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Feature

What is the role of doctors in managing demand on the NHS?

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1269 (Published 16 March 2017) Cite this as: BMJ 2017;356:j1269
  1. Gareth Iacobucci, senior news reporter, The BMJ
  1. giacobucci{at}bmj.com

As the NHS strains under pressure from rising patient activity, an ageing population, and financial constraints, The BMJ hosted a discussion on how clinicians should be helping to manage demand at last week’s Nuffield Trust health policy summit. Gareth Iacobucci reports

Jeremy Taylor, chief executive of the charities’ coalition National Voices, kicked off the debate by questioning the use of the term “managing demand.”

“It sets up an unhelpful dynamic in which people with healthcare needs go to clinicians and their stance is, “how can we minimise their use of my service,” he said.

“Yes, money is tight, but people will get ill and will need access to healthcare.”

Ashok Soni, chair of NHS England’s local professional network for pharmacy in London, said clinicians could do more to engage with patients about using medicines more appropriately and effectively.

“We know that between 30% and 50% [of medicines] are not used the way they are designed. Pharmacists have worked with care homes, and we’ve demonstrated quite significant savings in terms of better use of medicines there,” he said.

Martin Marshall, vice chair of the Royal College of General Practitioners and professor of healthcare improvement at University College London, spoke about the importance of strong relationships between GPs, consultants, and patients.

“We need to go back to reminding ourselves about relationships and continuity,” he said.

“I'm very comfortable having conversations with the patients I know about what is appropriate and what might be less appropriate. When I know a consultant well, I can pick up the phone [and] ask for their advice in two minutes rather than making a referral. That makes a massive difference.”

Andrew Fernando, GP and medical director of North Hampshire Urgent Care, said GPs should focus on being the advocate for their patient. This “will mean pushback on some of the targets. But if you get it right, it’s better for the patient and it’s cheaper for the system,” he said.

Looking at the evidence

Candace Imison, director of policy at the Nuffield Trust think tank, said that demand management schemes in which doctors were “an active part in the whole patient journey” tended to be more effective than those that encouraged “the game of handoff (between different parts of the system), which can stimulate waste and inappropriate referrals.”

Imison stressed the need to understand different types of demand and not take a “one size fits all” approach across primary care, emergency departments, and hospital care.

Maxine Power, director of innovation and improvement science at Salford Royal NHS Foundation Trust, talked about the importance of giving clinicians access to data that allows them to understand demand.

“As soon as you hand that to clinicians, their analytical thinking kicks in and they’re able to solve problems in a much more meaningful way,” she said.

Eileen Burns, president of the British Geriatrics Society, said the proactive management of elderly patients in care homes was an emerging example of an intervention that works.

“If you look at what prescriptions are now redundant [for patients in care homes], and if you look at advanced care planning, you can reduce admissions to hospital by about 30-40%. That’s one example where you can manage demand in a different way that’s the right way.”

But Burns sounded a note of caution about seeing new ways of working as vehicles for saving money. “You might reduce demand on the hospital [but] the cost reduction may not be as great as people have hoped it will be.”

Prevention

Amanda Philpott, chief officer of Eastbourne, Hailsham and Seaford Clinical Commissioning Group and Hastings and Rother Clinical Commissioning Group, said doctors should be “louder” about their role in public health and prevention.

Both Marshall and Power highlighted the importance of equipping GPs to tackle the wider determinants of health such as housing, education, and leisure.

“We need to be much more comfortable with reaching out into areas that may not classically be within our boundaries,” said Power.

Judith Smith, director of the Health Services Management Centre, University of Birmingham, said public health doctors had a good track record of working with GPs to help set priorities and investments over the past 25 years. But she expressed concern that this role “at the centre of the discussions” was in danger of being lost in local government.

Smith also talked about the importance of clinicians understanding how healthcare resources are deployed, and said the University of Birmingham had recently embedded a managerial element in its undergraduate medical training to reflect this.

“We’re finding huge enthusiasm from students. Some of them said, ‘Until I came onto this programme, I had no idea about the internal workings of a hospital [or that] health and social care were funded separately,”’ she said.

Marshall said that the UK still has a “very narrow view” of what constitutes a medical degree compared with other countries such as the US. Once qualified, he said today’s doctors had to recognise their responsibilities to their local population as well as their patients.

“I say to our medical students, the biggest difference between your generation and my generation is [that] you will need to accept your responsibilities as a system leader. When I look in their eyes I can see a combination of fear and excitement.”

Philpott said clinical commissioning had helped GPs understand their wider responsibilities. “We have certainly made much better decisions about where we put our investment [since CCGs came in],” she said.

But Taylor said he was concerned that current pressures were making it difficult for clinicians to engage in systematic change.

“Everybody’s struggling and experimenting … it seems like a complete mess. A lot of the stuff going on—sustainability and transformation plans, new care models, primary care home—fill you with hope, but the thing that’s missing is how to join it up,” he warned.

Skill mix

Soni argued that solutions to managing resources more effectively did not always have to be provided by doctors and nurses. He said pharmacists could help take pressure off GPs by managing more patients with long term conditions.

“Is it about training a doctor to do more, or is it about being able to understand how they utilise their colleagues to support people more effectively?” he asked. “I think we haven’t done that particularly well. We’ve tended to focus on “the medical solution.”

Fernando said he hoped that new models of working may offer GPs more “headspace” to focus on prevention and system leadership.

“If we can create some headspace for GPs … working with nurses, physios, and pharmacists to do prevention better, then that takes pressure off the more expensive parts of the system,” he said.

Burns cited examples of innovative skill mix in the community, such as nurses being trained to lead on proactive management of patients in care homes, and health coaches and lay workers being trained to help supplement the care provided by professionals.

“Hopefully at some point we will see an increase in medical students [and] nurses … but at the moment I think we need to think really imaginatively about who else can help us, and not always assume it has to be the GP or the nurse,” she concluded.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.