What is “demand”?

by Rob Findlay

We talk about the demand for healthcare all the time, but sometimes the talk is loose. If you hang around NHS offices for long enough you might hear statements like:

  • Demand can’t be that high – the contract doesn’t provide that much.
  • Last year we did 1,000, add 3% growth in demand, so that makes 1,030 next year.
  • I’ve got hips coming out of my ears.

…and so on.

This kind of talk confuses demand and activity. More accurately, we might say things like this:

  • Demand is likely to grow, but we don’t know exactly why or by how much.
  • The waiting list is the accumulated mismatch between demand and activity.
  • If we want to control waiting lists, we have to at least keep up with demand.
  • Historic demand is activity plus the growth in the waiting list (adjusted for removals).

This is the sort of thing that is built into good planning models, and it allows us to make other useful distinctions, like:

  • recurring activity is the activity required to keep up with demand; and
  • non-recurring activity is everything else, and it brings down the waiting list.

So far so good. But behind all this, we are making a big assumption that won’t spring out of a planning model: that all our “demand” represents real work that we need to do. For instance:

  • a patient is seen in outpatients by the wrong consultant and has to be rebooked with the right one; is the first appointment “demand”?
  • a patient is referred for unnecessary follow-up by a junior who is not confident enough to discharge; is this follow-up “demand”?
  • a patient is seen in outpatients, but the necessary test results aren’t ready so they have to be rebooked; is this “demand”?
  • a one-stop clinic replaces an outpatient-diagnostic-outpatient sequence; does demand fall by two-thirds?

And on the inpatient side, are any of the following “demand”?

  • a patient remains in an acute bed for a couple of days longer than necessary, waiting for a ward round and then drugs;
  • a patient arrives for surgery, but is sent home and rebooked because they had toast for breakfast;
  • a patient is admitted to avoid breaching the 4 hour A&E target, even though they don’t meet any AEP criteria.

These examples of “demand” are not caused by unmet healthcare needs in the population. Rather, they are artefacts of the system. How much of our total demand is created like this? 3 per cent? 10 per cent? 30 per cent? Do we have the faintest idea?

If it’s a sizeable proportion, and I suspect it probably is, then reducing it could substantially offset the (apparently) growing genuine demand for healthcare. Which would be handy at a time of near-frozen real-terms funding.

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