Posts Tagged ‘objectives’

Let’s take a look at how week-by-week profiling can help acute providers with winter pressures. We want to maximise capacity utilisation, and minimise the risk of bed crises, cancellations, and 18-week breaches.

We’ll take it in two stages:

1) Preparing for winter: We will look at how emergency and urgent elective demand are likely to vary, week by week, through the winter; then plan routine elective work around the peaks.

2) During winter: As each winter week goes by, we’ll update this profile with outturn demand and activity, so that our plans for the rest of winter can adapt rapidly and continuously to unfolding events.

Preparing for winter

Nobody knows exactly how winter is going to turn out, so we need to make some reasonable assumptions about how much demand is likely to come in, and how it will vary week by week. A good place to start is by looking at what happened last year or, even better, the last three years, and then adjust it for anything else we know is going to happen.

Armed with this information, we’re ready to start working on our plan. Because we’re focusing on the profiles during winter, let’s assume we have already run our strategic plan for the coming months (based on achieving 18 weeks, or filling the available capacity, or whatever scenario we chose). So we have already worked out the overall demand, activity, and capacity for this future period, as well as the waiting list and waiting times we want to end up with. If our dataset already includes demand and activity profiles then we don’t need any more data and can go straight into the week-by-week profiling.

In this worked example the screenshots are taken from Gooroo Planner, where the Profiling screen looks like this:

The large top chart is the interactive activity profile, and we are going to edit this to reprofile elective surgery around the peaks and troughs in emergency and urgent demand. The large bottom chart is interchangeable by clicking for any of the thumbnails at the bottom, so it can show either activity and urgent/emergency demand, beds, theatres, clinics, or waiting times.

Let’s start by zooming in on the bed profile. We start this analysis using data that is based on last year’s demand profile and last year’s outturn activity profile. We’ve picked a major surgical service, and we’re going to see if we can reprofile it to stay out of trouble over winter.

The blue line shows the the number of beds used by our surgical service, plotted against the left axis, and the straight blue line shows the number of beds notionally allocated to this service. The orange line shows the total beds on our whole hospital site, plotted against the right axis, and again the straight orange line shows the physical on-site bed limit. Clearly, we are heading for trouble in January and February, where the number of beds required is far larger than the number available. Looking at the blue line, we can see that we are making things worse by scheduling so much elective surgery during the winter peak; the “red alerts” we experienced last winter are starting to look disturbingly avoidable.

So let’s start by reducing our plans for elective inpatients during the height of the peak. This is a simple matter of clicking and editing the points on the interactive top chart, to reduce the balance of work profiled during January and February until the editable profile looks like this:

After doing that, we get a bed profile that looks like this:

Much better. But what happens to waiting times as a result of this surgical slow-down? A peek at the waiting times chart reveals this:

The blue line shows waiting times just for the elective inpatient stage of treatment, and the orange line shows the RTT wait for this surgical service: that’s the wait for new outpatients, plus the wait for elective inpatients or daycases (whichever is greater). All waits are on a “90 per cent treated within” basis, so the orange line is comparable with the 18 week target. The bad news is that our waiting list is going to spike over winter, rendering the 18 week target unsustainable for 3 or 4 months.

We don’t want that to happen if we can avoid it. So let’s see if we can front-load some surgery to head off the problem. In real life we would have more than one surgical service to reprofile, but for the sake of this example we’ll try to do it all just with this one. So we’ll crack on with as much elective inpatient surgery as possible over the autumn, then slow down for as short a time as possible to keep beds just nicely full over the winter peak (but not too full – we are working to a target occupancy to allow for in-week fluctuations), and then pick things up again in March to deliver the balance of our planned activity towards the end of the year.

When we’ve finished editing the activity profile, it looks like this:

Now our bed profile looks like this:

That’s fine. Waiting times?

That’s fine too: we’ve front-loaded enough surgery to get the list right down before winter, so that even when it spikes we shouldn’t see any breaches. Then the balance of our planned activity is just right to bring us in on target for year end. (In a real hospital you would have several surgical services to play with, rather than just one, so this example is on the extreme side to illustrate the principle.)

That’s our profile done, then, from the comfort of late summer / early autumn. What are we going to do once the snow starts to fall?

Reacting to events during winter

Fast-forward to late January, and it’s cold. Emergency admissions shot up when the GP surgeries reopened after New Year; nothing unusual in that. But last week it shot up again and we had to cancel surgery. How does this affect our plan?

The first thing to consider is this: does this spike mean that the total amount of demand has gone up, or might this peak be balanced by troughs later on? Frankly, who knows? Overall the external demand for healthcare rises stepwise every few years, and if demand happens to have gone up just in the last week then that may mean something, or nothing. If you want to add an extra chunk of demand to your forecast then that is easily done but, if the end result is forecasts that are more volatile but no more accurate, then what is the benefit? Ultimately it’s your call, but a compromise position might be to update the demand forecast every month, not every week, to smooth the volatility out a bit.

