12 minute read
COVID-19: TEST-TRACE-PROTECT IN WALES
COVID-19: TEST-TRACEPROTECT IN WALES
DORIS A. BEHRENS, DANIEL GARTNER, JEFF BROWN, ERYL POWELL, DANIEL WESTWOOD AND IZABELA SPERNAES
CONTACT TRACING IS AN ACKNOWLEDGED STRATEGY to limit the spread of Covid-19 in the community by breaking potential transmission links. In Wales, the Test, Trace, Protect (TTP) strategy includes an approach to testing people with symptoms in the community, tracing those they have come into close contact with, who may be at risk of having the virus, and protecting family, friends and our community by self-isolating. While so-called tracers collect all relevant information from symptomatic people only once, TTP advisors stay connected with (asymptomatic) contacts of Covid-19 cases for up to a fortnight – unless these contacts become cases themselves.
Aneurin Bevan University Health Board (ABUHB) is responsible for all healthcare needs of nearly 650,000 residents across Gwent, an area covering five boroughs in the South-East of Wales, and parts of neighbouring Powys. The Gwent TTP Service (GTTPS) is a collaboration between five Local Authorities (Caerphilly, Blaenau Gwent, Monmouthshire, Newport and Torfaen) and ABUHB.
The GTTPS asked the Modelling Team at ABUHB’s Continuous Improvement Centre (ABCi) to develop a tool assisting long-run workforce planning. It was intended that this tool would ensure that the GTTPS would better understand and anticipate workforce demand through autumn and winter 2020/21 to allow timely recruiting and training of contact tracers and advisors.
COPRODUCING A DECISION-SUPPORT TOOL Informed by intensive discussions and continuous adaption to the GTTPS’s needs, an Excel tool ‘translating’ the forecasted number of Covid-19 cases into workforce requirements was jointly developed. A screenshot of the tool can be seen in Figure 1. The expected (weekly) numbers of tracers and advisors (needed to turn around 99.9% of all service requests in 24hours) were expressed in whole-time equivalents (WTE). The user must identify the following information before running the tool: ‘Utilisation of Service (in %)’, ‘Baseline number of contacts per case’, ‘Average length of tracer call’, ‘Average length of first advisor call’, ‘Average length of contact follow-up advisor calls’, ‘Effective weekly working hours’ and ‘Proportion of contacts opting in for a follow-up call’. Some of these parameters are included as stationary values, others as time series, like the number of contacts per case.
All parameter values were initially calibrated based on expert opinion/ experience and updated continuously, guided by the GTTPS’s observations. For example, around 65% of contacts preferred to be followed up via phone – not via text message. The number of contacts per case varied substantially. It came down from 6 to 7 in summer 2020 to a median of 1.9 through autumn 2020, dwindling to 1.4 since Wales went into lockdown on 20th December 2020. Also, for every four people hired to work fulltime (37.5hours per week), a fifth person accounts for all sick leave, annual leave, etc. This results in a WTE ratio of 1.25. In other words, if a person is employed to work 37.5hours full-time, the time effective for workforce planning is equal to 30hours.
ENABLING DIALOGUE AND INFORMED DECISIONS The number of positive cases can be entered into the TTP Workforce Planning tool to compute the (modelled) number of tracers and advisors over time. These numbers enable decision-makers to come together and test the impact of their assumptions – embodied in parameter choices – on recommendations. The process of how parameters ‘translate’ into the expected workload becomes transparent. Additionally, (automatically updating) charts compare observed and forecasted case numbers. Likewise, the tool visualises modelled staff numbers
FIGURE 1 SCREENSHOT OF GTTPS WORKFORCE TOOL
and those recruited (and planned to be recruited) throughout the pandemic. So far, these visualisations enabled fruitful conversations between members of Local Authorities and ABUHB, mathematicians, epidemiologists, and public health experts−and empowered effective decision-making.
UNDERSTANDING THE PITFALLS OF PLANNING WITH AVERAGES Another issue was made transparent in discussions using the tool. The ‘fuzz-free’ modelling utilising average numbers for strategic planning anticipates implicitly service provision at full capacity. In other words, the recommended workforce size returned by the model can cope with averaged demand, not with peaks in demand. The latter leads to delays, which are highly counterproductive for contact tracing. The tool enabled insightful dialogue about this often-ignored fact. As a way out, the TTP Workforce Planning tool provided the inbuilt functionality to dial down utilisation from 100% to a lower level, e.g. 85%, to also account for training.
