This model was developed as part of an Action Learning Set for reablement services across Wales that involved nine Authorities and therefore saw an ithink model embedded within a wider toolkit supporting networked learning.  The model considers the impact of an optimised reablement service for a given local population and therefore provides an opportunity for reviewing local reablement services (in terms of both capacity and service model) in the context of the whole system.

Method

The model was built using ithink software following a review of national evidence and local experience in implementing reablement services. The Action Learning Set of which the project was a part convened a working group that met on three occasions to define the key issues and develop the model framework with the assistance of the consultants.

Context

The National Assembly for Wales had identified reablement services as a priority and had therefore asked the Social Services Improvement Agency to support Local Authorities in developing these services. The work continues to be promoted through the SSIA website as a key tool in reablement implementation across Wales.

Implementation

After making the tool available on the SSIA website Authorities have been encouraged to adopt the workbook and modelling approach to refine their plans for the development and enhancement of reablement services.

Evaluation

We have worked with WSP over two years on our reablement work programme. Their approach ensured the full engagement of a number of Councils and facilitated consensus building. The specific work on the capacity modelling tool enabled Councils and their partners to understand systems modelling and how to apply it to the development of their service. The feedback from participating council has been very positive and importantly has helped them to better understand their service and the impact that specific changes would have. It has also helped them to better understand gaps in their current knowledge and led to data development actions as well as operational changes. The resulting refinement / improvement of their operating model has helped a number of participating councils to realise cashable and non cashable efficiencies. – Vicky Poole, Social Services Improvement Agency, Wales

Further Information

A full report on the Reablement Framework Modelling Tool is available on request from Peter Lacey .

To support local partners in exploring the impact of implementing the National Dementia Strategy where the impact of priority interventions are seen in both capacity requirements and costs/benefits across the whole system. Model outputs are provided for a range of alternative locally determined scenarios for different parts of the system. Local Authority and Health costs and benefits are identified both separately and together over the medium and longer term.

Method

The model was built using ithink software using an innovative and distinctive demographic ‘hub’ developed exclusively by WSP that simulates the expected incidence and prevalence of dementia for a given population and enables calibration to an initial dementia diagnosis gap, i.e. the difference between expected prevalence and numbers of people on a local GP dementia register. An excel link provides an input that can be specified to any local demographic profile.

The model interface enables people to explore different scenarios in the areas identified in the model purpose above with outputs being provided as both cost and capacity estimates over time.

The model is based on extensive research and engagement with several Local Authority and Health partnerships. In each case an iterative process of client engagement has been undertaken to define and then develop the model structure, inputs and outputs.

Context

The coalition government has re-emphasised its commitment to supporting the implementation of the National Dementia Strategy. The results of the work, in the form of a generic framework model for a typical 400,000 population, have therefore been made available to any Local Authority requesting one – to date approximately 100 people have been provided with this model on an auto-run CD.

Evaluation

I am using your Whole Systems Modelling report to help me in writing the business case for implementing the local dementia strategy. Can I first say how fantastic I have found the report. It is very clear and easy to understand, and really does provide all the info I need to work on my write up.  - NHS Brighton and Hove

Further Information

A full report on the dementia Framework Modelling Tool is available on request from Peter Lacey .

This model has been developed through the sponsorship of the National End of Life Care Programme Team and has received regular input and support from members of the National End of Life Care Programme Board. The model was developed through an engagement process including commissioners and care professionals from health and social care. It has been built using iThink software and is based on national demographic profiles with the potential to be calibrated to local needs. It reflects the best available research and intelligence through active and ongoing links with the lead Public Health Observatory for End of Life Care and ongoing academic research in this area. The workforce element of the modelling has been undertaken in partnership with Skills for Health who have applied their Functional Health Mapping tool to key points on the pathway that have then been able to translate into quantified and costed care and support that changes in response to the overall model dynamics

Method

The model was built using ithink software following analysis of national cause of death data, including age and place of death. There were two engagement processes that dovetailed to produce the overall result. The first involved a wide group of between 30-40 professionals who were involved in three workshops that were used to define the issue, develop the model framework and respond to work undertaken by the consultants on an iterative basis. Between the second and third of these events a smaller engagement process was undertaken to develop detailed workforce requirements at key points on the end of life care pathway.

