Intended for healthcare professionals

Education And Debate Managing demand

Managing demand for secondary care services: the changing context

BMJ 1998; 317 doi: (Published 11 July 1998) Cite this as: BMJ 1998;317:135
  1. Nigel Edwards (, director,
  2. Martin Hensher, health economist
  1. London Health Economics Consortium, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  1. Correspondence to: Mr Edwards

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

    Little strong evidence exists to explain the sustained growth in demand for hospital services shown in the table, but changes in population structure, numbers of people living alone, pressures on primary care, risk management, patient expectations, and an increased ability to treat are frequently cited as possible reasons for this seemingly inexorable rise.1

    The desire to reduce, or at least contain, demand in the hospital sector is undoubtedly related to this growth and to the need to control costs. There is also a concern about the appropriateness of hospital care for many conditions, and there are growing opportunities to provide modes of care which may better meet patients' needs and may, in some circumstances, be cheaper.

    The previous paper in this series discussed demand management at the interface between primary care and secondary care. Attempts to segment primary and secondary care are inevitably somewhat artificial. figure 1, however, shows a highly simplified representation of the relation over time between the natural progression of a chronic illness and the thresholds between different healthcare sectors.

    Summary points

    • There has been a sustained growth in demand for hospital services, which has been accommodated despite a decline in bed numbers

    • Further ways of managing demand for secondary care include condition-specific waiting lists, medical assessment units, use of protocols, and a single point of access to non-hospital alternatives

    • Once patients are in hospital protocols can help limit their stay, but the biggest impact will come from discharging patients to other forms of care

    • We need a new currency for secondary care, couched in terms of what needs to be done, rather than where it is done

    Below a certain degree of severity (threshold A) a patient's condition can be managed …

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