COLLABORATING FOR SUCCESS By early February 2021, the strategic Workforce Planning tool had demonstrated the ability to support decision-making for scale-up approaches within the GTTPS. Jonathan Keen, Head of the Coordination Unit for the Gwent Test Trace Protect Service (GTTPS): ‘The TTP Workload model was an invaluable tool to assist the Gwent Test Trace Protect Service to determine the additional recruitment required to deliver contact tracing at a time of increasing case numbers. It provided a clear understanding of the potential trajectory for the number of Covid-19 cases and contacts of cases. It then estimated the workforce required to manage this level of demand effectively. This was used to provide a rationale for the final decision on numbers to be recruited, and therefore for the additional financial cost that was to be incurred’.
The tool has also been able to project staffing ratios (using epidemiological models) required to deliver an effective service for the Gwent communities. Looking into the GTTPS’s future, the tool enables a forward-thinking look of future scale up and scale down approaches for workforce planning that will require utilising different staff ratios as we progress through this pandemic. Doris A. Behrens is a Professor at the Danube University Krems, Austria, and head of the department for Economy and Health. She holds Postdoc positions at Cardiff University and Aneurin Bevan University Health Board.
Daniel Gartner is a Senior Lecturer of Operational Research and a researcher-inresidence at the Aneurin Bevan University Health Board’s Mathematical Modelling Unit.
Jeff Brown is Programme Manager for the Regional Cell Delivery Programme (part of the Gwent Test Trace and Protect Service) and Director of JBPS Advisory Solutions Limited.
Eryl Powell is a Consultant in Public Health for Public Health Wales. During the Covid-19 pandemic she is the lead for the Aneurin Bevan University Health Board Incident Coordination Centre and is the Health Board lead for the Gwent Test Trace Protect Service.
Daniel Westwood, Senior Project Manager within Aneurin Bevan Health Board for the Test, Trace and Protect Programme is based at the Aneurin Bevan University Health Board Incident Coordination Centre.
Izabela Spernaes is a service lead for the Mathematical Modelling team within the Aneurin Bevan Continuous Improvement team (ABCi). As part of this role, she is raising the awareness of modelling in the health board.
O.R. SUPPORT FOR PLANNING UNDER UNCERTAINTY
Nicola Morrill
‘We need diversity of thought in the world to face new challenges’ Tim Berners-Lee
I thought it would be useful, given the current climate we all find ourselves in, to share with you the role that Operational Research (O.R.) has to play in supporting planning in uncertain times.
I understand that there is a school of thought that would argue against planning when everything is so changeable: I subscribe to a different view. I accept that most plans ‘don’t survive contact’ but believe the value lies in the process of planning. The richer the common understanding is of a situation, how it could evolve and how different options could play out, the more able organisations will be able to adapt in, hopefully, a timely manner.
VUCA AS A TOOL FOR THINKING There are many different ways to think about uncertainty and the different forms it can take. In business, VUCA is an increasingly used phrase. It refers to a situation that is volatile, uncertain, complex and ambiguous. Sounds pretty relevant to life with COVID-19!
Table 1 provides a brief description of what is meant by the terms.
Figure 1, of the four dimensions of VUCA (taken from http://bit.ly/VUCAarticle with permission of Jeroen Kraaijenbrink), provides a visual representation of each of these characteristics in isolation, i.e. a purely volatile (but not uncertain, complex or ambiguous) world, there is a lot of fast, but predictable change. It is likely that the VUCA dimensions do not happen in isolation of each other.
DEALING WITH VUCA VUCA means that plans are highly subject to change. The balance of effort perhaps needs to shift between creating the plan (less time) and testing and understanding the plan in a range of contexts (more time).
Volatility
Uncertainty
Complexity
Ambiguity BRIEF DESCRIPTION The nature, speed, volume and magnitude of change is not predictable, causing consistent turbulence. Lack of predictability in issues and events make it difficult to see future outcomes or make decisions. Many difficult to understand and interconnected variables Lack of clarity behind causes of what is happening – lots of ‘unknowns unknowns’
TABLE 1 VUCA DESCRIPTION
FIGURE 1 THE FOUR DIMENSIONS OF VUCA © Jeroen Kraaijenbrink
There is a lot of guidance and suggestions out there about how to deal with a VUCA situation, including VUCA Prime. Summing the key points from the material I found:
• Volatility – Manage it. Build in slack. Create a vision. • Uncertainty – Navigate it. Increase understanding.
