demarketing and managing demand in healthcare demarketing and by lindahy

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									What economists
forget –
demarketing and
managing demand
in healthcare
       Annabelle Mark
       Professor of Healthcare
       Middlesex University
       Business School UK
NHS Futures? 10 – 30 %
What problem do we have?

Increasing demands –
reducing resources

What strategies do we adopt –
restrict supply side access by
cost, access, availability.

What alternatives ways of
thinking do we have ?
Managing Demand
WHERE?        Tourism – Water –
              Transport - Health

In health 3 drivers:

n   Failure of economics to consider
    demand rather than supply side issues

n   De-marketing - persuading people they
    do not need a service you provide. 

n   Interest in changing behaviour
Failure of economics to
consider demand rather than
supply side issues
     Victims of Moral Hazard ?

 n  - arises when financial incentives
    within the healthcare system lead to:
 - inefficient demand for care by
    consumers or
 - inefficient supply of care by providers

     Eg 1995 UK work on GP night visits
     Led in part to NHS Direct
De-marketing - persuading people they do
not need a service you provide
         Its four aspects are :

         n   - general demarketing            eg whole services to
             shrink total level of demand – glue ear

         n   - selective demarketing            ie from certain sections
             of consumers – long waits

         n   - ostensible demarketing            ie appear to discourage
             as a device to increase – public/private

         n   - unintentional demarketing                eg where attempts
             to increase drive customers away – male doctors in FP

                          EXPLICIT VERSUS
                        IMPLICIT ACTIVITIES
                          ASK WHO GAINS?
Changing Behaviour

 n   increasing problems in manipulating
     supply as a proxy for demand

 n   growth of technology opportunities

 n   consumerism & its multiple

 n   organizational change

 n   Pandemics like swine flu
n2 definitions of demand –
which applies to Australia?

n   UK = the process of identifying where
    how and why people demand healthcare
    and the best methods of curtailing,
    coping or creating this demand such
    that the most cost effective,
    appropriate and equitable healthcare
    can be developed with the public 
    Pencheon 5 article series in BMJ 1998
    Pencheon 5 article series in BMJ 1998 

n   USA (trademarked) definition is
    the support of individuals so that
    they may make rational health
    and medical decisions based on a
    consideration of benefits and
    risks. It is concerned with
    making more appropriate use of
    health services, not reducing it
    or making it cheaper although
    both of these may occur
    n    American definition of demand implies
         a rational act but need to understand
         the role played by subjective
         rationality & emotion
        in relation to society, organisations
         and the individual

    n    individual is the “carrier of meaning”
         between places.

    "Medical Practice is essentially an
      intellectual pursuit. Being ill is a
      highly emotional experience"(Kennedy 2001)
- Manage upstream
  Eg accessing UK care:

  n   Ask friend/family
  n   Consult self care literature
  n   Look at
  n   Phone national 08 45 46 47 number
  n                   op
      Phone local co-op nurse practitioner
  n                   op
      Phone local co-op GP
  n   Visit to local co- nurse practitioner
  n   Visit to local co- GP
  n   Visit from local co
                        co-op nurse practitioner
  n   Visit from local co
                        co-op GP
  n   Visit A & E

Model of Emotion Driven
Rational / Emotional
n   Health belief models assume conscious rational
    choice for best outcome.
    Deans Story – 2 Journeys micro/macro.

n   Closing the Rational/Emotional Gap –
    relationships to encounters (GUTEK)

n   “emotion is constructed on line as part of the
    developing relationship emerging from a real
    time encounter between people”

Emotional Intelligence/Emotional Labour
Relationships to Encounters                                    (based on Gutek 1997)

n   RELATIONSHIPS                                                ENCOUNTERS

n   Participants are known to each other        Participants are strangers
n   All providers not equivalent                Providers interchangeable
n   Based on trust                              Based on rules
n   Elitist: individuals treated differently    Egalitarian: individuals treated alike
n   Customized service                          Standardized service
n   Difficult to start                          Easy to enter
n   Difficult to end; loyalty a factor          No obligation to repeat interaction
n   Fosters knowledge of other                 Fosters stereotyping of other
n   Creates weak ties, networks                 Does not foster networks
n   Does not need infrastructure               Is embedded in infrastructure
n   Fosters emotional involvement              Often requires emotional labour
n   Inherent feedback loop                     Feedback loop via management
                                               NOT between consumer & provider
n   Become more effective over time            Designed to maximise efficiency
Turning the problem of supply
induced demand on its head
     n   Relocate control to reduce
         demand (eg NHS Direct)
     n   control when “they” want it e.g.
         boundary between rational &
         emotional where is it?
     n   move from paternalism to
         participation confers control
     n   explicitness in process - rights
         & responsibilities - costs &
  n   Commissioned research of this
      demand management tool including

  Report 2001
  n                    Messenger”-
    “Don‛t Shoot the Messenger” an
    evaluation of the transition from
    Harmoni to NHS Direct in West
    London A.L. Mark & I.D.H. Shepherd

  n    what technology are individuals
      now most emotionally attached to?
Growth of technology opportunities
The Role of Mobile Phones in Increasing Accessibility and Efficiency in
Healthcare 2006 Imperial College/Vodaphone

                        90% 15 to 44 have mobiles in UK

          Savings £240-370m pa NHS in England via Short Message
                    Service (SMS) appointment reminders

