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Scoping the Future (CRUK)The Strategy Unit was a partner in this project, led by the Health Services Management Centre at the University of Birmingham. The project was commissioned by Cancer Research UK to understand the capacity of endoscopy services to meet growing demand. The work included evidence collation, qualitative interviews with staff managing and delivering endoscopy services across England, quantitative modelling and analysis and triangulation of all the findings to make a series of recommendations. The findings were shared with the Independent Cancer Taskforce to inform the recently published cancer strategy.
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Making the Case for Integrating Mental and Physical Health Care - Full Report.The Strategy Unit, inspired by earlier research published by the Nuffield Trust, has created a ground breaking report for all STPs which investigates in detail the interaction between mental and physical health. The work describes and unpacks the gap between the physical health and life expectancy of those in contact with specialist mental health services and the rest of the population, and examines levels of variation in health care utilisation. ‘Making the Case for Integrating Physical and Mental Health Care’ has been designed to inform greater partnership working within local health economies to drive better health outcomes for patients and improved levels of efficiency. The Black Country STP were the pilot area for this work, and subsequently NHS England commissioned a version of the report for all 44 STPs in England. These STP reports were published via STP leads in May 2017 and have received wide-spread acclaim for their quality, depth and real-world practical relevance. We are particularly enthused by the positive reaction from the clinical community, with lots of examples where our work has helped to catalyse clinically- led service improvement initiatives The reports give STPs bespoke data and analysis, setting out the scope to improve patient care by better integrating mental and physical health services, in line with the ambition set out in the Five Year Forward View for the NHS. They also model potential benefits and opportunities for financial reinvestment from reduced pressure on acute care and elsewhere. Director of the Strategy Unit, Peter Spilsbury, said: “This report is important. Using newly linked national data and novel analysis, it can unpack for each STP area one of the biggest yet least spoken about health gaps facing our society - the gap between the physical health and life expectancy of those in contact with mental health services and the rest of the population.” "Some of the differentials in both health outcomes and health service utilisation are eye opening but we have been able to use these findings (and the summary of the evidence base provided) to begin building a broad coalition of local partners to identify and implement practical changes. I commend it enthusiastically to colleagues as a catalyst for much needed change.” According to the study, men with mental health disorders in England are estimated to live 19 years less than those without. For women this gap is around 16 years and the figures for both can vary substantially between STP localities.
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Evaluation of an Integrated Mental Health Liaison Service (Rapid Assessment Interface and Discharge Service) in Northern IrelandA high proportion of patients treated for physical health conditions also have co-morbid mental health problems; and there is growing acceptance of a need to raise awareness of mental health issues in acute hospitals and improve the experience of care and treatment for this group. In response to such challenges, the Northern Health and Social Care Trust, one of five health and social care trusts in Northern Ireland, introduced a specialised multidisciplinary mental health liaison team—known as Rapid Assessment Interface and Discharge service[1]. The Rapid Assessment Interface and Discharge model involves rapid assessment of patients presenting to the ED with mental health, self-harm or substance misuse needs and those admitted to general hospital wards so that they can receive appropriate interventions for their physical and mental health, either in the community or in hospital. The Trust wanted to understand the effectiveness of the Rapid Assessment Interface and Discharge service and be sufficiently confident in the conclusions to make decisions about long-term funding for the service. We worked with the Trust to design a quantitative evaluation study capable of providing reliable inference about the effectiveness of the new service. A retrospective matched cohort study design was used to compare likelihood of admission from the emergency department and average length of stay for patients treated by 