendances are to

MIUs, the WICs and UCCs may induce about• 0.5m new contacts each year• 1.5m follow-on contacts

Big uncertainties

• Small studies not designed to answer this question• Response rates• Reliability of reported intentions• The volume of MIU attendances which may induce

relatively little additional utilisation• The longer term effects of call lines when they have

bedded-in.

Big uncertainties

• Small studies not designed to answer this question• Response rates• Reliability of reported intentions• The volume of MIU attendances which may induce

relatively little additional utilisation• The longer term effects of call lines when they have

bedded-in.

Thank you

Copyright ©2000 BMJ Publishing Group Ltd.

Munro, J. et al. BMJ 2000;321:150-153

Impact of NHS Direct on emergency and urgent care services

Intentions and outcomes in 249 patients attending two GP-WICs

What would you have done if the GP-WIC had not been available?

Intention to use other services after consultation

Outcome

ED 202 (23.2) 38 14 (5.6)

GP 340 (39.0) 146 73 (29.3)

Self/nothing 103 (11.8) 659 -

GP-WIC - 8 141 (56.2)

Other 226 (25.9) 22 21 (8.8)

Total 871 (100.0%) 873 (100.0%) 249 (100.0)

We know that the 23.2% who said they would have gone to ED exaggerates the true proportion.So

Intentions and outcomes in patients attending two GP-WICs

What would you have done if the GP-WIC had not been available?

Intention to use other services after consultation

Outcome

ED 202 (23.2) 38 14 (5.6)

GP 340 (39.0) 146 73 (29.3)

Other 226 (25.9) 30 21 (8.8)

Self/nothing 103 (11.8) 659 141 (56.2)

Total 871 (100.0%) 873 (100.0%) 249 (100.0)

We know that the 23.2% who said they would have gone to ED exaggerates the true proportion who would have gone to ED.So, other intentions are likely to be unreliable.