Context

The National End of Life Care Programme remains a coalition government priority and is the subject of the development of national tariffs for community services. This project was commissioned in this context in order to support commissioners, in partnership with local stakeholders, in understanding and securing an appropriate and needs led service response to the end of life care needs of their local population.

Implementation

The final tool has been developed both as a generic framework tool, available on the National End of Life Care Intelligence Network website, and as having the potential to support local strategy and implementation for end of life care services.

Evaluation

Thank you for sending through the draft report which is very comprehensive and I think not only tells the story of the project but really demonstrates the actual and potential of the model. You have also made what is a complicated subject into a very interesting and easily digestible read.  – Anita Hayes, Deputy Director, National Programme for End of Life Care

Further Information

A full report on the EoLC Framework Modelling Tool is available on request from Peter Lacey .

This modelling project was commissioned by South of Tyne Adult Mental Health Services to find new ways of designing processes to achieve better patient flow, deliver greater care,  raise staff support, and provide better value-for-money for the delivery of mental health services in South Tyneside. The modelling undertaken by Focused-On Ltd.

Method

Modelling work was conducted with a discrete event simulation – FlowModel implement in Extend (ImagineThat Inc)

Staff moved from paper process maps to PC-based PatientFlow planning. Their drawings linked to source data, reference material plus shift profiles, duration (usually defined as a triangular distribution) of value-adding activities and courses of treatment, and identify which staff and facilities are needed.

The focus was on the first 3 Steps:

• Recognition in Primary Care
• Brief Interventions
• Complex Interventions (non-psychotic illnesses)

PatientFlow plans – charting patient pathways in the model:

(click on image to enlarge)

This phase gave everyone a shared-understanding. Clinical staff were reassured by its “fairness” and it engendered both “integrity & respect”. It also provided a good understanding of the therapy skills within the teams.

The resulting simulation FlowModel could then be used to identify and measure likely patient queues and test the impact of organisational changes and the appropriate engagement of services that might be better provided via service level agreements with voluntary sector and other external providers.

(click on image to enlarge)

Implementation

The PatientFlow plans and the simulation FlowModel are being used very succesfully in collaboration by the local commissioner, the lead GP, and providers to build and deploy their ‘dream team’ of therapists in a way that can meet the 50% increase in referrals within approved headcount and budget.

Now, commissioners for adult mental health services across all South of Tyne are taking this work right through to crisis resolution & home treatment and in-patient psychiatric beds

Evaluation

“We have used the PatientFlow Planning software to design and document when and where Therapy Services are going to be delivered as part of our Stepped Care Plan, and this has helped us to secure clinical support at the outset.

We quickly gained a more detailed and more rigorous understanding of which skills and resources were currently available and where the gaps in services were, but this in itself couldn’t help us to plan how to optimise the skills and experience of our Staff alongside external Advisors and Counsellors. We have, therefore, used our PatientFlows and the professional services of ‘Focused On Health’ to design and calibrate a simulation FlowModel which means we can actually see the likely impact of our decisions on the process dynamics.

Now, we can quickly and easily measure the Queues & Wait Times likely to be experienced by Patients and test the expected benefits of sharply focused recruitment, dedicated Service Level Agreements, and investing in our Staff and deploying their new skills for the benefit of our Patients.

With these new tools and our new ways of working, it will be much easier in future to optimise our Local Delivery Plans with the Mental Health Services demanded by local Practised Based Commissioning.  We are confident that extending the PatientFlow and FlowModelling work that we have already done will help South Tyneside NHS Primary Care Trust to improve significantly Patient access to psychological therapies and that greater levels of Care will be sustained through better value for money processes.”
- Terry Prior, Commissioner for Mental Health Services South Tyneside.

Further Information

More information can be found at: www.focused-on.com or contact Steve Burnell.

The Cancer Reform Strategy requires all Breast Screening Services (BSS) to extend the age range of eligible women from 50-70 to 47-73 and that analogue screening machines are upgraded to digital. Eligible women must be invited to screening at least every 36 months.