'Rapid Assessment Interface and Discharge' with a matched comparison group of similar patients treated in other acute hospitals in the region. All research into cause-and-effect relationships, faces the challenge of maximising similarity of groups being compared to ensure fairness of the comparison and unbiasedness of the findings. We applied a novel matching algorithm—genetic matching[2]— to select a group of comparison patients. Simulation studies have shown genetic matching achieves better covariate balance and produces more stable and unbiased treatment effect estimates[3]. Our study found, for patients treated by the Rapid Assessment Interface and Discharge service in the ED their average risk (or chance) of admission was 18.7% lower (95% confidence interval –9.3% to –27.3%). Average length of stay for a wider group of patients treated on general wards (including those benefitting indirectly from the presence of 'Rapid Assessment Interface and Discharge' Service) was 10.8% lower (95% confidence interval –9.2% to –12.4%). Both findings were statistically highly significant (P <0.001). The findings from our evaluation were instrumental in decisions that have led to the Rapid Assessment Interface and Discharge service in the Northern HSC Trust moving to a more sustainable footing
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Estimating the impact of the proposed reforms to the Mental Health Act on the workload of psychiatristsIn January 2021, the Government published a White Paper, setting out its plans to reform the Mental Health Act. The Government invited views on the paper and in July 2021, it published a summary of the consultation responses and its plans to address the issues raised. The proposed reforms aim to ensure mental health service users have choice and autonomy wherever possible, that restrictions on service users’ freedoms are minimised and that opportunities for therapeutic benefit whilst detained are maximised. The reforms seek to deliver these objectives by altering the rights and responsibilities described in the 1983 Act or by introducing new rights and responsibilities. This analysis, conducted for the Royal College of Psychiatrists, estimates the likely impacts of Mental Health Act reforms on the workload of psychiatrists and the number of additional psychiatrists that would be required to meet these new obligations. Estimating the impact of the reforms is a prerequisite to adequately resourcing them. Failure to do so will create implementation risks and may inadvertently displace or interfere with other important aspects of a psychiatrist’s role. This issue is particularly important at present when demand for mental health services is high and rising rapidly.
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Making the case for integrating physical and mental health services in England - National overviewThis is a national overview report of our Making the case for integrating physical and mental health services reporting which took place in July 2017. The original reports looked at the physical health of people who use mental health services; life expectancy, acute hospital use and opportunities to improve service quality and efficiency.
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Socio-economic inequalities in access to planned hospital care: causes and consequencesTacking inequalities in health is a long-standing NHS policy objective. Variation in the experiences and outcomes of different communities during the COVID-19 pandemic served to bring this issue back into focus. In the Summer and Autumn of 2020, as the first wave of the pandemic subsided, concern grew about reduced access to routine hospital care: diagnostics, outpatient care and planned surgery. Waiting lists and waiting times began to grow. The network of Decision Support Units in the Midlands recognised the potential for this issue to exacerbate existing inequalities. They jointly commissioned this analysis to explore the extent, causes and consequences of socio-economic inequalities in access to planned hospital care. The recent NHS Planning Guidance emphasises the importance of identifying and tackling these inequalities. The report has four objectives: To describe socio-economic inequalities in access to planned hospital care To identify where in the patient pathways these, inequalities in planned care emerge To explore potential drivers of these inequalities To explore whether poor access to planned care in some communities leads to increased demand for unplanned care. The report builds on earlier research, advancing our understanding in some key areas. Although further analysis may certainly add benefit, this report is sufficient to support some immediate and targeted actions. We look forward to working with the network of Decision Support Units in the Midlands to improve the outcomes for people living in the most deprived parts of the region.