Collect and share information. • Complexity – Reduce it. Bring clarity. • Ambiguity – Bring clarity. Experiment. Understand cause and effect. Be agile.
A key theme is about improving understanding of the situation.
HOW CAN O.R. HELP? O.R. is a broad discipline with a huge range of tools used to assist decision makers. Many of these are relevant in VUCA and more than I have space to cover. I highlight a few areas that will assist in the suggestions of how to deal with VUCA, particularly aiding understanding and exploration of a situation.
Problem structuring methods (PSMs) PSMs refer to a whole host of methods that seek to support situations characterised by uncertainty, conflict and complexity; pretty ideal for use in a VUCA world. They apply modelling approaches, normally in a group setting, to help structure a problem and improve understanding of the situation and the dynamics, rather than to directly find a solution. This ranges from drawing a (rich) picture to represent views of the situation, identifying and exploring stakeholder interests through to more complex modelling. The level of expertise required for each different.
Systems modelling Systems models are representations of socio-technical systems that aim to improve understanding of a situation, helping to identify problems and supporting planning. These range from diagrams at one end of a spectrum through to quantitative representations of a situation.
Figure 2 is from an article in The Lancet on a systems approach to preventing and responding to COVID-19 (http://bit.ly/SystemDiagram). It is an example of a systems diagram, which highlights key factors (from the perspective of the model creators) influencing the management of
FIGURE 2 SYSTEMS DIAGRAM ILLUSTRATING SOME OF THE COMPONENTS IN RESPONSE TO THE COVID-19 THREAT
COVID-19. Words at the base of an arrow influence the words at the head of the arrow, either in a negative of positive way. This starts to build a rich understanding of the situation, possible areas for influence and the likely impact of these. See also the article on System Dynamics in this issue.
Foresight – scenario planning An increasingly commonly used approach is that of scenario planning, which helps explore what the future could look like. There are a range of methods that are available to create scenarios and these are widely written about. Scenarios are not predictive tools but provide support to planning by, for instance, providing insights into the key drivers of a situation and surfacing assumptions that may be being made. Scenarios are a particularly useful tool to use in a high uncertain situation where a range of futures, some that many may think are unlikely, can be articulated and their potential impacts explored.
Some questions organisations are using scenarios to explore just now are:
• What might COVID-19 mean for the world this decade? [Shell] • What will the internet be like in 2025? [Cisco] • How could tourism potentially evolve over the next 18 to 24 months? [Tourist Board]
A growing area of O.R., behavioural O.R., aims to explore and understand the role and impact of behaviour in O.R. work. The O.R. community has much more information on the areas mentioned above and more - whether that be case studies, training or further development of the areas mentioned. ensure diversity of thought; in a VUCA situation it is key!
While experience absolutely has its place, it should not be the only voice. Hearing from an alternative perspective could very well highlight a whole new way of doing things or an innovative way to address a current challenge. There is much evidence of the business benefit it brings.
So, if you are not able to immediately access some of the tools that can assist in planning in a VUCA environment, one thing you can do is ensure there is a diverse range of voices involved in the planning you are undertaking. Make sure you have that fresh perspective and welcome the challenge – it will help ensure that you have a resilient plan able to adjust.
WANT TO LEARN MORE? If there is something, related to O.R., that you would like me to consider for my next ‘column’ in Impact then please get in touch. I’ll be pondering what to write about over the coming months…. The goal is to share the discipline with users/ potential users of O.R. by highlighting how it could support ‘business’ challenges they may be facing.
In the meantime, I’ll leave you with a quote I like from Albert Einstein ‘Assumptions are made, and most assumptions are wrong’.
INCLUDING A DIVERSE RANGE OF VOICES IS ESSENTIAL Most of the tools that can help with VUCA, particularly increase understanding of the situation, are participatory and interactive in nature. While it is always good to Nicola Morrill is a Systems Thinking Consultant at Dstl, a certified coach and the current Diversity Champion of the O.R. Society. She writes in a private capacity – all views expressed are her own and all examples are available in the open domain. You can contact her on Nicola.impact@gmail.com
