News: Trolley waits and bed blocking are two of the most intractable problems to hit trusts. Laura Donnelly asks whether theories of demand management can offer hope to trusts in no-star hell

'It is a really difficult one to tackle. They've been trying to do it for years. When I was a hospital porter in my university holidays in 1981, we had a poster of a boy with a saucepan on his head in accident and emergency.'

For NHS Confederation policy director Nigel Edwards, there is nothing new in the government's bid to manage demand and divert patients away from the busiest parts of the system.

The NHS speaks of pathways of care. For patients at the sharp end, trolley waits and bed-blocking better describe a path littered with obstructions and bottle-necks.

And so far, attempts to manage demand and supply have had limited success. Some of the more cynical commentators have suggested that even the best internal and external efforts to manage demand are tinkering at the edges of shortfalls in capacity and resources that cannot be disguised.

Nonetheless, those managing capacity cannot afford to give up on the theory. Trolley waits and high numbers of delayed discharges were the quickest way to get a no-star rating when the system was launched last month.

There are many strands to managing demand and supply - but Mr Edwards believes that very basic weaknesses in health systems are at the root of the bulk of blockages. Not least of which is the artificial divide between primary and secondary care, under which many GPs see little incentive to keep patients out of secondary systems.

'I was struck by something [Professor Sir] George Alberti [Royal College of Physicians president] said - 'There is no them'.

There comes a point when people have to stop playing the blame game. At the moment, people are responding to the incentives in the system. We say, take a whole-systems approach but, of course, we can't measure whole systems.'

Many commentators believe that local primary care must catch up with talk at national policy level and increase the responsibility it takes for reducing its referral rate and dealing with more problems within primary care. They feel that not enough work has been done to measure the success of schemes that have tried to achieve these aims.

Alan Maynard, professor of heath economics at York University, says:

'People get referred inappropriately by a phenomenal amount.We have no evidence about how much guidelines are adhered to. Even if they were made mandatory, you have still got the problem of how do you check the protocols are being followed? Primary care is a data-free environment. We do not know what GPs do.'

He believes the government threw a lot of resources into NHS Direct 'on a wing and a prayer', and still do not know 'whether it is substituting or complementing GPs or A&E'.Meanwhile, 'the primary care people are essentially corner-shop enterprises. What they do varies enormously - I do not think primary care, except for odd pockets, has ever addressed that.

'The trusts are suddenly realising now that their chief executives are going to be shot if they do not hit their targets or get their stars - what's amazing is that it has taken this long.'

United Bristol Healthcare trust chief executive Hugh Ross is one of those. UBHT got no stars, and long trolley waits were a key reason. Mr Ross has so far been seen as one of the NHS's success stories - the man who turned round a notorious trust; the 'manager's manager'. But his attempts to remain on-message falter on the subject of systems improvements to tackle its capacity issues.

'We have been working through a six-month action plan to try to address as many problems as possible. We have made literally over 100 changes to our processes.'

Following the no-star rating, the National Patients Access Team visited UBHT in an attempt to share the secrets of good demand and supply management. But according to Mr Ross, the NPAT members were impressed with what they saw: 'It was good to have that external confirmation.' He pauses: We still have as many long trolley waits as we had before.

'We keep taking advice from anyone who will give it. We will take all the advice they can give.

We welcomed the news that we hadn't missed anything obvious.

We have adopted good-practice advice, but there is not enough capacity in the system.

'I am coming to the conclusion that we are getting into a law of diminishing returns.'

At UBHT, emergency admissions are up 8 per cent on last year. Financial shortages have led Bristol city council to bring in a 'two-out one-in' policy, which means that for every two places vacated in nursing homes, just one is offered to local hospital patients. Avon is at the bottom of the national beds inquiry, and Mr Ross says the Avon health economy is short of about 250 acute and community beds and 600 nurses.

Attempts to bring down referrals have made little difference: 'We are working very hard with GPs on demand management, but our research has shown that the vast majority are not inappropriate. It is really a question of increasing capacity in the community.'