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Measuring the effect of the coronavirus pandemic on population healthOne feature of the pandemic has been the fast-flowing stream of facts and numbers about the impact of Covid-19. At the same time, we’ve had to absorb the meaning of terms that were previously the preserve of epidemiologists and public health professionals. This has made it hard to see the ‘real’ story. There has been so much information – some of it seemingly contradictory – that, at times, we have all found ourselves struggling to understand why advice has changed or numbers differ. And now, as we (hopefully) move out of the pandemic itself, there is an important societal and political process of reckoning. In approaching this, the task of explanation will be aided by a solid, factual foundation. So this report examines some basic questions: How many people have died from Covid-19? How many more people have died from the wider impact of the pandemic, including policy responses? How many years of life have been lost to Covid-19? Were most victims of Covid-19 going to die of other causes within a short timeframe? What has been the effect of the pandemic on life expectancy? We walk carefully and neutrally through these questions, using data to help provide answers. In each case, we explain the strengths and limitations of the different sources of data, and how choice of methods might lead to different results, before implementing a set of public health and actuarial techniques to deliver a rounded assessment of the pandemic’s effect on population health. Initiated as part of the Analytical Collaboration, this report is our contribution to establishing a solid, empirical basis for learning from the pandemic:
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Risk and Reward Sharing for NHS Integrated Care SystemsRisk and reward sharing is a simple and attractive concept, offering a commissioner the opportunity to co-opt and incentivise a provider to moderate growth in healthcare demand by sharing in the savings or cost over-runs. The Centers for Medicare and Medicaid Services (CMS), a US government agency, has established a comprehensive approach to risk and reward sharing for US Accountable Care Organisations: the Shared Savings Program. This paper draws out the central themes from the Shared Savings Program and translates these into an NHS context. The rationale that underpins the development of Accountable Care Organisations in the US and Integrated Care Systems in England is similar: to moderate healthcare costs through service coordination and integration. However, US ACOs and English ICSs are vastly different in scale (on average, US ACOs provide services to c. 19,000 enrolled patients) and operate in radically different political, financial and cultural contexts. In the US, ACOs are required to sign up to one of three risk-sharing ‘tracks’. Track 1 is a one-sided risk-sharing model where providers have the potential to share in savings if priced activity falls below expected levels, but are not required to pay a share of any cost over-runs. Tracks 2 and 3 are two-sided models, exposing providers to an increasing proportion of upside and downside risks. Six years since the first ACOs were established more than 90% of ACOs remain on track 1. This suggests that to date, providers have a limited appetite for risk. It also offers some insight into the level of confidence that US ACOs have in their ability to moderate demand growth. Complexity is a key feature of any robust risk-reward sharing arrangement and is likely to increase transaction costs above those associated with fee-for-service arrangements. The complexity arises as the commissioner or system designer attempts to ensure that the incentives accurately reflect the policy intention, and do not instead reward cost shunting, quality reductions or chance variations in costs. It is possible to extend risk-reward sharing to multiple partners within an Integrated Care System and to organisations outside the scope of an ICS. But these extensions add further complexity. The notion of a ‘counterfactual’ is central to risk-reward sharing. In this context a counterfactual is the price of healthcare activity that might be expected under normal circumstances. It is the benchmark against which priced activity levels are assessed at year end. If priced activity falls below this level, then the provider may be entitled to a reward payment. If it exceeds this level, then a penalty may be applied. There are many approaches to calculating and agreeing counterfactuals, but none are simple. These calculations determine the allocation of significant sums of money. If the NHS is to make best use of risk and reward sharing, then it must be aware of the complexities and hazards inherent in these arrangements as well as the potential benefits.
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Palliative and End of Life Care Report for Children and Young PeopleCommissioned by NHS England, this report describes the the characteristics and levels of resource required by children and young people (CYP) (0-25 years) with life limiting conditions and/or life threatening conditions (LLC). The scope of this report does not attempt to explain or address the complexity of life threatening conditions and palliative end of life care for children and young people; it does however highlight a new and emerging population of significance for the NHS in England. People aged 0-25 span both paediatric and adult services, Clinical Commissioning Groups and Specialised and Direct Commissioning. It is much reported that there is a broad and complex age transition period in this cohort and this report therefore covers this whole period. This report draws on information from a range of primary sources including Hospital Episode Statistics (HES), Secondary Users Service (SUS) and ONS population projections and death registrations to provide intelligence on the prevalence, acute utilisation and characteristics of these complex patients. Also available is a companion report commissioned by NHS England describing the status and context of palliative and end of life care services in the West Midlands, it may be helpful and provide additional context to read these two reports in conjunction. The main chapters of the report focus on; Chapter 2 – Prevalence analyses – Identifies CYP with an LLC registered with a GP practice in the West Midlands who have been in contact with hospital services since April 2006. The chapter examines how prevalence has changed over the past decade and summarises the cohorts by demographics and condition characteristics. Chapter 3 - Acute healthcare utilisation – Identifies and summarises all acute hospital activity in HES for the cohort including A&E, Inpatients and Outpatients. Activity is identified whether it is related to the LLC or not, and is described in terms of overall trends and demographic and condition characteristics between 2011/12 and 2015/16. The cost of activity by CCG, STP and provider is also summarised in this section. Activity in the 12 months prior to death has been examined at each point of delivery for those who died in 2015/16. Chapter 4 – Historical deaths and forecasts - Examines the trend in deaths for all CYP in the West Midlands (0-25 years) over the past decade and compares this to deaths in our cohort. Deaths for all CYP are forecasted until 2022/23.
