The use of modelling to try out different approaches in urgent care offers a safe and inexpensive way to find and implement sustainable solutions for the NHS, says Terry Young
Tackling the current NHS crisis in urgent care is a delicate process because so many critical services flow through the emergency department and so many confounding factors impact, often indirectly, on it. Changes in the relationship between GPs and hospitals, for instance, or very small increases in long-stay populations quickly develop into unacceptable waiting and overcrowding in emergency departments and acute medical units.
‘We want NHS England to require every significant service or infrastructural change to be modelled in advance’
A sustainable solution requires a new way for the many care sectors and health professionals to collaborate – from primary care, hospitals, social care and community based care, as well as commissioners and, of course, patients themselves. This is the route to the right response that brings everyone on board. Then, they need to “work the ‘problem’ together”, testing out options in a safe environment where mistakes can be made without hurting patients or staff or costing a fortune.
Emergency Simulation − How modelling is resuscitating NHS Urgent and Unscheduled Care, published by the Cumberland Initiative academic group, shows just how this can and is being done by NHS pioneers, who are using modelling to test drive different approaches.
It shows how modelling provides a safe, inexpensive way to try new methods, uniting the many stakeholders needed to find and implement sustainable solutions. It challenges the government to take a much more systematic approach − we want NHS England to require every significant service or infrastructural change to be modelled in advance.
What can be achieved?
The Royal Free London Foundation Trust had embarked on planning for a new emergency department when local reconfiguration in London meant that the emergency department would need to manage additional patients from rerouted ambulances. The big question was: “Will the new emergency department cope with additional demand − when will it fall over?”
So the trust used simulation to model existing and increased activities through the new department to test whether it would still be fit for purpose. The simulation was also used to understand the expected change in flow through the emergency department and the likely impact on beds. The simulation assured all concerned that the department would manage the demand expected. The Royal Free is now also simulating its elective and acute bed capacity requirements (and optimised elective schedules) and plans to simulate its operating theatres and outpatients.
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Kate Slemeck, executive director of operations at the trust, explains: “Simulation has allowed us to understand how patients flow through the hospital and to test our improvement ideas before implementation. We have great manager and clinician engagement and more confidence in our decisions.”
In Cardiff, Julie Vile is part of the first generation of modellers to be embedded in the NHS at the Aneurin Bevan Health Board. She is modelling the impact of dealing in different ways with elderly and frail patients who account for most of the health board’s increase in demand for accident and emergency services. She also wants to model introduction of handheld monitors and virtual wards to focus people’s attention on those patients who are occupying a bed who should be cared for elsewhere.
‘Simulation has allowed us to understand how patients flow through the hospital and to test our improvement ideas before implementation’
“Mathematical modelling could also be used to help hospitals to manage elective arrivals and discharges,” explains Dr Vile. “I hope to show that, if consultants began working at 8am daily, as they do in the clinical decision unit, instead of 9am, this could lead to earlier patient discharges and reduce overcrowding in A&E. I also want to model ways in which wards could take some responsibility and share the risk when a hospital reaches high levels of escalation. So we could look at wards simply taking on one extra patient each in a temporary bed or trolley to ‘board’ them. This typically encourages ward staff to discharge patients as quickly as possible.”
Case for change
Danny Antebi, director of continuous improvement at the Aneurin Bevan Health Board, adds: “Making the case for change needs the right data, the capacity to win hearts and minds and an assurance of patient safety. Modelling is helping us to make the case.”
Modellers have also been working on ambulance services in Wales, which until recently had the worst response times in the UK. Using a mathematically based forecasting technique, they were able to predict ambulance demand for the next week within 2 per cent accuracy, allowing optimisation of shift patterns and rosters.
“We demonstrated that the service did not necessarily need to buy more ambulances,” says Vincent Knight of Cardiff University’s school of mathematics. “We showed that if ambulances could achieve the 20 minute turnaround [which was not always possible], it’s as effective as making more ambulances available.”
Modelling has shown that the best way to reduce bed occupancy and improve emergency and unscheduled care in Nottingham was neither early discharge nor separating majors from minors in the emergency department, but via measures to keep elderly patients out of hospital.
“Such modelling allows hospitals − faced with a raft of potential improvement strategies − to focus their energy first on the big wins,” explains Sally Brailsford of Southampton University, who led the modelling team.
Andrew Fordyce is a consultant oral and maxillofacial surgeon and clinical systems engineer at Torbay Hospital in Devon. Faced with a proposal that the hospital should close beds alongside some medical divisional changes to reduce length of stay, he decided to use to modelling. He explains: “The finance people could see the complexities of what resulted from the changes and said: ‘We can’t go ahead with the closures.’ The clinicians were relieved and the exercise showed in a clear light to all present that we need to rethink our plans.”
‘We should not be surprised by these findings. Nobody would design a smartphone or an airport without modelling capacity’
Modelling has recently given managers in Lincolnshire the confidence to invest in a GP presence in A&E, to create intermediate care and to close acute beds. Simulation is being used to develop innovative funding mechanisms supporting integrated health and social care for people with long term conditions.
We should not be surprised by these findings. Nobody would design a smartphone or an airport without modelling capacity. It looks increasingly strange that so many people believe that we can roll out health measures on the basis of intuition and past experience.
Across industry, the general rule is that uncertainty costs us; so commerce, aerospace and the military invest heavily in managing risk and creating viable options in the event of difficulties. They do this with modelling and other statistical methods, making predictions and planning against adverse conditions or unintended consequences.
The Cumberland Initiative has built a network of pioneering clinicians, managers, modellers, academics and industry specialists to develop a holistic approach to healthcare problems, and explore the interconnections of the whole system, using modelling. The benefits of our approach are being felt on the ground and the applications are making a difference in the current urgent care crisis.
However, the political and policy leadership continues to fall down, failing to make the most of its insights across the system, particularly during a dangerous winter for the NHS.
Terry Young is professor of healthcare systems at Brunel University and co-founder of the Cumberland Initiative