For the service in Barking, Dagenham, Havering, Redbridge, and Brentwood areas, this would mean a step-increase from 79,000 eligible women to 104,000 in 2010 rising to 117,000 in 2020. This rise is all the more challenging when a service is struggling to maintain its 36-month round-length. On the face of it, the service would need to replace 3 analogue screening machines with 5 new digital ones and significantly increase headcount when other BSS were recruiting scarce resources too.

Method

The project had 3 Phases:

Phase1 of the project was focused on understanding and choosing the most appropriate sites for the mobile and static screening facilities.

(click on image to enlarge)

This required the post codes of 79,000 women across all of the area codes.

The agreed scenario means the King George site will serve Barking & Dagenham Women plus those in the Ilford area; women living in B&D will travel to the Hospital to utilise the increased daily capacity. The other static screening facility will be located at either Victoria or Harold Wood to serve the Romford localities and a single mobile facility will serve Woodford & Brentwood women.

Phase 2 of the project was focused on finding a pragmatic and economic schedule for the next 10 years including age extension (inviting women aged 47 to 73) as of December 2010.

This was particularly challenging due to the service’s past and present need to use its assessment facilities to maintain a 36-month round-length. On the face-of-it, the service would need at least 5 screening machines to replace the existing single mobile & double mobile.

Schedules have been prepared and accepted by the client that require only 3 new facilities; two will be static and operate at 80 invites per day by running extended hours and a single mobile will operate at 58 invites per day by making use of digital technology.

(click on image to enlarge)

These schedules necessitate an interim period (2011) of old + new whilst the service overcomes its legacy problems of stress and agglomeration and moves across to new digital facilities.

This strategy offers a massive cost saving equivalent to 2 digital facilities.

Phase 3 of the project is focused on validating staff availability and includes a simulation model to verify consistent 36 month round-length.

(click on image to enlarge)

The new facilities and extended hours need to be supported by a team of at least 16 WTE (Whole Time Equivalent) radiographers & assistants.

Implementation

“The project had three natural phases: Site Locations, Screening Schedules, and Staffing. However, the combined challenges of age extension, Round-length  and optimal spend is significantly more difficult when using large area codes rather than individual GP Practices as the basis for inviting eligible women.”

“We had to redesign our Scheduling software.”

- Brent Wherry, Technical Director, Focused_On Ltd.

Evaluation

“Focused_On have demonstrated great understanding, patience, and skill in helping us to find a robust solution to a problem that was becoming quite intractable or very expensive. Now, we have a viable plan for success.”

“Commissioners and BHRT can be confident in making the investment choices and resource allocation decisions.”

- Victor Ferreira, Lead Commissioner.

Further Information

More information can be found at: www.focused-on.com/Breasts.html

Prior to and during 2009 pandemic, there was discussion of whether triage protocols should be used to restrict access to critical care to a subgroup of patients. Thought experiments and simple, data-free mathematical modelling were used to stress the importance of a triage process having a clear objective and to highlight the nature and scale of differences there would have to exist between groups of patients before triage could confer benefit.

Context

Initiated prior to the 2009 H1N1 pandemic, this work became a focus of much attention and debate within the paediatric intensive care community during the pandemic. Our work fed directly into guidance issued by Paediatric Intensive Care Society and informed discussions between the professional societies and the Department of Health around the use of critical care resources.

Method

Published protocols for implementing triage to critical care during a pandemic were reviewed and found to lack clarity in terms of the objectives of triage. A model based on insights from queueing theory was devised that allowed estimation of outcomes for systems with and without the use of triage. The model was then used to identify circumstances in which triage conferred net benefit in terms of the number of survivors across the system.

Evaluation

“We undertook a project with CORU to explore triage during a pandemic in the paediatric critically ill population and together, we presented our findings to a large group of UK intensivists in an attempt to develop guidance should demand for PICU outstrip capacity. CORU worked enthusiastically to draw the attention of clinicians to the potential pitfalls in developing triage protocols and they developed a data free model to illustrate the impact of triage. Their findings brought clarity to a difficult debate within the profession and we were impressed by their commitment to help us with this challenge.”