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Palliative and End of Life Care in the West MidlandsCommissioned by NHS England, this report describes the status and context of palliative and end of life care services in the six Sustainability and Transformation Partnerships in the West Midlands. The report contains data on trends and forecast numbers of deaths, place of death, palliative care registers, acute healthcare use prior to death, availability of specialist-level palliative care and summarises the results of recent palliative care reviews and audits. The number of deaths in England has reduced year on year since the early 1980’s despite increases in population size. In 2011 there were four hundred and fifty thousand deaths in England, lower than at any point since the NHS was founded, but since 2011 the number of deaths per annum has increased and ONS forecast that this upward trend will continue for the foreseeable future with a 25% increase in annual deaths by 2039. This implies that demand for end of life care has been comparatively low in recent years but will rise considerably in the years ahead. Hospital remains the most common place of death, although all parts of the West Midlands have seen decreases in the proportion of deaths in this setting. There are now five thousand fewer deaths per year in hospital than in 2006. A very large proportion of deaths from frailty and degenerative conditions occur in either a hospital or care home setting. Without service redesign, we might expect these settings to experience most demand pressure as frailty deaths increase rapidly. Palliative care registers are intended to assist GP practices to manage the care of patients in their last 12 months of life and evidence suggests that patients on palliative care registers are more likely to receive well-coordinated care. Despite significant improvements in recent years, the number of patients on palliative care registers in the West Midlands falls well short of the expected number. Acute hospital utilisation increases significantly in the last 12 months of life. Despite unprecedented pressure on hospital beds, patients continue to receive non-beneficial treatments in hospitals in the last months of life. A&E attendances and emergency admissions rise sharply in the last year of life, often peaking in the month of death. In May 2017, there were 52 Consultants in Palliative Medicine working a total of 450 (half-day) sessions per week. One fifth of these sessions were delivered as part of a community palliative care team with the remaining sessions shared between hospitals and hospices. In their most recent CQC inspection,6 12 hospitals in the West Midlands received ‘Good’ ratings for end of life care. A further 6 were assessed as ‘requiring improvement’ and one was assessed as ‘inadequate’. All of the hospices in the West Midlands received a ‘good’ or ‘’outstanding’ rating in their most recent CQC inspection.
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The Effect of Demographic Change on Acute Hospital UtilisationRecognising that the effect of population ageing can be overstated, we set out to ask what effect an older population will have on demand for health and care services. Here, we explain why typical approaches ‘overlook the fact that rising life expectancy makes … older people “younger”, healthier, and fitter than their peers in earlier cohorts’. This report is the first in a set of three reports produced by the Strategy Unit that each address a crucial aspect of commissioner planning for acute services. As a collective, these three reports provide a useful and robust framework on which local commissioning organisations can base their strategic planning.
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Changes to Admission ThresholdsThis analysis builds on a paper, Changes in Admission Thresholds in English Emergency Departments, which explores changes in the casemix of patients attending emergency departments (EDs) and the propensity of EDs to admit patients. The report incorporates additional analysis commissioned by NHS England, extending the scope of the analysis and refining the methodology.
