The Department of Health would have us believe that demand management is a straightforward and egalitarian system of getting the best for patients. But is 'care and resource utilisation' really just about balancing the books? Daloni Carlisle reports

The policy documents on 'care and resource utilisation' paint a rosy picture.

CRU - as demand management appears to have been rebranded - is 'all about giving the patient the right treatment in the right place at the right time,' says the Department of Health.

Its document, Care and Resource Utilisation: ensuring appropriateness of care was published alongside the 2007-08 operating framework before Christmas.

'In some cases, this will mean providing more care than at present. In other cases, it will mean changing the location of care. In others, it means changing the patient pathway. The common thread is that service redesigns will be owned and agreed by clinicians, working in partnership across primary and secondary care, to deliver integrated, well-designed services,' it claims.

In the real world the picture is radically different. Many primary care trusts have implemented a range of demand management schemes, unilaterally issuing lists of routine procedures that they will not fund without prior approval, setting up referral management centres, attempting to place primary care staff in accident and emergency and halting consultant-to-consultant referrals.

With a few exceptions, these have pitched acute trusts against PCTs, doctors against managers and sent the British Medical Association and MPs shouting 'foul' to the media.

Among acute trusts and the clinical establishment, the feeling is that these schemes are simply a cover for financial cutbacks and have very little to do with improving patient care.

BMA consultants and specialists committee chair Jonathan Fielden says: 'Any system has limits and you have to manage demand and supply. The concept is correct but what is happening now is being done for short-term financial gain.'

The BMA is against prior approval, for example arguing that all GP referrals are, de facto, appropriate. More specifically, the BMA has set itself up in opposition to independent clinical assessment, treatment and support centres, currently in the negotiation stage in NHS North West.

The theory is that only one quarter of referrals to hospital should result in an admission. The rest get their treatment elsewhere. 'We want to set up a one-stop shop where patients see a consultant and then get any diagnostic tests or primary care treatment on the spot,' explains an NHS North West spokesman.

The BMA sees it differently. 'These proposals could represent a significant threat to local hospitals,' says Dr Fielden. 'It's a good idea but it is being handed to the private sector without due competition or ability of the NHS to be involved.'

This is all a horrible misunderstanding, says the spokesman. 'Hospitals will be able to treat more people because less of their time will be spent seeing outpatients. It's all about increasing capacity and reaching the 18-week target.'

Tell that to Colin Holden, president elect of the British Association of Dermatologists. Dermatology is an outpatient specialty, he points out. His organisation claims demand management has reduced referrals in the specialty by 20 per cent, threatening the existence of some hospital departments.

'PCTs have told us off the record that this is all about finance, although they wouldn't say it out loud,' he says. 'Demand management is crucifying us.'

Concerns are not confined to the medics. Acute trust managers who agree with the principle of demand management express concern about the imposition of schemes which are too heavy-handed.

Philosophical investigation

Nancy Hallett, chief executive of Homerton University Hospital trust in London, says: 'There is nothing wrong philosophically with trying to anchor the patient in primary care and make sure that is where most of their care is met,' she says. 'But to have a blanket policy that says no practising, registered hospital consultant can refer to another consultant cannot be right. This cannot be in the patient's interest.'

Some PCTs are ready to admit that finances drive demand management. North Yorkshire and York PCT, which has run into strong opposition from local MPs, doctors and the press for its demand management plans, has been quite open.

A spokesman put it like this: 'At the beginning of January the board agreed a package of measures to save£10m by the end of the financial year. That has included prior approval for some procedures and non-urgent things not going ahead at the moment.'

Advocates say that this is not - or should not be - the motivation behind such schemes. Go back to the CRU guidance and look at what it says about working through practice-based commissioning and taking clinicians with you, they say.

Among them is Improvement Foundation head and Derbyshire GP Sir John Oldham. He prefers not to use the actual words demand management. 'It's more appropriate to talk about people being seen in the right place at the right time by the right people,' he says.

