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Demand management

by Rob Findlay

Who can manage the demand for healthcare? GPs can. But who else?

Most of the NHS’s work starts with a referral from a GP. That simple fact leads to GPs being described as the “gatekeepers of the NHS” and asked, one way or another, to take responsibility for managing (i.e. restraining) demand and solving all the NHS’s financial woes.

As financial pressures grow, the calls on GPs to restrain referrals and costs will become louder. But how much should GPs take on? Could the temptations to enrich themselves in unethical ways become too strong? And is there a more interesting way to achieve the same objectives, that involve patients and other players more?

Let’s start from where we are now, with GPs having some limited ability to influence the patient pathway and its cost. What makes it limited? Because referrals are fire-and-forget: when a patient has been referred to a consultant, the consultant “owns” the patient, and the consultant has the discretion to make tertiary referrals, keep the patient in bed, prescribe drugs… in short to spend the commissioner’s money on the patient largely as the consultant sees fit (and often to the advantage of the Trust that employs the consultant).

Certainly there are good clinical reasons for this arrangement. But in no other industry would a customer let its suppliers order work from themselves at the customer’s expense.

GPs do sometimes have powers to interrupt the patient pathway using Prior Approval schemes. These can allow commissioners to withhold payment for work that was not approved in advance, either explicitly or by being part of an approved pathway. But Prior Approval schemes have to be agreed with the provider before they can be written into the contract, and a cash-strapped Trust may not welcome a potential loss of valuable excess bed day payments.

So should GPs be given power over the whole patient pathway from end to end, to interrupt consultant-led care, and pull patients out of acute hospitals for transfer to lower-cost providers? Not so fast. Apart from the good clinical reasons mentioned above, it would generate great resistance and ill-will between GPs and consultants: the very people who most need to work co-operatively together if financial control is to be devolved successfully to the front line. So is this line of thinking all a dead end?

No, wait. We’re forgetting somebody. I don’t mean to be unhelpful, but what about the patient?*

The patient (or, if incapable, the patient’s representative) needs to give informed consent at every step along the pathway. Patients are not usually familiar with all the consultants available, their special interests, or the waiting times, infection risks, and other quality standards at each provider. So they need to be informed by healthcare professionals whose judgement they can trust. That certainly includes their consultant, if they are under a consultant’s care. But it surely also includes their GP, no matter whose care they are under?

Now an answer is starting to emerge. If GPs were more available to inform and advise patients at all stages of the patient pathway, even when they are lying in a hospital bed, then patients could manage their own pathways more effectively. Most would choose lower-intensity care closer to home if they could, which aligns well with the preferences of their GP when finances are also considered. It also neatly blunts the potential for a (hypothetical) unscrupulous GP to make money simply by delaying referral, as the patient would be unlikely to agree, and hospital consultants would be involved in the clinical governance process for reviewing the pathways they are using.

This means more work for GPs, and that would cost money of course. But who could be better placed to judge the merits of that trade-off, than the commissioning GPs themselves? Putting patients in control of their own pathways, with guidance at every step from their GPs, is an idea worth trying.

*(“What about the patient?” is a fun game to play in NHS management meetings. If the discussion starts veering off in a direction you don’t like, lean forward and very earnestly ask “what about the patient?”. It stops the discussion stone dead, everybody takes turns to make politically-correct statements about patients, and nobody will have the courage to get back on-topic. Warning: doesn’t work against practising clinicians.)

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