HEALTHY O.R. IN WALES

PAUL HARPER

THE DEMAND FOR HEALTHCARE SERVICES in the UK continues to increase and the deficit between supply and demand proves to be economically costly and typically has a detrimental impact on factors such as waiting times, quality of care, NHS staff morale and patient satisfaction. From an O.R. perspective, healthcare systems are stochastic in nature; that is, they typically operate in an environment of uncertainty and variability, both at scale and within highly complex and connected networks. For example, imagine planning and managing the services in a large hospital, both operationally (on a day to day basis) and more strategically to plan ahead. Hundreds of patients may expect to pass through different care pathways each day, each with varying resource needs required in an efficient and effective manner. Help is needed to forecast demand, schedule clinics, calculate the workforce size and skill-mix needed, and to roster staff. Furthermore decisions must be made on how best to schedule operating theatres and assign them to surgeons, how to reduce waiting times and cancellations within budgetary constraints, improve health outcomes, and make decisions on where to locate services geographically to ensure equitable coverage or the ability to reach patients within a critical time limit.

But the hospital is just one part a much larger connected healthcare system. What happens here is

influenced by, and influences, policy decisions within primary care and GPs, community care, social care, preventive care services and public health for example. Whilst the NHS is in many places working hard to improve services, one might reflect that it is typically carried out in silos that don’t consider the wider system view, so changes in one part might actually have an unintended and undesired impact elsewhere.

Seemingly, given such immense pressures on services and current levels of funding, the NHS and indeed healthcare systems globally, therefore can’t simply do more of the same if it is to be sustainable. Staff are already working incredibly hard and the system is mostly at full capacity, but perhaps the NHS can try and work smarter with the help of O.R. With O.R. methods we can build mathematical and simulation-based models of current processes and use them to explore “what if?” scenarios to evaluate the likely consequence of different ways of working whilst incorporating the stochasticity and complexity, and move towards optimally configured services. This is much safer than experimenting with changes to the system for real and seeing what happens.

Staff are already working incredibly hard and the system is mostly at full capacity, but perhaps the NHS can try and work smarter with the help of O.R.

THE HEALTHCARE MODELLING CENTRE CYMRU The Health Modelling Centre Cymru (hmc2) is helping to create impact through an on-going dialogue between modellers, clinicians and NHS managers, encouraging them to engage, innovate and test alternatives using O.R. methods, and to train NHS employees themselves in O.R. tools.

One novel initiative of hmc2 was the creation of a researchers in residence programme in partnership with the Aneurin Bevan University Health Board (ABUHB). The modelling unit sits within ABCi (Aneurin Bevan Continuous Improvement) and currently consists of four O.R. modellers who are the first of a new generation of modellers to be embedded within the NHS Wales. Joint funding between the University and ABCi allowed the permanent appointment of Dr Gartner as the ‘Aneurin Bevan Senior Lecturer in O.R.’, helping to cement the relationship and strategic partnership between the two organisations. Joint working agreements allow the team to operate from office space at both the University and in the Health Board. ABCi also has matchfunded several PhD studentships and has hosted to-date 30 MSc student summer research projects.

ABCi exists to help and support clinical teams to improve the safety, quality and efficiency of care they deliver with a strong focus on patient experience. The unique opportunity to be embedded within this team brings numerous benefits to the O.R. analysts: not only are they directly linked with improvement coaches, financial planners, senior managers and clinicians, but they are regarded by NHS staff as ‘colleagues’, giving them access to a wide range of opportunities to pioneer novel modelling techniques within the NHS. The team also works closely alongside the Information Department. The ability to speedily provide the necessary data has been key in allowing the modellers to progress their analyses and deliver results at pace. The modelling unit is making a significant contribution impacting on the efficiency, effectiveness and quality of healthcare provided by ABUHB to a population of nearly 650,000.

the O.R. analysts are regarded by NHS staff as ‘colleagues’, giving them access to a wide range of opportunities to pioneer novel modelling techniques within the NHS

A WIDE VARIETY OF APPLICATION Over the past six years since its launch, the appetite for modelling across the Health Board has by far exceeded expectations and the team receives enquiries from across the full range of functions and specialities in the health board: clinical and support services; primary, community, and hospital based. A range of O.R. techniques have been used to approach the problems such as forecasting, demand and capacity planning, simulation, optimisation, and scheduling. Some of the projects commissioned from the team in which modelling tools have been applied include: • Supporting the design of a new £350M hospital build; • Modelling the dynamics of day surgery flow and clinic flow at Royal

Gwent Hospital; • Analysing the effect of individuals presenting in A&E under the influence of alcohol; • Designing an innovative tool to support caseload management for

Mental Health Teams;

Evaluating the impact of Frailty Teams on emergency presentations and admissions; Investing the effects of changing the shift patterns of staff in a Pathology Laboratory; Modelling workforce requirements for digitisation of health records; Modelling patient flow in Fracture and Orthopaedic clinics.

The successful results of these projects have enabled senior managers and clinicians to recognise the value of the O.R. approach at ABUHB such that modelling techniques have now truly become an integral part of design and delivery of their services.

