This presentation was given by Jon Nicoll, Professor of Health Services Research in the School of Health and Related Research (ScHARR) at the University of Sheffield. He discusses induced demand and utilisation of the emergency and urgent care system and how services such as walk-in centres and phone lines can affect demand and utilisation. Professor Nicoll spoke at the event: "Supply induced demand as it relates to general practice" (http://www.nuffieldtrust.org.uk/talks/supply-induced-demand-it-relates-general-practice) in March 2014.

1. Induced demand for and utilisation of
the emergency and urgent care system
Jon Nicholl
ScHARR, Sheffield

2. Induced demand and utilisation for face-to-face
services
1. First contacts for new problems (demand)
(affected by accessibility)
2. Further contacts for the same problem
(utilisation) (affected by appropriateness of first
contact)

3. Induced demand and utilisation by call
lines
• Call lines could alter demand and utilisation of
existing services, for example by
o Increasing demand by advising some people who would
have looked after themselves to make f-to-f contact, or
o Reducing utilisation by sending people to the right place
first time, and reducing the need for further contacts for
the same problem

4. Studies of NHS Direct and NHS111 show that call lines do not
appear to alter utilisation
http://www.sheffield.ac.uk/scharr/sections/hsr/mcru/reports. Turner et al. BMJ Open 2013. doi:10.1136/bmjopen-2013-003451
% change in system activity following start of NHS111 in 4 pilot sites relative to
control sites

5. Commuter WICs

6. Induced demand by commuter WICs
Self-reported pre-consultation intentions in patients attending 6
privately managed, Dr staffed, commuter walk-in centres
Pre-consultation intentions
(What would you have done if the
WIC had not been available?)
N (%)
ED 139 (11.7)
GP 631 (53.2)
Other 228 (19.2)
Self/nothing 189 (15.9)
Total 1187(100.0%)

7. Induced potential utilisation by commuter WICs
Self-reported post-consultation plans in patients attending 6 privately
managed, Dr staffed, commuter walk-in centres
Pre-consultation
intentions
(What would you have done if
the WIC had not been available?)
N (%)
Post-consultation
plans
N (%)
ED 139 (11.7) 74 (5.0)
GP 631 (53.2) 368 (25.0)
Other 228 (19.2) 295 (20.0)
Self/nothing 189 (15.9) 737 (50.0)
Total 1187(100.0%) 1474 (100.0%)
O’Cathain et al. BJGP 2009. doi: 10.3399/bjgpo9X473150. Coster et al. BJGP 2009. doi: 10.3399/bjgpo9X473169

8. GP-led Urgent care centres

9. Induced demand by GP-led urgent care centres
Self-reported pre-consultation intentions in patients attending two
privately managed, Dr staffed, urgent care centres
Pre-consultation
intentions
(What would you have done
if the GP-WIC had not been
available?)
N (%)
ED 202 (23.2)
GP 340 (39.0)
Other 226 (25.9)
Self/nothing 103 (11.8)
Total 871 (100.0%)
Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410

10. Induced potential utilisation by GP-led urgent care centres
Self-reported post-consultation plans in patients attending two
privately managed, Dr staffed, urgent care centres
Pre-consultation
intentions
(What would you have done
if the GP-WIC had not been
available?)
N (%)
Post-consultation
plans
N (%)
ED 202 (23.2) 38 (4.4)
GP 340 (39.0) 146 (16.7)
Other 226 (25.9) 30 (3.4)
Self/nothing 103 (11.8) 659 (75.5)
Total 871 (100.0%) 873 (100.0%)
Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410

11. Induced utilisation by GP-led urgent care centres
Self-reported 4 wk post-consultation use of other services by patients
attending two privately managed, Dr staffed, urgent care centres
Pre-consultation
intentions
(What would you have done
if the GP-WIC had not been
available?)
N (%)
Post-consultation
plans
N (%)
Actual use of services
post-consultation
N (%)
ED 202 (23.2) 38 (4.4) 14 (5.6)
GP 340 (39.0) 146 (16.7) 73 (29.3)
Other 226 (25.9) 30 (3.4) 21 (8.8)
Self/nothing 103 (11.8) 659 (75.5) 141 (56.2)
Total 871 (100.0%) 873 (100.0%) 249 (100.0)
Arain et al. EMJ 2014. doi: 10.1136/emermed-2013-202410

12. Estimating the volume of induced utilisation
• Call lines don’t appear to change demand or utilisation
• Demand: 12-16% of patients attending walk-in urgent
care centres said that they would not have made any
contact if the service hadn’t been available
• Utilisation: 30-35% of patients who use walk-in urgent
care centres go on to contact their GP or an ED

13. Estimating the volume of induced urgent care
first attenders at type 3 EDs
In 2012/13 there
were 6.6m type 3
ED contacts
There were an unknown N of type 3 ED minor injury unit attendances in 1994/5

14. Estimating the volume of induced utilisation
• MIUs began to be introduced in the 1990s
• GP and nurse-led walk-in centres began to be
introduced in 2000.
• Assuming about 1/3rd
of type 3 ED attendances are to
MIUs, the WICs and UCCs may induce about
• 0.5m new contacts each year
• 1.5m follow-on contacts

15. Big uncertainties
• Small studies not designed to answer this question
• Response rates
• Reliability of reported intentions
• The volume of MIU attendances which may induce
relatively little additional utilisation
• The longer term effects of call lines when they have
bedded-in.

16. Big uncertainties
• Small studies not designed to answer this question
• Response rates
• Reliability of reported intentions
• The volume of MIU attendances which may induce
relatively little additional utilisation
• The longer term effects of call lines when they have
bedded-in.
Thank you

17. Copyright ©2000 BMJ Publishing Group Ltd.
Munro, J. et al. BMJ 2000;321:150-153
Impact of NHS Direct on emergency and urgent care services

18. Intentions and outcomes in 249 patients
attending two GP-WICs
What would you have
done if the GP-WIC
had not been
available?
Intention to use
other services
after consultation
Outcome
ED 202 (23.2) 38 14 (5.6)
GP 340 (39.0) 146 73 (29.3)
Self/nothing 103 (11.8) 659 -
GP-WIC - 8 141 (56.2)
Other 226 (25.9) 22 21 (8.8)
Total 871 (100.0%) 873 (100.0%) 249 (100.0)
We know that the 23.2% who said they would have gone to ED exaggerates the
true proportion.
So

19. Intentions and outcomes in patients attending two GP-WICs
What would you have
done if the GP-WIC
had not been
available?
Intention to use
other services
after consultation
Outcome
ED 202 (23.2) 38 14 (5.6)
GP 340 (39.0) 146 73 (29.3)
Other 226 (25.9) 30 21 (8.8)
Self/nothing 103 (11.8) 659 141 (56.2)
Total 871 (100.0%) 873 (100.0%) 249 (100.0)
We know that the 23.2% who said they would have gone to ED exaggerates the
true proportion who would have gone to ED.
So, other intentions are likely to be unreliable.