The problem of DTOC has basically been addressed, but the problem of demand most certainly has not.
It is encouraging that the NHS’s Time for Care scheme will be fully rolled out over the next three years following impressive results from the pilot scheme. In the pilot, some 205,157 clinical hours were freed up last year, equating to more than 1.2 million GP appointments. This is much needed in a system that is visibly overheating.
It is also interesting to see that a number of the improvements require only low level behavioural interventions to achieve significant change. For example, by changing the default and offering telephone appointments in the first instance, demand for face-to-face appointments reduced by 8%. Low level intervention is something that I know works very effectively, but is often undervalued at an executive level. Often senior leaders search for the “big” solution, the “game changer”, at the expense of the small and localised changes that, in aggregate, make a much bigger impact overall.
From our own work to influence demand in complex systems, such as adult social care and children’s social services, we have seen more than a 30% reduction in demand at the service front door.
Some of the other interventions described by the various reports include more appropriate support being provided in the community through 20,000 more staff including: clinical pharmacists, physiotherapists, community paramedics, associate physicians and social prescribing link workers. This is a welcome investment in community-based healthcare and will no doubt significantly ease the burden on GP practices.
However, of the reports that I have seen, one question that they fail to answer is: what is the extent of avoidable demand? At one level, the structural interventions introduced through Time for Care are merely shifting the burden, without answering the question of whether the demand should exist in the first place, and if it can’t be avoided, whether it could be appropriately delayed. Our work in complex systems, including A&E admissions, social care and children with special educational needs, shows that when assessing recent cases, professionals conclude that approximately 40% of presentations could have been delayed or avoided if existing services had been more accessible, or services had been reconfigured to support preventative activity.
The NHS is absolutely on the right track now. Scaling the trial will require engagement with the wider GP community to encourage innovation rather than mandating interventions. Facilitative support to highlight opportunities and test local solutions will need to be at the core of the rollout mechanism – simply sharing best practice and guidance will not be sufficient or effective; the day job gets in the way!