A range of O.R. techniques have been used to approach the problems such as forecasting, demand and capacity planning, simulation, optimisation, and scheduling

Judith Paget, ABUHB Chief Executive noted: “The modelling unit’s success has led to better planning for the organisation and better analysis: far better decisions are made as a result of the input of the modellers.” Trish Chalk, Clinical Futures Lead at ABUHB added “This unique and innovative partnership has delivered considerable impact in developing and applying Operational Research methods for improving our NHS services and patient outcomes.”

Alongside research in collaboration with neighbouring Cardiff and Vale University Health Board, and for other NHS partners across the UK, the wider impact of the work has included:

Realising net efficiency gains of £1.6M per year in the emergency department at University Hospital of Wales through improved staff rostering and better use of A&E resources; Redesign and optimisation of mental health caseloads resulting in improved health outcomes for severely mentally ill adults across South Wales (measured by a reduction in the Adult Camberwell Assessment of Need

(CANSAS) per patient by an average of 51%, reduced time off work due to severe mental health episodes by 65% and a reduction in the number of crisis admissions by 66%) and avoiding ineffective and unnecessary acute hospital admissions by 79% with associated annual cost savings of £7.3 million. Demand and capacity modelling to inform the introduction of the NHS Wales national 111 telephone helpline for people needing urgent healthcare advice out-of-hours, resulting in improved patient experiences and a reduction of 26% in ambulance journeys; Reducing the mortality of trauma patients across South London by 54% and stroke patients by 60%, through the creation of a new facilities and urgent care processes designed using mathematical models; Optimising master surgical schedules for operating theatres across several NHS hospitals resulting in annual cost savings of £0.9 million that have been re-invested into other vital patient care services. Providing modelling support for Welsh Government’s decision to implement a Single Cancer Pathway for all patients in Wales, thus becoming the first UK nation to introduce a single waiting time target. Our research quantified the necessary resourcing levels and additional funding required for implementation that was subsequently announced by the Cabinet Secretary for Health and Social Services. Provision of hospital capacity planning tools in use across the UK. This unique and innovative partnership has delivered considerable impact in developing and applying Operational Research methods for improving our NHS services and patient outcomes

This work has been disseminated nationally and internationally, in the media and at a range of events designed to engage the public with O.R. The Cardiff University team have received several awards in recognition of their innovative approach and real-world impact, including a Times Higher Education (THE) award for ‘Outstanding Contribution to Innovation and Technology’.

RESPONDING TO COVID-19 The value of O.R. and benefits of our close partnership with NHS Wales were again evident as the COVID-19 crisis hit the U.K. Members of the modelling team were immediately deployed to help with initial demand and capacity planning and logistics for vital local resources, as the virus threatened to overwhelm the healthcare services. In fact, early on in the crisis, the Gwent region (served by the ABUHB) had one of the highest rates of infection anywhere in the UK. O.R. has been instrumental in the planning for the Grange University Hospital just outside Newport, a new 560 bed specialist and critical care centre due to open in 2021. Thanks to a herculean effort, the hospital was partially opened (some 350 beds) almost a year early to provide vital extra beds through the coronavirus outbreak. Other responses made by the modelling team included exploration of mass testing logistics, and discussions with the Chief Scientific Office for Wales on the economic impact of the mitigation phase and probabilistic modelling with non-homogeneity considerations to estimate the predicted number of cases and assessment of intervention strategies.

TRAINING IN HEALTHCARE MODELLING The team has developed a set of training courses in healthcare modelling in conjunction with the PenCHORD Group at Exeter University. These are aimed at NHS staff who wish to learn more about how O.R. modelling can help with their improvement projects, but also for those keen to develop their own skills. A number of successful training programmes have run over several years, including one-day workshops on Data Analysis in Excel, Presenting and Displaying Data, Systems Thinking in Healthcare, and Essential Statistics in Healthcare. To-date, in collaboration with the NHS Delivery Unit, more than 350 NHS Wales staff have attended these training courses.

More recently the modelling unit have introduced a Modelling Fellows programme. During the first cohort of six members of health board staff who had chosen to undertake an ABCi Modelling Fellowship, we taught a number of O.R. skills and techniques to develop their own projects. These included the potential impact of additional pharmacy and therapies staff in the emergency department, modelling optimal nursing ratios for pressure ulcer prevention, forecasting scheduled care demand and the development of a decision support

tool to assist with elective orthopaedic scheduling. These training courses lead onto the possibility of a part-time MSc study in O.R. and Applied Statistics at Cardiff University.

“The ABCi mathematical modelling team delivered interactive teaching across the course and were

extremely engaging and supportive,” said one of the first cohort of modelling fellows, Emma-Jayne. “I have a greater understanding and appreciation of mathematical and O.R. modelling and the vital resource it can be to support therapy services in everyday planning, quality improvement and future service design.” She also outlined how her new skills are benefiting her in the workplace: “I am currently applying the learning to current practice, looking at forecasting seasonality for front door therapies and modelling follow up variation.”

Paul Harper, Professor of O.R. in the School of Mathematics, Cardiff University, is the director of the Health Modelling Centre Cymru and of the Cardiff University Data Innovation Research Institute. He is a Fellow of the Learned Society of Wales (FLSW), a Companion of the O.R. Society and has been appointed as member of sub-panel 10 Mathematical Sciences for the Research Excellence Framework (REF) 2021.