On the basis of a week’s worth of data, then, let’s assume it’s a wobble in the profile not an uptick in total demand. We also have outturn data on the activity we delivered for electives, as well as emergencies. So let’s update both our demand profile and our activity profile with the latest week’s data and see where we stand now.

The loss of surgery means that we are now heading for a 21 week RTT wait at the peak in mid-March, whereas before we were expecting to peak at 18 weeks. Perhaps we should have allowed a bit more margin for error in our original plan. However if our assumption about demand (that this spike is likely to be offset by less demand at other times) is correct, then we should have capacity to bring in the displaced patients over the coming weeks to restore the position, as the revised bed profile shows.

And so it goes, week by week, month by month, until the days start to lengthen again. Forecasting demand is not an exact science, especially at a week-by-week level of detail, so our plans for winter are always going to have a large amount of guesswork mixed in with the logic.

In this worked example, January’s spike in demand caused problems with cancellations and the risk of waiting times breaches. That kind of thing is a risk unless we can provide a more substantial buffer in capacity (e.g. in the form of lower bed occupancy) to absorb the variation. Nevertheless, in this example we were in a much better position than we had been the year before, when we had been galloping merrily towards a severe, prolonged, and utterly predictable bed crisis before the winter had even begun.

This worked example was illustrated using Gooroo Planner with integrated week-by-week profiling; you can see a slideshow version of it here. If you are already using Gooroo Planner then profiling is available to you now: look for the profiling button at the top of the Reports view page. If you aren’t using Gooroo Planner already, and would like to take a look, then email info@nhsgooroo.co.uk for a free on-site demo.

It isn’t a trick question. Surely any major public service should have high-level objectives? Especially one that has been around for half a century and spends £100 billion a year.

But does it?

If you go to the NHS website you will find “core principles”, not objectives as such. When the NHS was founded in 1948 they were:

• That it meet the needs of everyone
• That it be free at the point of delivery
• That it be based on clinical need, not ability to pay

In 2000 these were extended by the Labour Government of the day to:

• The NHS will provide a comprehensive range of services
• The NHS will shape its services around the needs and preferences of individual patients, their families and their carers
• The NHS will respond to the different needs of different populations
• The NHS will improve the quality of services and minimise errors
• The NHS will support and value its staff
• Public funds for healthcare will be devoted solely to NHS patients
• The NHS will work with others to ensure a seamless service for patients
• The NHS will help to keep people healthy and reduce health inequalities
• The NHS will respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

We can tell that these are principles, rather than objectives, by asking ourselves a simple question: could we tell if the NHS failed to achieve them? The answer is: not easily.

In 2010 the same Government published the NHS Constitution, which contains “Seven key principles”, “underpinned by core NHS values”. Although there are overlaps, they are different from the core principles listed above. The Constitution principles were:

1. The NHS provides a comprehensive service, available to all
2. Access to NHS services is based on clinical need, not an individual’s ability to pay
3. The NHS aspires to the highest standards of excellence and professionalism
4. NHS services must reflect the needs and preferences of patients, their families and their carers
5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population
6. The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources
7. The NHS is accountable to the public, communities and patients that it serves

… and the core NHS values were:

• Respect and dignity
• Commitment to quality of care
• Compassion
• Improving lives
• Working together for patients
• Everyone counts

Hmm. We aren’t any closer to something crunchy. What about the more operational guidance produced by the NHS? Does the annual operating framework contain any objectives?

Indeed it does. The current operating framework contains 18 “existing commitments”, for example:

A maximum wait of one month from diagnosis to treatment for all cancers”

and 63 national “vital signs” in three tiers of priority, for example:

NHS Breast Cancer Screening Programme will be extended to all women aged 47–73 by 2012

Much crunchier, but suddenly we’re deep into the detail. These are really sub-objectives created on the basis that, if you achieve them, then they will contribute to your overall objectives. The operating framework does direct us to the 5-year plan for the NHS which “set out a five year vision for the NHS and should be read in conjunction with this NHS Operating Framework which operationalises the first year of that vision”… and so we are straight back to the “vision” again without finding any high-level objectives in between.

Is there anywhere else we could look? How about the legislation that governs the NHS, now consolidated into the NHS Act 2006. Its opening clauses say:

The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of illness.

…which has several qualifications in it, but could become an objective by changing the first line to: “The objective of the NHS is to secure improvement—”. Add an objective to spend within budget, and to secure local political agreement before making changes to services, and we are starting to build something like high-level objectives for the NHS.

Other areas of life have objectives. For a business it might be “maximising owner value over the long term by selling goods or services” (Sternberg); carefully worded, requiring plenty of sub-objectives to make it happen, but a high-level objective nonetheless.

It seems the NHS has chosen not to define its high-level objectives, preferring to leave a wide gap between vision and detail. Which leads us to the next question. Why?