At Birmingham Heartlands and Solihull trust, chief executive Mark Goldman admitted earlier this month that with at least 100 people awaiting discharge, the trust was having to be 'innovative in front-door initiatives and demand management'.

'We are trying to shorten lengths of stay, trying to collaborate with primary care on stepdown facilities.'

David Hunter, professor of health policy and management at Durham University, has sympathy for trust chief executives being forced to toughen up: 'I think the pathway of care is becoming as much of an issue for trusts as it is for primary care, ' but adds: 'I am not sure this is something they have really cracked at all.'

Meanwhile, he believes that enthusiasm at a policy level from organisations such as the NHS Alliance is not matched by commitment on the ground. 'I think there is a mix. There is a problem that people do not want to be responsible for rationing. It is a poisoned chalice.'

NHS Alliance chair Dr Michael Dixon agrees that success in schemes to cut referrals to secondary care has been patchy. But he believes the last thing the service needs is more guidelines or any sort of top-down approach.

'If you are really going to make a difference, you need to have local ownership. If the National Institute for Clinical Excellence sends out guidance, you do not know if people will read it and you certainly do not know if people will stick to it.' His own practice has cut referral rates on lumbar x-rays by 50 per cent after providing all partners with figures comparing their individual rates with those of their colleagues.

But Dr Dixon believes early optimism that primary care could take pressures off A&E may have been misguided. 'We did a study of emergency admissions and had a consultant and GP at the door of a local hospital - we found just 10 per cent could have been demand-managed.'

Nigel Edwards agrees that the real rewards can be found not in emergency care, but in diverting patients away from outpatients by creating more multidisciplinary teams within primary care for services such as physiotherapy.

He believes current star systems do little to help, by focusing on acute trusts performing poorly on trolley waits and delayed discharges, rather than on their relationships with primary care and community services.

'What we need is to remove the perverse incentives and bring in 360-degree appraisal, so we look at the whole health economy.

What do the current incentives do? Make people dissemble, to put it nicely. A lot of effort goes into meeting the measures. It is a question of playing the system and leaving before you get caught.'

Hips vs hysterectomies: 'you're skating on thin ice' Paul Zollinger-Read, a GP working for the Modernisation Agency on demand management, is enthusiastic on the potential of improved systems. Next month, he is due to publish a paper entitled The Referral Wizard advising GPs on the best way to manage demand. It focuses on four elements - referral rates and why 'outlying' figures skew their averages; the queues (looking at outpatient templates to put queues in an efficient order); the level of demand; and working out how to implement guidelines. It will link to a website.

Meanwhile, the Department of Health has commissioned two papers from Birmingham University's health services management centre examining the potential of individual demand management systems. A final evaluation on the first wave of booked admissions will be out at the start of next year, while a paper on slot systems and priority scoring is due by the end of 2001.

Dr Zollinger-Read believes that so far, health systems in the UK have failed to use priority scoring properly because they have not identified a fixed length of time for which people should wait.

What is more, services which try to prioritise should be wary of the pitfalls. 'If you try to score replacement hips for visibility, pain and loss of function against, say, a hysterectomy, you are skating on thin ice.'

He suggests that scoring cannot provide a universal panacea:

'Scoring has a place but it doesn't work when you have long waits and it doesn't work when you have very short waits. . . and when it is used for more generic problems it adds no value.'

As for slot systems, limiting the number of referrals a GP or practice is allowed to make to one trust can mean that when the limit is reached, a neighbouring trust gets hit: 'Your solution becomes someone else's problem, ' Dr Zollinger-Read puts it. He believes the big answers lie further down the line, in two projects run by Karen Castille of the National Patients Access Team and Dr John Oldham from the Primary Care Collaborative. Both are based on a premise that the service needs to focus on throughput and minimising variability, by better linking the steps within the patient's journey. Ms Castille is looking at redesigning emergency care and Dr Oldham at elective procedures.

Dr Zollinger-Read is optimistic that a combination of small changes now and longer-term focus on patient flow could make a 'very significant' difference in ending the 'chaos' current systems can bring. 'Many people feel that demand is infinite - but I am not one of them.'