Title of paper:

Demand Management Framework

Lead/Director:
Sally Edwards, Director of Strategic Service Development

Author:
Mark Harris, Head of Planning & Service Development

Date of Board Meeting:

22nd September 2005

Process by which paper produced including committee and/or staff:

Collation of existing work streams and key recommendations from Strategic Health
Authority review of demand management.

Evidence to support any paper:

N/A

Implications for PCT:

The PCT has already commenced work on some schemes and needs to define other
schemes, which will shift activity between sectors. The capacity plan will need to become
a dynamic document to be supported by demand management.

Elements of Risk:
To be defined within individual projects. Overall risk is that existing methods of providing
activity are unsustainable from the perspectives of capacity and affordability.

Resource Implications:
These will be defined as key measurables against every project.

Communications Plan:
Review through Commissioning & Performance Group
Summary to PEC and Board meetings.

Summary and Recommendation:

The Board is asked to agree that this framework is used to draw together and implement
the programme of demand management projects.

Purpose:

To Note
DEMAND MANAGEMENT FRAMEWORK – AUGUST 2005 (updated)

1.0 Background

1.1 Current position

The PCTs capacity plan sets out the activity required to meet the NHS Plan targets. The
Local Delivery Plan and subsequent agreement of Service Level Agreements have however
remained a distinct process.

Constraints on commissioners abilities to move funding from secondary to primary care have
inhibited the development of primary and community care alternatives to secondary care
provision and annual referral growth has therefore been managed largely through increased
capacity in secondary care.

This is acknowledged as an unsustainable cycle, which PCTs must break. This paper focuses
on a process within which demand management can be taken forward by the PCT. It does
not detail the specific detail of existing projects, as this is contained within project mandates
and project plans.

1.2 Definitions

Demand management has usually been a term assigned to projects aimed solely at reducing
activity in secondary care for in-year financial risk avoidance. Locally these have largely found
limited success, with pre-implementation evidence being weak and measurement of impact
often non-existent.

The term demand management is also sometimes perceived, by clinicians in particular, as

one associated with plans to restrict or limit access to services for patients.

In industry, demand management is a term used to describe forecasting and planning for
demand, defining where services are best placed to meet that demand within available
resources and ensuring that actions are taken to be prepared for the demand when it occurs.
In the NHS this is a similar process with the complication that most health economies are
starting from a position where demand is already met by services being provided in a
financially unsustainable manner.

To succeed demand management work streams in the NHS must :-

Examples of fulfilling criteria

Be evidence based • Draw upon existing successful projects
operating elsewhere
• Draw upon published best practice or
guidance from the Department of Health
• Show short and long term impacts in
activity and resource to allow resource
shifts to occur
Be measurable • Clearly identified impact assurance in
activity terms with firm timescales
Demonstrate improved patient • Service level agreement variations
outcomes, make better use of completed to withdraw resource from
financial resource, or both existing provider
Have clinical engagement throughout • Initiation by clinicans
• Agreement reached with existing providers
with reference to the change
Work alongside dynamic capacity • Capacity plan shows shift in activity and is
planning validated against actual activity information

The challenge for PCTs is to ensure in-year activity pressures are managed whilst creating
headroom to implement projects, which address the early stages of a disease pathway and
will have impacts over a longer period of time.

If capacity planning is the tool to define the activity required and where it is to be provided
from,– then demand management is the tool to move from where we are now to the stated
capacity plan.

1.3 Types of demand management

Surrey and Sussex Strategic Health Authority have undertaken a review of existing demand
management approaches within PCTs and describe the types of projects as set out below.
HARDER TO IMPLEMENT

Unscheduled care (including

intermediate care)
Tertiary referral review
Long-term conditions
Use of CAS and triage/primary
care treatment for targeted elective
procedures
Secondary care admissions
EASIER TO IMPLEMENT

Limited GPSI services
Review of procedures of limited
value
protocols
O/P follow-up ratios
Scoring systems to assist triage

LOW IMPACT HIGH IMPACT

Those projects within the “Easier to implement” boxes are also projects which are more likely
to have impacts visible in the shorter term. Those in the “Harder to implement” are more likely
to demonstrate impacts over a longer time period.

The PCT must therefore ensure projects are underway so that easier to implement projects
are facilitated and the longer term and larger scale projects are not discarded simply because
the impact is more difficult to define.
2.0 Framework for Demand Management

2.1 Overarching principles

• Demand management must not be used as a barrier to accessing appropriate services
or create additional delays for patients moving between settings.
• Existing policies must be adhered to. E.g. “Approach to commissioning services of
variable benefit.”
• Opportunities for providing alternative services must be explored with NHS bodies,
independent sector and voluntary sector partners.
• Projects must be measurable and have clinical engagement.
2.2 Understanding demand in Surrey Heath & Woking PCT
Whilst some analysis has already taken place locally, a full picture of activity is required in
order to both prioritise work areas, understand activity growth and to highlight where to
measure impacts of projects. It is critical that this information is available at the outset of
defining projects to ensure successful project outcomes.
It is equally important that any projects which are aimed at shifting activities from one sector
to another include discussion with existing providers who may need to consider the effect on
their own capacity.
There remain four areas where there are constraints on currently available robust information:-
• Referral information is not currently provided by secondary care or collected from
primary care
• Outpatient data is not diagnostically coded in secondary care
• Activity is commissioned at speciality level only (within outpatient settings this is
already moving towards clinic level as part of the introduction of Choose & Book)
• Tertiary referrals are often not coded as such by the receiving Trust. In addition there
are referrals made by GP’s, which have been seen by a consultant and passed back to
the GP for onward referral. These are also tertiary referrals and not recorded as such.