He points to a range of schemes developed through practice-based commissioning that are reducing hospital admission by 25 per cent by careful scrutiny of referrals and better management of long-term conditions.

The DoH has cited similar figures, claiming a replication of practice-based commissioning's best schemes could translate into 2.5 million fewer hospital referrals a year.

Among its success stories is the Kingston co-operative initiative, where GPs have set up a system of referral management that they run themselves.

All GP referrals are examined for appropriateness, GPs have agreed some exclusions (procedures that they will not refer because they don't work) and have started to examine consultant-to-consultant referrals too ('Refer to sender', pages 20-23, 10 August 2006).

It has not been without its ups and downs, says medical director and GP Dr Charles Alessi, but to date GPs have cut their referrals to hospital by 25 per cent. The DoH cites it as a model from which others can learn.

Income support

But not everyone appears to share their enthusiasm: the local hospital trust has warned its consultants not to carry out any work in the community that could compromise trust income.

Dr Alessi is positive, but says organisations need to do more to devolve control. 'For it to work PCTs really must embrace practice-based commissioning. That's still not really happening. PCTs are reluctant to let go of the reins and instead set up large structures that are not really the answer.

'Until they devolve control and budgets it will not work.'

Sir John Oldham agrees. 'Demand management can be a pretty emotive phrase,' he says. 'It is developing everywhere and is the direction of travel. Some people are going through the motions because they are not sure if the policy trajectory is going to change. But practice-based commissioning is here to stay and so is care and resource utilisation.'

Acute trusts are also feeling threatened, and no wonder. The new contract has spelt out the financial discipline behind demand management. With PCTs no longer obliged to pay for activity that has exceeded forecast, a significant amount of risk now falls to acute trusts, and foundation trusts in particular.

'There are some built in tensions,' admits Tameside and Glossop PCT chief executive Tim Riley. 'It is clear that PCTs are expected to manage the patient journey. But there is still an issue for the hospitals. It's not easy to give up management of their forward order book.'

The third way

Birmingham East and North PCT has successfully pioneered a range of demand management tools, including peer review of GP referrals and prior approval, and managed to keep its acute trust on side - their work is one of the models cited in the CRU guidance.

'We have been really systematic about how we have examined the data,' says PCT executive director Andrew Donald. 'It has totally changed the activities of the PCT and moved us into a strong commissioning role because we have become very forensic about it.'

In January the PCT agreed a grey list of procedures, not just with clinical directors in practice-based commissioning groups but also with the acute trust, as Mr Donald puts it: 'We do not want to fall out with our acute trust.

'The bottom line is we can actively demonstrate we are managing demand. We are also demonstrating that lots of activities that shouldn't happen do not happen.'

If Birmingham East and North PCT is the model for managing demand, NHS North West is pioneering the longer-term approach of utilisation management. Again it is based on examination of the data: who is admitted to hospital, why, when and what alternatives might be available. Again it forms part of the CRU guidance.

'It allows PCT and provider organisations to plan over time their investment and disinvestment strategy,' says PCT head of unscheduled care Seamus McGirr.

NHS North West director of commissioning and performance Joe Rafferty describes utilisation management as an intelligent commissioning tool. 'It allows a commissioning process that acknowledges there will be knock-ons,' he says. So, take your data on treating deep vein thrombosis in the community, show the medics it has better clinical outcomes, show the finance people it is cheaper and develop alternative services in consultation with the acute side.

The idea is developing slowly and steadily. Mr Rafferty and Mr McGirr have presented it to all the royal medical and nursing colleges and the BMA and met with support.

'We do operate in a cash-limited system' says Mr Rafferty. 'We need ways to have conversations about the what, when, where and who, and within what resources. We need to do that within sound management principles.

'This allows clinicians and managers to have a structured debate. It's giving us the evidence on which to hold a debate, and that's what's been missing up to now.'

Care and Resource Utilisation: ensuring appropriateness of care can be downloaded