         Improvement in glucose levels of 10% for young diabetics using
          a SMS support system- reduce complications of blindness by
                       76% and kidney disease by 50%

           Calls to NHS Direct through mobile are increasing faster
           than by landlines, especially in groups who were previously
                           low users of NHS services
   - shifting the locus of control and
   promoting explicitness allows risk
   to be shared

   -demanding healthcare is a far
   bigger activity than supplying it
   yet we still know little about it

   - start by comparing real
   professional and personal
   responses – Bristol behaviour
Managing Whose Demand?
  Demand from:

  public for services to be available

  patients for services as they are

  professionals - but conflict in
  service to individual patients
  and the population
Managing to demand or
demanding to manage?
 n   Participation in decision making benefits
     individuals & populations

 n   patients values incorporated when
     empowered with decision making

 n   opportunity to participate via knowledge

 n   prevalence of chronic disease provides
     incentive & opportunity (see mobile
     phone report examples eg diabetes)

 n   involvement confers control
  Where next? 

UK  First round: “One of the odder aspects of the latest data 
is that only 10% of those who sought help from a GP or the 
National Pandemic Flu helpline and subsequently took a swab 
test actually showed signs of infection.”Demarket selected groups?
test actually showed signs of infection.” 
The international size of
the problem
Australian Winter
­ population 1/3 size of the UK’s has
had twice as many deaths 
21 million, 27 663 confirmed cases  95 deaths median age 51 v 
83 for seasonal influenza , 3281 hospital admissions August 2009.
           n    "The big concern from our perspective would 
                be the lack of consistent information the 
                general public received, especially about what 
                they should do," said Carol Bennett, executive 
                director Consumers Health Forum Australia. 

           n    Boundaries and barriers  ­ states, professions, 
                communities, treatments eg ECMO, vaccine 

           n    Fear associated with young healthy people 
                               viral plus behavioural issues?
                seriously ill –viral plus behavioural issues?
Swine Flu – UK responses
  n   Pandemic flu: A national framework for responding
      to an influenza pandemic DOH April 2009
  n   “it is likely that some treatments will need to be
      deferred, clinical care standards will be modified and
      access to some treatments and services will be
      restricted “
  n   Because
  n   “given a 50% clinical attack rate, a locality with
      100,000 people could expect 11,000 clinical cases
      of influenza-like illness in the peak week of a
      pandemic, with 440 of these people requiring

  n   Assumption of rationality at all times
  n   “Additional security measures may be necessary 
      because of the potential risks of conflict directed at staff 
      making triage decisions.”
      making triage decisions.” 
n    Panorama UK Sept 09 

“Experts’ advice was interspersed with 
  personal experiences of swine flu, and I 
  was left wondering what viewers will 
  remember more; the slightly dull and 
  reassuring facts spoken by bland­faced 
  reassuring facts spoken by bland 
  experts, or the emotive interviews with a 
  handful of patients and relatives for 
  whom swine flu has caused devastation “
Conclusions on Demand
n   the real barrier to promoting better access is not
    only cost but the FEAR (emotion) of supply induced
n   infantilising and patronising people into a helpless
    dependency leads to coughs in ER and “wait and see”
    for central chest pain
n   raising subtle and unclear barriers to access makes
    demand more and poor and access unfair
n   managing interfaces well is vital (clear evidence based
    criteria - plus appropriate emotional response)

n   more graduated access (default should not be
    admission - alternatives required)

n   demand is not a problem to be buried but a real thing
    to be understood and influenced
n   Advisor to The Change
    Foundation Toronto Canada
n     Report published Spring 2005
n   “Turning the Tide - managing
    demand in health and
   n    Mark A, Pencheon, D. Elliott R (2001) "Demanding to Manage and 
        Managing to Demand" in Tavakoli, M., Davies, H.T.O., and Malek, M. 
        (eds.) "Health Policy and Economics: Strategic Issues in Health Care 
        Management" Ashgate Publishing Aldershot 
   n    A Mark & R Brennan 1995 Demarketing managing demand in the UK 
        National Health Service  Public Money & Management Vol.15 No 3 pp17­ 
        National Health Service  Public Money & Management Vol.15 No 3 pp17 
   n    A Mark & R Elliott  1997 Demarketing dysfunctional demand in the UK 
        NHS International Journal of Health Planning and Management  Vol.12  pp 
   n    A.Mark D Pencheon & R Elliott 2000 Demanding Healthcare International 
        Journal of Health Planning & Management Vol.15  pp 237­253 
        Journal of Health Planning & Management Vol.15  pp 237 
   n    Mark  A  (2003)  "Modelling  Demand  ­  a  rejoinder"  British  Journal  of 
                     Management Vol 9 No 2 p67­71 
        Healthcare Management 
   n    Mark  A  &  Shepherd  I (2003)  How  has  NHS  Direct changed  primary care 
                            of Telemedicine and Telecare. Vol 9 no 8 57­59 
        provision.  Journal of 
   n    Mark.A  &  Shepherd  I.  2004  NHS  Direct:  managing  demand  for  primary 
                             Journal of Health Planning and Management Vol 19 79­ 
        care? International Journal 
   n    Mark  A  2006  Emotional  affects  ­developing  understanding  of  healthcare 
        organisation  in  Research  on  Emotions  in  Organisations,  Volume  2: 
        Individual  and  organisational  perspectives  on  emotion  management  and 
                            Neal Ashkanasy and Charmine Hartel  Elsevier
        display Wilf Zerbe, Neal

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