Dr Paula Lister, Consultant Intensivist, Great Ormond Street Hospital

Further Information

For more information : www.ucl.ac.uk/operational-research

Cardiac surgeons faced the problem of how to present surgical outcomes in a way that accounted for differences in case-mix between surgeons or over time. A simple graphical technique was devised, called VLAD. VLAD charts are now used world-wide for a variety of clinical outcomes.

Context

In the mid-1990’s, cardiac surgeons and surgical units were comparing 30-day mortality rates. Some were using a risk model developed by US academic surgeon Parsonnet to ensure fairer comparison with surgeons who took on a less challenging mix of patients. UK Surgeon Tom Treasure asked the Clinical Operational Research Unit at UCL to assist him in developing a way of incorporating such risk-adjustment into the time-series presentation of surgical results.

Method

Operational Researchers sat in on seminars and team meetings at the cardiac surgery unit of St Georges Hospital, immersing themselves in the context of this problem and getting a sense of how the cardiac surgeons responded to different forms of evidence and data. In parallel, the project team went through a process of repeated prototyping before settling on a simple graphical tool for the presentation of risk-adjusted mortality data in a time-series. Essentially, the chart, called a Variable Life Adjusted Display (VLAD) is a running tally of the expected number of deaths minus the actual number deaths, the expected number of deaths calculated using a risk model. Subsequent versions have included colour coding to present exact prediction intervals associated with a sequence of cases (see below) and the use of chronological time rather than case number.

Evaluation

This work continues to be a phenomenal success. VLAD is used by most if not all cardiac surgery units in the UK and by many worldwide. The technique has been adapted to monitor other clinical outcomes such as survival following myocardial infarction, the occurrence of surgical wound infections and neonatal deaths.

Further Information

Can be found at : http://linkinghub.elsevier.com/retrieve/pii/S0140-6736%2897%2906507-0

NHS Grampian wanted to understand the effect that demographic change and new clinical practice would have on the potential demand for CT and MRI scanners over the next 5 and 10 years. They thought they would need to buy new scanners to meet projected demand.

With the cost of a new scanner at around £1m, this is a significant investment in healthcare at a time when budgets are tight. To test when new scanners would be needed, NHS Grampian decided to use the Scenario Generator tool which simulates population use of the health service and can model the impact of increasing demand on existing capacity.

Various “what if” demand scenarios were modelled and showed the varying levels of demand which might need to be met.

The model showed the queues building up when Grampian’s current capacity could no longer cope with the demand.  NHS Grampian found that no additional capacity would be required over the ten year period if the impact of new clinical practice were not taken into account. However when the model factored in clinical processes which will use scanners rather than other procedures, Grampian found that additional capacity would be required at several periods over the ten years to cope with the demand.

The results showed that additional capacity would be needed for CT scans in 3 years, 7 years and 9 years time, and for MRI scans in 5 years, 8years and 10 years time.

However when Grampian tested further scenarios which mirrored the use of the highest performing scanner, they found that for CT scanners, they would still need a new scanner in year 3, but would then be able to manage until year 7. Further, if they increased the utilisation of scanners to 7 days a week, it would be feasible to manage on existing capacity for a further 7 years for both types of scanners.

Evaluation

Scenario Generator has provided Grampian with a means of understanding the effects of forecast increases in demand for scanners on current capacity, and help them understand when and how to invest.

“This project has really helps us understand how to plan to ensure we have both the capacity and finance to meet our patient’s demands. We can really see the potential of using SIMUL8’s software tools to help us plan both investment and disinvestment in the future” – Jillian Evans, Head of Health Intelligence, NHS Grampian.

Further Information

Further Information about Scenario Generator can be found at: www.scenario-generator.com

The population of an East Midlands town is expected to double in the next 10 years, and the PCT wanted to know what health services would be required to meet the needs of the population.  The future of the local hospital was also the subject of debate, so the PCT and the hospital wanted to understand the impact of population growth on any future plans.

The hospital had an A&E department with attendance of fewer than 30,000 a year. One of the questions under consideration was whether the A&E department should be turned into an Urgent Care Centre, dealing with minor injuries only. This posed further questions about what the future purpose of the hospital should be. However, if the local population doubled in size, would this change the decisions about the nature of the hospital?