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Waiting Times and Attendance Durations at English A&E DepartmentsWaiting times in A&E have become the defining healthcare performance issue of our time, much like elective waiting times and hospital acquired infections have been in the past. Since 2004, the NHS in England has sought to ensure that patients spend no more than 4 hours in Accident and Emergency Departments. In recent years reported performance has deteriorated and, in the winter of 2017/18, almost one quarter of attendances at major A&E departments breached the target maximum duration. The decline in performance has been steady, sustained and almost ubiquitous. Attempts to restore performance levels have waxed and waned whilst the media’s interest in the target continues to grow. In 2018, NHS England announced plans to review all constitutional waiting times targets, reopening the intense debate about the value and impact of the 4-hour A&E target. Whilst there is no shortage of commentary on the subject, there have been few detailed analyses of the factors that are driving increases in A&E attendance durations and 4-hour breaches. In the absence of clear causal explanations, responsibility for ‘poor performance’ is often levelled at A&E departments, with implications of poor management and inefficiency. This report presents a detailed review of the demand-side, supply-side, practice and emergent factors that lead to 4-hour breaches with a particular focus on changes that have taken place since 2010. The report reviews both commonly cited causal factors and a range of more novel hypotheses. It sets out the causal theories underpinning each factor and seeks statistical evidence in support of them. Finally, the analysis scales the relative impact of each causal factor and aims to provide an explanation for the recent deterioration in A&E waiting times within the limits of national datasets. New insights emerge which have the potential to reshape the received wisdom about the performance of A&E departments, carrying important implications for healthcare policy and system leadership.
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Modelling Patients Flows under Potential Configurations of Emergency Centres with Specialised ServicesOnsite, 24/7 access to complex vascular surgery, hyper acute stroke services and primary percutaneous coronary interventions are expected to be a pre-requisite for a hospital to be designated as an emergency centre with specialised services. This paper sets out the patient access and patient flow implications of reconfiguring and centralising these three services within the West Midlands.
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Change on Acute Hospital UtilisationRecognising that the effect of population ageing can be overstated, we set out to ask what effect an older population will have on demand for health and care services. Here, we explain why typical approaches ‘overlook the fact that rising life expectancy makes … older people “younger”, healthier, and fitter than their peers in earlier cohorts’. This report is the first in a set of three reports produced by the Strategy Unit that each address a crucial aspect of commissioner planning for acute services. As a collective, these three reports provide a useful and robust framework on which local commissioning organisations can base their strategic planning.
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Identifying Potential QIPP Opportunities - Dudley ExampleGiven the pressures within the NHS, being able to identify opportunities for efficiencies and improvements is vital to inform commissioning intentions. This report is an example of analytical work which to support commissioners. The objective of this report is to provide information to support CCGs to review inpatient, outpatient and A&E utilisation rates and identify potential QIPP opportunities. Rather than focusing on hospital utilisation rates as a whole, the report shows utilisation rates for those subsets of hospital activity which may be amenable to commissioner based QIPP schemes. The report compares the rates in these subsets with the rates in a set of nearest-neighbour comparator CCGs. We recommend that this information should be reviewed in conjunction with a wider planning process. This report is the second in a set of three reports produced by the Strategy Unit that each address a crucial aspect of commissioner planning for acute services. As a collective these three reports provide a useful and robust framework on which local commissioners can base their strategic planning.”
