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Managing demand and ensuring access

The sixth of our eight-part guide on the basics of PBC, produced by Michelle Webster and Beverley Slater of the Improvement Foundation

The sixth of our eight-part guide on the basics of PBC, produced by Michelle Webster and Beverley Slater of the Improvement Foundation

Official definition

The effective and fair use of resources so that clinical time is available to focus on appropriate patients.

Put into layman's terms

Ensuring the service is accessible for the people who need it – and that the service is not accessed by those who don't.

What it involves

Assessing whether health services are being utilised correctly and then taking action.

The rationale for service redesign is providing people with access to the services they need in the most effective and efficient way. Therefore the whole process of managing demand and ensuring access is an essential complementary activity to clinical redesign.

In order to realise the anticipated benefits of a new service, a plan for managing demand needs to be developed alongside the implementation plan.

This may involve using one or more of a range of techniques, which are referred to as ‘care and resource utilisation' techniques, in the Department of Health's policy guidance.

Important because…

In a business model, where greater service use means more profit, managing demand is not an issue – there can never be too much demand. But for public services, free at the point of use and resourced within a fixed budget, appropriate access does legitimately need to be managed.

GPs have always managed demand through their role as gatekeepers to secondary care, restricting access to those with clinically appropriate needs. Practice-based commissioning has introduced a direct link between the power of the GP to spend the health budget (through referrals) and the responsibility to get best value from the overall budget.

How to go about it…

Tools to help understand where there is inappropriate use of services include:

• Utilisation management review – an intensive review of hospital admissions over a period to identify how patients could have been managed more appropriately and then taking action to improve the situation. This approach requires investment and involvement of the whole health system.

• Benchmarking – comparison of practice or PCT data with local or national averages through statistical sources such as programme budgeting or QOF results websites (see links below) will provide initial indications of where resource use is above average.

• Process mapping – understanding the current pathways through a multidisciplinary exercise highlights where duplication, gaps or confusion currently exist in patient pathways.

Tools to help make more appropriate use of services include:

• Peer review of referrals – comparison of referrals between practice teams.

• Risk profiling – developing and using GP practice registers for clinical conditions such as CVD, common mental health conditions or population groups such as frail elderly will identify target groups for proactive case management.

• Group prior approval – commissioners and providers agree in advance how to manage patients or pathways. Providers agree to treat all patients to the agreed protocol.

• Individual prior approval – providers must get agreement from the commissioner before initiating treatment on a specific patient. This usually only applies to patients with high-cost, complex care pathways. Must never delay clinically necessary treatment.

• Clinical assessment services – the introduction of clinical triage and treatment by a practitioner with a special clinical interest into a patient pathway. If a substantial proportion of patients still need referral to secondary care the overall service is unlikely to be efficient use of resources.

• Advice only referrals – agreement with hospital specialists for advice only at a much lower cost than a full referral for a special class of referrals so that the majority can be cared for in primary care.

Underpinning the success of many of these approaches is the willingness of individual GPs and other primary care referrers to adapt their referral behaviours. This will be considered in next month's article.

Background/relevant policy

Managing efficient access to appropriate care within fixed resources is central to the whole of the Government's policy on commissioning and PBC.

The care and resource utilisation policy documents, designed to aid this process, can be accessed on the DH website.

Pitfalls to avoid

Imposed demand management systems are less likely to be successful. They should be developed in consultation with all relevant parties before being introduced.

Do not ignore the demand management element of the service redesign process or your redesign will not release the resources identified in the business plan.


Care and resource utilisation: ensuring appropriateness of care and How to identify opportunities for care resource utilisation.

National Programme Budget (with comparative data)

Quality and outcomes framework results

Michelle Webster is national commissioning lead and Beverley Slater is national knowledge management lead for the Improvement Foundation which runs advanced commissioning courses.

Next month: Clinical decision-making

Finite resources in the NHS means demand has to be managed

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