Method

The PCT used Scenario Generator to model the expected growth of the population as new housing developments were occupied over the next 11 years. The model was validated to ensure that the baseline represented the current pattern of health service use in the town. Particular attention was paid to A&E attendance, admissions and outpatient appointments.

The PCT also considered current outpatient activity in the town, debating the matter in a series of workshops set up to discuss the future of the local hospital. The discussion centred on:

• The volume of A&E attendance at the hospital and whether the A&E department should change to dealing with minor injuries only.
• The potential of bringing back to the hospital outpatient appointments currently dealt with in other hospitals 20 miles away.
• Whether the growing population would make these options more or less viable.

The PCT aimed to use the results from the workshops, data analysis, simulations and modelling to inform a public consultation on the future of the hospital, and to build on the experience to extend modelling and simulation techniques to the PCT’s Strategic Plan.

Results

The results of the population growth modelling showed expected increase and demand and cost for the key areas of service as a result of population growth.

Further Scenario Generator scenarios were run, taking into account the population growth and reducing outpatient appointments carried out in hospital. Results showed that costs to the system could be reduced over time.

Considering these results caused the PCT to think about current outpatient activity in more depth. A potential saving of £2.1 m was identified with the further advantage of saving 11,800 patient journeys to hospitals 20 miles away.

At the same time, further Scenario Generator modelling was carried out to understand the impact of dealing only with minor injuries in the local hospital, and whether the increased population would require additional services. This demonstrated that the additional population would only increase demand on the A&E by a further 8000 patients, which would still not be sufficient to sustain an A&E department.

Evaluation

Simulation and modelling provided the PCT with a means to understand the way in which the town population uses the health service from first point of contact through to more complex forms of heatlhcare.

It enabled them to understand:

• The volume of additional primary care required for the new population.
• The impact of decommissioning outpatients, or delivery outpatient care locally.
• Any cost increases or savings as a result of different scenarios.
• The impact of changing an A&E department to an Urgent Care facility in the context of increasing demand.

Further Information

More information about Scenario Generator can be found at: www.scenario-generator.com

Stockport PCT experienced a rise in GP Referral to Secondary Care from April 2008 which coincided with the introduced of Free Choice in the Choose and Book system. Previously, if a G.P. made a referral to Trauma and Orthopaedics, General Surgery, Dermatology, Urology or Gynecology the Choose & Book system would direct the referral to the local Tier 2 service. In April 2008,’Free choice’ was introduced, which removed this facility and referrals to Tier 2 services fell.  In the first 6 months of 2008/2009 Tier 2 accounted for just 23% of total referrals, compared with 33% for the same period the previous year.

The PCT wanted to understand the effect of a change in demand on waiting times. The initial analysis centered on the Orthopaedic Assessment Service (OAS). Using Scenario Generator, the PCT modelled the contracted flow of activity to determine if it was feasible for all patients to be seen within a 4 weeks period.

Method

The PCT built a pathway to simulate contracted levels of activity at each stage of the patient journey, assuming waiting times of:

• 24 hours from referral to triage
• A minimum of 3 days from triage to the first appointment, with a maximum length of 14 days, but typically 7 days (to give patient reasonable notice to attend)
• 18 days from the first appointment to follow up with a window factored in to allow for assumed diagnostics (CONTRACTED)

The pathway is outlined below:

Results

The results showed that, at the contracted levels of demand and capacity, 97% of patients could be seen within 28 days and 100% of patients could be seen within 37 days.

Evaluation

Simulation and modelling provided the PCT with a means of understanding the flow of patients from referral through to discharge, and the expected time taken during the process. From this position they expect to go on to examine the impact on waiting times if there is further demand on services, if the service is redesigned, or if there are changes to the capacity available in the system. A similar system can also be used to examine other pathways.

“This has helped us to understand current demand and flow, and will enable us to have a more meaningful dialogue with our providers about future contracting arrangements” -  Lisa Maginnis, Analyst, Stockport PCT

Tips for Other Users

“Always start with a simple question first, it will help you define the problem better and focus on the right details to help you get an answer”

Further Information

More information about Scenario Generator can be found at: www.scenario-generator.com