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Martin Cresswell

With half of all hospital admissions avoidable, discussing demand isn’t optional

The concept of demand management is increasingly gaining traction across the NHS as a route to delivering sustainable services, and is a feature of the NHS Long Term Plan launched in January.

But while the NHS is moving towards Integrated Care Systems as the primary mechanism for delivering change and reform, the fundamental need to understand the nature of demand is at risk of being ignored. Moving from one structural solution to another structural solution will fail without giving due attention to human behaviour and what drives demand within a system.

Reform will also fail unless the illusion of control in the health and care systems is acknowledged. It is usual that these systems are defined by senior managers and system leaders as ‘complicated’, and that they can be controlled if the right processes are put in place.  At IMPOWER we know this is a misdiagnosis – that in fact, the influences on the health and care pathway are many and dynamic, and cannot be controlled. We reframe these systems as ‘complex’ – they are non-linear systems, where responsibilities are distributed and where success depends on creating the right relationships across and between system boundaries. This reframing – which lies at the heart of our EDGEWORK approach – enables our clients to achieve better outcomes at lower cost.

IMPOWER have undertaken a series of projects working at the front door of the health and care system – contact and assessments in social care, and A&E in health – to explore why people ask for support from the state.

In each project we ask mixed groups of professionals who work across the system (social workers, nurses, consultants, GPs, police) to review existing recent cases where individuals had been admitted into “the system” and services provided.  For every case, the mixed groups reached an agreed position on whether providing state assistance could have been avoided, delayed or was unavoidable. This excluded fundamental lifestyle changes (e.g. smoking cessation, increasing exercise, reducing alcohol consumption) as alternatives to admission.

Across the health and care system, our results show that 40-50% of admissions could have been avoided or delayed if more appropriate support had been in place.  To illustrate the point, let’s examine an example from a project looking at A&E admissions:

CASE STUDY: Preventing Admission to Hospital and Discharge Delay

Patient A: ‘Dorothy’

  • 98-year-old who lived at home but was feeling generally unwell and was admitted to hospital following a 999 call
  • Condition deteriorated during her 90-day stay in hospital, the duration of which she was medically fit
  • Initial discussions about returning home with an increased package of care but on discharge was placed into a nursing home

Patient B: ‘Elizabeth’

  • 75-year-old who lived alone with a package of care from the local authority. Admitted to hospital with pneumonia via her GP following a concern from her carers.
  • Could have avoided admission had GP been involved earlier. Discharge was planned for 21 days after admission.
  • Elizabeth stayed in hospital for 129 days, including a delay caused by waiting for court of protection to move into a care home.
  • No consideration was made to get her back home. She could have been discharged home had action been taken earlier.

For both women, admission to (and then a lengthy stay in) hospital could have been avoided, as could placement into a nursing or care home. The actions taken (or lack of actions taken) not only resulted in a reduction in their independence as they could not return to their own homes, but also led to higher costs for the local council.

The issue in both of these examples is not that services were not available, or that changing organisational structures would have delivered a better result. Rather, it is that at various points along the patient journey the knowledge and behavioural conditions needed to take more appropriate decisions were not present. The frameworks within which public services operate drive a cautious approach to risk management which, while very understandable, can deliver worse outcomes for a significant number of individuals and actually increase the cost to the public purse.

All leaders in the health and social care sectors want to deliver good services and a balanced budget. In our view, to do that, we must enable each local citizen – our neighbours, families, communities – to maximise their independence and enjoy better outcomes, while, at the same time, helping services to manage their limited budgets. Using demand management and behavioural science, we can delay, reduce or eliminate unnecessary demand, and deliver better outcomes that cost less.

Do get in touch if you would like to discuss this further.

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