Action Ref. Description Timescale

A1 Referral information to be made available June 05
from Frimley Park Hospital, Ashford & St (not complete, new outpatients
Peters and Royal Surrey County. being used as proxy until information
is available)
A2 New Outpatient data to be analysed by June 05
specialty showing growth and outcomes of (partially complete, outcome of
appointment (to include non acute appointment to be added)
outpatients e.g. childrens services)
A3 Follow up outpatient data to be analysed by June 05
specialty showing growth, and ratio to new (completed for General Surgery,
outpatient appointments (to include non T&O, ENT, Ophalmology &
Dermatology)
acute outpatients e.g. childrens services)
A4 Daycase and inpatient information to be June 05
analysed showing growth by procedure, (completed for General Surgery,
ratio’s of daycase v inpatient activity. T&O, ENT, Ophalmology &
Dermatology)
A5 Emergency activity information to be June 05
analysed by ICD10 chapter (and in full (completed)
diagnostic detail) showing volumes of short
and long stay First Finished Consultant
Episode (FFCE) and Occupied Bed Days.
2.4 Scoping target areas and identifying projects

Information needs to be considered against the following questions to scope the projects
required to initiate any change :-

• How do the services compare to the benchmarking statements made in the

Modernisation Agency’s “10 High Impact Changes for Service Improvement and
Delivery?”
• What are areas of most volume?
• How did activity arrive in the location in which it was undertaken?
• Were there existing alternatives?
• Is there an alternative method of providing the activity?
• Would the activity have occurred if another process had been in place at any place in
the patient’s pathway.
• What examples from elsewhere could be applied to this activity?
• What lessons can be learned from patient experience?

Clinical engagement must be sought in defining any project areas, and where service
changes are envisaged, Patient and Public Involvement in the redesign should be
encouraged.

It is recommended that clinical engagement is initially through the emerging Practice Based
Commissioning locality representatives at the Commissioning and Performance Group, and
through ongoing visits to practices to discuss commissioning more widely.

An approach to planning and implementing demand management designed by Surrey &

Sussex Strategic Health Authority is attached at Appendix 2.

Identification of projects will be through use of the information analysis and discussions with
Practice Based Commissioning localities. Practice Based Commissioning initiated projects
can therefore interface with the methodology within this framework where it is supportive to do
so.

2.5 Existing projects

The PCT is already committed and undertaking a number of projects which address aspects
of demand.

Appendix 1 details existing projects that have been initiated. These projects do not all have
measurable outputs defined and work is underway to ensure that this is in place to support
project implementation.

Additional projects will be added to this list throughout the year and becoming operational or
piloted as soon as it is practical to do so.

2.6 Integration with existing work streams

Demand management as a process to support capacity planning must remain integrated with
the principles defined within the Enhanced Services Strategy and the emergent Practice
Based Commissioning agenda. It is likely that early practice based commissioners will lead on
some projects defined within this framework, particularly on the outpatient aspects of surgical
specialties and emergency admission avoidance for chronic care.
Action Ref. Description Timescale
B1 Measured benefits of existing projects June 05
defined (ongoing)
B2 PCT activity at local Trusts measured against July 05
10 High Impact Changes (completed)
B3 New projects defined from activity analysis July 05
(ongoing)

3.0 Project Implementation

3.1 Project approaches

Demand management can operate as a programme of work with smaller projects and pilots. It
is recommended that a project approach such as PRINCE2 is used to ensure a structure and
clear accountability to the work. This will enable the “agreed outcomes to be delivered
(acceptance criteria)” to be measured. Using PRINCE2 will provide milestones and project
plans which can be reported through the Dynamic Change software.

It is recommended that the following PRINCE2 products are used as a minimum to enable
accountability, measurable outputs, progress reports and handover to Practice Based
Commissioning.

Product Description
Project Mandate Acts as the trigger for a project and details the
sponsor and accountable manager for delivery as
well as expected outputs of the project.
Project Plan Provides the detail of the project to be undertaken
including milestones, timescales and resource
issues
Highlight reports Provides structured progress against the project
plan for review. It is intended that this is provided
through Dynamic Change Board.
Risk Log Provides a log of the risks and the agreed
countermeasures. Acts to ensure that risks are not
left identified with no action taken.
Issue Log Provides a log of issues that arise and the decisions
taken.
Lessons Learned Log Logs lessons learned for use in similar projects.
Post Project Review Plan Measures whether expectations have been met.

