This is the first of five articles on ways of managing demand for health care

The challenge of meeting the demand for public services that are free at the point of use is increasing. Examples, in increasing order of complexity and controversy, include water, higher education, road space, and health care. These services are perceived as important to society in general, and demand is rising rapidly and unsustainably.

Such increases in demand can be managed either by reducing the demand—, for example, by charging, as for water or road space—or by increasing the supply—, for example, via increased funding, as with student loans. In health care, perversely, we do the opposite of both these approaches: we fuel demand by failing to manage it—for example, by not curbing expectations—and we are often forced to cut supply through lack of resources.

Demand for health care is undoubtedly rising. The average number of consultations for children in each of the first years of life (even after excluding surveillance and immunisations) has, in one general practice, risen from 3.73 per child in 1960 to 17.2 in 1990.1 We need to understand better how this ever increasing demand for health care is initiated and expressed and use this understanding to manage the whole system better. Professionals have the same increasing expectations from the service as the public does. Managing the pressure on the health service is as much about managing the expectations and rights of professionals to treat as it is about managing the expectations of patients to be treated.