Despite real improvements in performance against waiting list and waiting time standards in recent years, it is clear that the NHS faces a challenge in coping with the growing pressure of an increased demand for its services.
We also know that during this period of financial constraint, the system is spending significant extra amounts, for example, on private providers, waiting list initiatives at premium rates and opening unbudgeted ‘escalation’ beds at premium cost.
Even more importantly, where these short-term unplanned decisions are made, it is not always possible to create extra capacity, meaning that those in need of care may not receive it.
Better demand and capacity planning is essential to support improved decision-making and use of valuable resources. Although solving such complex challenges will require more than a single technical solution, I firmly believe that if demand and capacity flows are better understood and analysed, some of this extra expenditure could be reduced.
Understanding your business
Businesses use ever more sophisticated predictive analytics to manage demand and capacity and this is an opportunity we are increasingly exploring in healthcare.
In the NHS we often claim we are different, especially in emergency care. We are partly driven by the variety that arrives at the front door and you can’t just turn it away. The risk this creates is that we give up on planning and just deal with it as it arrives.
Although it is not known, for example, if someone is going to have a car accident, our best planning providers increasingly do predict how many patients will come through in any particular week, day, and even hour.
On the elective side, there are reasonably robust forward plans for referrals into providers by specialty, which can be modelled through to predicted theatre, cancer pathway or diagnostic demand.
I suggest what we have failed to do is uniformly equip operational managers and clinicians with the skills and knowledge, and increasingly the time, to use that information to best plan their service delivery. That’s the overarching challenge – how can we possibly sufficiently match demand and capacity if we don’t spend enough time analysing and understanding it?
Managing demand and capacity in local NHS services
At its most simple, a consultant and service manager in a small outpatient specialty should be able to analyse pretty quickly and accurately how many new and follow up outpatients can be seen. Then, after comparing with referral predictions and looking at patients already waiting, the scale of the challenge to ‘clear the backlog’ and recurrently meet the demand can be identified and solutions worked through.
In my experience, sometimes services have the capacity, but they’ve misaligned it with too many new patient slots and not enough follow-ups or vice versa, and a re-profiling of clinic templates, rather than buying new capacity, is the solution. Now, more than ever, we need to be smarter at using the capacity we already have.
At the more complicated end of planning, services are competing for shared resources such as theatres and beds while, for all but a few ring-fenced areas, the strain services are under to meet emergency care needs means planning for elective demand – with ever-squeezed capacity.
At this level of complexity, it’s best to use a standardised approach across services drawing on organisation-wide expertise, as well as operational teams, to model how things interrelate.
Commissioning on a local and regional level
To effectively commission care, clinical commissioning groups need to identify demand for services, taking into account peaks and troughs and seasonal pressures. They can then assess where local providers are able to offer the required capacity and when they might need to access additional capacity.
Sustainability and transformation partnerships
Sustainability and transformation plans bring a new dimension to commissioning, as STP footprints may drive demand and capacity planning across a much broader area.
So understanding demand and capacity when commissioners and providers are jointly looking at issues and making significant decisions is key. They are not just looking at whether a few more staff or clinic slots are needed, but whether we need to expand or close a service? Do we build new hospitals? Coming to the wrong solutions could be very costly.
Equipping local NHS services to manage demand and capacity more effectively
My conversations with people in the NHS and consultancies working for it, reinforces my view that people haven’t been supported with some of the core management skills they need.
I would say we have rightly focused on leadership over the years, but maybe at the expense of good management. One, and only one, of the core areas we haven’t yet tackled is demand and capacity management.
The National Demand and Capacity Programme, sponsored by NHS Improvement and NHS England, was set up last year to help local NHS services develop their own skills and knowledge to manage demand and capacity more effectively, rather than having to rely on outside (sometimes expensive) help.
It includes a free Trainer Programme with six modules. Aimed at operational staff, it will create a pool of 300-400 trainers over three years embedded in local health systems, who will be able to cascade training and support within their organisations.
It will support local operational demand and capacity planning, on a service and organisational level, which will feed into annual activity and STP planning.
The programme also includes demand and capacity models which can be adapted for local use and stakeholder events for those commissioning and managing services.
We need to ensure core operational skills are embedded in our services. Through the Demand and Capacity Programme we will support the building of capability and capacity where it is best delivered, rather than having a large central team. We want to build a cohort of local managers, skilled in demand and capacity planning, who in turn will upskill others in their organisation.
Adam Sewell-Jones has been executive director of improvement at NHS Improvement since April 2016, when responsibilities were transferred from Monitor, the healthcare sector regulator where he was executive director of provider sustainability. NHS Improvement is a joint sponsor with NHS England of the NHS’s Demand and Capacity Programme.