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Horizontal or Vertical: Which way to integrate?In 2011, Primary Care Trusts faced a difficult choice. The Transforming Community Services policy required a complete break of commissioner and provider functions. But what should PCTs do with the community health services they delivered; vertically integrate with an acute trust, horizontally integrate with a mental health trust, or set up a stand-alone community trust or Community Interest Company? Seven years on, this report explores the impact this choice had on the level and growth in emergency hospital use in older people and considers the wider implications for the NHS as it develops new models of care and integrated care systems. Boards and senior managers making decisions about whether to structurally integrate services are not well supported by research on the subject. The relative merits of vertical (i.e. acute-primary) or horizontal (i.e. primary – community / mental health) integration are also not well established. The paper focuses on the impact of changes to district nursing services (the largest service subject to the Transforming Community Services policy) on emergency hospital use of older people, a key metric of interest for national government. Whilst no single metric can adequately describe the functioning of a health and care system, the rate of emergency hospital admissions and bed-days provides insight into how well the main components of a system work together to manage patient care proactively. The paper seeks to answer the following question: Does structural integration of district nursing services with acute or other community health services have an impact on levels of emergency hospital admissions of older people? It also encourages reflection on policies that lead to structural change. In 2010-11, emphatic and definitive claims were made about the benefits of Transforming Community Services. Substantial resources were used to develop plans and extensive assurance processes were put in place to check that these would deliver the changes required. But as far as we can tell, no attempt was made to test whether the promised benefits were realised. Eight years on and familiar claims are being made about benefits of structurally integrating services. Management teams are exploring options and developing plans and regulators are establishing new assurance frameworks. The question of whether and how to structurally integrate services lies at the heart of this process. This paper attempts to draw out the lessons from Transforming Community Services for those wrestling with this question.
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Exploring Mental Health Inpatient CapacityThis report explores the pressures on inpatient mental health services across Sustainability and Transformation Partnerships in England, drawing on a wide range of datasets, published research and interviews with staff working on mental health services. The report was commissioned by and includes a response from the Royal College of Psychiatrists. Inpatient services form a critical component of mental health provision, providing clinicians with a means of rapidly reducing the risk of suicide, self-harm and harm to others and an environment in which complex treatment regimens can be safely initiated and calibrated. In 2015, the Royal College of Psychiatrists established an independent commission in response to concerns about the provision of acute inpatient psychiatric services. The Commission, chaired by Lord Nigel Crisp, found that many people were unable to access high-quality acute care when needed. The commission made twelve recommendations which were widely endorsed. Whilst some progress has been made in the four years since the commission reported its conclusions, concerns about the capacity of inpatient mental health services remain. This report reviews the current situation relating to mental health bed capacity, drawing on an analysis of the data, interviews and surveys with members of the Royal College of Psychiatrists and a review of the latest evidence. The report was commissioned by the Royal College of Psychiatrists in December 2018 for publication in Autumn 2019.
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How will we know if Integrated Care Systems reduce demand for urgent care?It may be tempting to consider the blended payment system as a technical tool for determining the allocation of resources between commissioners and providers - something that can be left to analysts and finance specialists to negotiate. But the implications of the blended payment system are far reaching: Decisions about planned activity levels will determine the total funding envelope for urgent care within a system and will influence the behaviour of healthcare providers and the services they deliver to patients. This is an unusual situation where senior managers in commissioner and provider organisations must engage in the detail, however esoteric it may seem, to ensure both the financial sustainability of their organisations and the quality and accessibility of services for the populations they serve. For most NHS services, healthcare commissioners pay providers according to the rules and prices of the National Tariff Payment System (NTPS). Until April 2019, the NTPS operated on a fee-for-service basis. At face value, the fee-for-service model appears to offer providers an incentive to increase supply and therefore sets the financial sustainability of providers against that of the health system as a whole. It is believed that such tensions might be resolved with the introduction of risk-and-reward-sharing, or “blended payment”, schemes. This alternative payment model encourages the provider to moderate growth in activity by assigning them a share of the annual savings or the cost over-runs. The risk-reward sharing model is currently seen as the most appropriate way to distribute resources in the healthcare system and, as a consequence, the NTPS has recently adopted blended payments for emergency activity. Central to the blended system is the recommendation that commissioners and providers reach agreement on “planned” activity levels (the future activity that might be expected under normal circumstances). The provider’s subsequent performance is measured relative to these levels, and rewards or penalties allocated. It is therefore vital that these levels be fair and credible, and that the methods used to create them be authoritative and transparent. Moreover, these levels must be calibrated to support the objectives of the national healthcare system. Yet, official documents offer little detail on these crucial planned levels, and no firm guidance on how to produce them. This is problematic since falling back on conventional forecasting methods in this context may lead to the unfair allocation of millions of pounds worth of incentives and a missed opportunity to improve commissioner-provider relations. This paper has three objectives: To illustrate the workings of the blended payment system. To demonstrate that inappropriate modelling of “planned” activity levels could divert tens of millions of pounds away from the emergency care system. To pinpoint the reasons why conventional forecasting approaches are unsuitable in this context, and to suggest alternatives.
