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Demand Management


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Demand Management
 


What is it and how can it help me?

Demand management is about understanding demand. The process should focus on using planning and forecasting skills to ensure patients receive the most appropriate care in the right setting. It is not about managing the number and type of referrals.

When does it work best?

By focusing on outcomes and ensuring that patients receive the right care in the right setting, you will increase the consistency for similar conditions. This can help to reduce the variation which may cause unnecessary delays.

How to use it

There are a variety of demand management approaches which can be used at various stages of the patient pathway. Some of the most successful are detailed below.

1. Reducing unplanned hospital admissions to benefit all patients
Reducing inappropriate and unplanned hospital admissions enables services to work at optimum efficiency. This helps to ensure that the patients who truly need these services are seen as quickly as possible.

Typically, these initiatives involve multidisciplinary primary care teams, proactively managing the care of individuals within their own home, often referred to as intermediate care. The patients are often elderly or sufferers of long term conditions. The aim is to ensure that these patients do not develop an acute episode of their chronic disease requiring a visit to A&E. The model may involve regular visits or telephone calls from healthcare staff to provide patients with reassurance. The team may also be on-call for when the patient needs extra support.

Examples of these initiatives include:
- Community matron model
- Increased self-care at home e.g. via telemonitoring and telemedicine
- Community virtual ward round
Ambulatory emergency care
- Case managers who target high risk, long term condition patients etc

Recommendations for optimum implementation:

  • Use analytical tools and techniques to proactively identify key groups of patients who would benefit from this type of community intervention.
  • Communicate the whole intervention process clearly to patients and assure them that this out of hospital care is of high quality

2. Predicting type and source of demand are the key to managing it

Using information tools and techniques to improve forecasting is a major component of successful demand management. Having access to high quality information on activity and current demand will enable you to model and predict future demand. The Big Wizard Guide provides useful details on using techniques to help gather intelligence from referral information.

Recommendations for optimum implementation:

  • Collect and share robust information
  • Use planning and forecasting procedures and techniques

3. Clinical referral protocols help to increase consistency of referrals

A number of organisations, both within primary care (GP referrals) and secondary care (consultant to consultant referrals) have successfully worked with their clinicians to introduce referral protocols. The aim of these protocols should always be to improve the quality of referrals via the use of shared clinical knowledge and expertise. High quality, appropriate referrals will reduce the chance of referral to the incorrect specialist. This eliminates the delays caused by unsuitable referrals.

Many PCTs have set up referral management centres to act as a collection point for referrals before they are forwarded to secondary care. Different models have been developed: some act purely as information gathering centres, others clinically assess and triage referrals eg clinical assessment centres. The key is that these centres concentrate on working with primary and secondary care clinicians so they have the information necessary to make high quality, consistent referrals. The Department of Health have published advice and guidance around the setting up of referral management schemes.

Recommendations for optimum implementation:

  • Protocols should be clinically driven with input and buy-in from both primary and secondary care clinicians right from the beginning
  • Often these centres distance GPs from hospital doctors, so telephone advice should be available directly between GP and specialist
  • Be aware that the protocols can be simple and straightforward - and still have an impact
  • Referrals should include plenty of relevant information to aid clinicians
  • Referral management centres should not add unnecessary delays for patients
  • Commissioners and providers should share a collaborative approach

4. Patient centred commissioning can help to provide services more suited to users' needs

Many believe that, because primary care practices have a much closer relationship with local patients, they can commission services more suited to their needs. This belief is fundamental to the introduction of practice based commissioning. If services are commissioned with patients' needs truly acknowledged, this increases the probability of providing the right care in the right setting. This in turn reduces inappropriate demand on services. Patient centred commissioning may result in secondary care being provided in a mixture of settings eg acute hospital, nurse-led clinics, GPs with special interests.

Recommendations for optimum implementation:

  • Commissioning activities should be truly patient focused: gather patients' views to provide input into the commissioning process.

5. Care and resource utilisation techniques

In December 2006, the Department of Health released Care and Resource Utilisation: Ensuring Appropriateness of Care. This document discussed reviewing current care pathways to ensure that they are fit for purpose and help to provide the right treatment, in the right place, at the right time.

The two key techniques that the guidance provides information on are utilisation management and prior approval. Utilisation management can help to identify patients admitted to hospital who could have been treated in an alternative setting. This has reduced inappropriate admissions and length of stay in some areas. Prior approval helps commissioners and providers determine, in advance, groups of patients who are to be assessed accordingly owned protocols.

Recommendations for optimum implementation:

  • Establish excellent communication channels between primary and secondary care clinicians
  • Ensure that the service redesign work made necessary by the use of these techniques is owned by both primary and secondary care clinicians

6. Pre-operative assessment can reduce the demand on hospital services

Before being admitted for surgery, patients are assessed to ensure that they are physically fit and fully prepared for the procedure. This has many benefits for reducing the demand on hospital services. For example, it avoids patients being admitted who are then later discovered to be unfit for surgery. It has been shown to improve the recovery times of patients, enabling them to leave hospital quicker and reducing the demand on hospital beds.

Recommendations for optimum implementation:

Examples

These organisations have put the demand management strategies outlined into practice:

(i) Community or crisis intervention teams - These are multidisciplinary teams who are on call and who can establish resources required for care to prevent unnecessary hospital admissions. A DH press release in 2006 entitled 'Improving healthcare by reducing unnecessary emergency admissions' provides several examples of successful community intervention teams.

(ii) Pre-operative assessment - This is a comprehensive physical assessment and pre-surgical preparation programme. It includes screening for after-hospital support needs. Furthermore, it aims to ensure that patients are fully informed and better prepared for the process they will undergo.

(iii) Enhanced Recovery Programme  - The Enhanced Recovery Programme is a structured, evidence based approach to prepare patients for surgery and reduce its physical impact. This means that patients recover more quickly, enabling early discharge. This programme has been used successfully at Torbay Hospital.

(iv) Integrated health and social care management teams - Project Blue Sky is working with localities in East Devon to develop locality integrated health and social care management teams. These teams can commission patient centred services based on local population needs ensuring that they are at the forefront of developing and commissioning services.

What next?

A key element of demand management is taking the needs and views of patients into consideration when commissioning services. We recommend the use of the getting patients' perspectives tool.

Other useful tools and techniques on this website

The following tools on our website may also be of use:

A comprehensive guide to demand and capacity
An overview of variation: what it is and identifying its source
A quick overview of modelling, benchmarking and forecasting
Action Planning
Enhanced Recovery
Reducing cancelled operations

Additional resources

Websites:

Department of Health: Care and Resource Utilisation - Ensuring Appropriateness of Care

Department of Health: Implementing Care Closer to Home: Convenient Quality Care for Patients

© Copyright NHS Institute for Innovation and Improvement 2008