3.2 Piloting schemes

Whilst projects can operate using a formal project management tool, innovation and local
good ideas can be supported within a culture of piloting and testing. Using the Plan, Do,
Study, Act (PDSA) principles championed by the National Primary Care Collaborative will
enable ideas to be tested at an early stage, where awaiting a full project work up would
unnecessarily delay progress.

3.3 Risk management

An integral part of PRINCE2 is the maintenance of a risk log. Where demand management is
used to address capacity or resource difficulties it is therefore vital that impacts are measured
from the outset and that variances from expected profile of change are analysed, understood
and acted upon. This may include the requirement for additional projects to be defined or
existing ones amended.

Action Ref. Description Timescale

C1 All projects to use PRINCE2 products and Ongoing
to have Project Mandates and Acceptance
Criteria defined
C2 Risk Log for the demand management June 05
programme to be produced (Set up and ongoing)

4.0 Monitoring and Review

4.1 Defining impacts

At the outset of projects, clear measurements of impact in activity and the resource to move
from one setting to another. Service Level Agreements will need to support any movements of
financial resource and activity movements need to be reflected in capacity planning.

Measurements need to collect information of activity passing through the new process as well
as the change in the previous process.

As a minimum all demand management projects must be able to demonstrate:-

• volume of activity shifting between settings
• associated financial resource
• timescale over which activity will shift, profiled for measurement
• any assumptions over meeting unmet need
• details of expected long term health gains/outcomes

4.2 Reviewing outcomes

By ensuring expected impacts are defined and start positions baselined, success of projects
or pilots can be demonstrated and where appropriate rolled out or expanded. It is vital to
ensure clinical engagement in the review of the outcomes of a project.

4.3 Capacity planning

The outputs of projects and any agreed expansions or roll out will need to feed into the
capacity plan which should be a dynamic planning tool reflecting activity in all sectors.

Action Ref. Description Timescale

D1 Projects to be set up on Dynamic Change Ongoing
software for ongoing PEC and Board
progress reporting
D2 Project end points to be set so that Ongoing
handover to mainstreaming work or rollout
is defined
APPENDIX 1

EXISTING DEMAND MANAGEMENT PROJECTS –AT AUGUST 2005

Surgery / Service Area Specialty Scope Measurement SHAW PCT Lead

Medicine
Surgery New Outpatients Trauma & Frimley Park Hospital Clearnet OP data Mark Harris
Triage Orthopaedics reduction
Surgery Follow Up Ophthalmology, All non local Clearnet OP data Mark Harris
Outpatients (High Trauma & providers, but in reduction
Impact Change Orthopaedics, particular Moorfields,
No. 5) ENT & Great Ormond
Dermatology Street, Royal
National
Orthopaedic,
Heatherwood &
Wexham Park, Royal
Free, Guys and St
Thomas’ and St
Georges
Surgery Enforcement of low General Surgery Initially local Trusts, Clearnet procedure Shelley Eugene / Sharon
priority procedures with review of any codes for elective Campbell
policy non-local activity. activity
Surgery Minor Surgery in Dermatology Frimley Park Hospital Clearnet procedure Ken Bates / Surrey Heath
Primary Care codes for elective Practice Based
activity Commissioners
Surgery Minor Surgery in Dermatology / Ashford & St Peters Clearnet procedure Mark Harris / Shelley
Primary Care General Surgery codes for elective Eugene
activity
Medicine Primary Care front General Medicine Ashford & St Peters A&E Attends, Mark Harris / Shelley
door in A&E Clearnet data on Eugene
short stay
emergency
admissions
Medicine GPSI in Cardiology Cardiology Frimley Park & Julie Gardner
Ashford & St Peters
Medicine Expansion to falls General Medicine, Frimley Park A&E Attends,
service Trauma & Clearnet data on
Orthopaedics, short stay
General Surgery emergency
admissions, Surrey
Ambulance data on
999 call reasons
Medicine Community Various All local providers A&E Attends, Kirsty Thirlby
Matrons Clearnet data on
short stay & long
stay emergency
admissions, Surrey
Ambulance data on
999 call reasons
Appendix 2: Approach to Demand Management Planning and Implementation

Monitoring and Decision-making Monitoring and

analysis and testing Implementation review

• Referral monitoring • Options appraisal • Implementation of • Regular monitoring

• Analysis of trends • Pilot testing schemes of impact of
• Benchmarking and • Analysis of impact • Clear deliverables schemes – clinical,
comparison and measurable activity, financial
• Identification of objectives • Review of viability
priority areas • Link with capacity
planning

Clinical Engagement
Patient and Public Involvement
Programme Management
Secondary Care Engagement
 ATTACHMENT F-1

Appendix 3 – High Impact Changes

R:\Board PCT\Items for 22nd Sept 05\F - 1.doc

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