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Modelling the impact of covid on waiting lists for planned careWorking with the national collaboration to coordinate covid-related analysis, and the NHSE/I Midlands region, the Strategy Unit has produced a ‘systems dynamics’ model of waiting lists for planned care. The model is freely available for non-commercial use across the NHS. Here, Steven Wyatt and Mike Woodall explain what we did and how we did it. Health services have changed radically and rapidly in response to the covid pandemic. Services were redesigned to manage anticipated surges in covid cases and associated risks. As the initial system shock subsided, attention has turned to the unintended effects of these changes. Access to planned acute care, diagnostics, outpatient care and planned surgery are now significant concerns. The pre-covid position was far from perfect. For several years prior, waiting lists for planned care had grown; waiting times had increased; breaches of constitutional standards had become commonplace. Yet the analytics and management of waiting list had been largely perfected. Processes can always be improved, but the story was one of demand outstripping supply - rather than of poor analysis or management. We understood the dynamics of waiting lists and times. We knew what to do: even if resource constraints meant we couldn’t always do it. This certainty has gone. Covid changed many of the rules of the game simultaneously and radically. Patients’ willingness to present at primary care; their ability to get an appointment; GPs’ willingness to refer to secondary care; the willingness of patients to take up hospital appointments; mortality whilst waiting; hospital staffing levels; diagnostic, bed and theatre capacity. All of these parameters have changed. Some will return to pre-covid levels; others will find a new natural level. Circumstances have changed – and so have potential management responses. New national resources may become available; Nightingale capacity could be repurposed; constitutional standards might be dropped or reset. Responses that would have been unfeasible, uneconomic, or inappropriate only a few months ago might become real possibilities. How will clinicians and managers respond to such fluidity, dynamism and uncertainty? Pre-covid models will be of limited use. Their founding assumptions have melted. Some will therefore abandon any attempt to model - relying instead on instinct. But crisis management can’t be sustained. It will prove inefficient and error prone. A better option is to embrace the complexity and uncertainty: to evolve a new set of methods and models better suited to new and fluid circumstances. The key here is not to crave certainty. It does not stop everyone, but nobody can say with confidence how the next few months will pan out. We need approaches that understand which, of the many new unknowns, have the greatest potential to influence outcomes. We need approaches that can identify, prioritise - and then remedy – limiting factors in our knowledge. This thinking underpins our waiting list simulation model. We wanted to offer analysts and managers a facility to safely explore uncertainties and scenarios. We wanted to them to see how different strategies might fair under changing circumstances. So we chose to build these models within a system dynamics (SD) framework. SD is a well-tested, agile modelling approach that tracks changes in stocks and flows. Stocks are quantities of interest (e.g. patients on a waiting lists, staff, beds). Flows are mechanisms by which stocks increase or deplete. SD has its limitations. But where delayed effects, accumulations and feedback loops are present, then SD is a good fit. (Alternative modelling paradigms, such as discrete event simulation would be more suitable if the key concern is understanding how the distribution of waiting times are likely to change in the future). In producing the model, we found that: Waiting lists did not increase in the few months after the lockdown. This is not cause for celebration The two main factors that determine the change in waiting list size are the rates of planned care activity (removing patients from the waiting list) and rate of new referrals (adding new patients onto the list). In the months immediately following lockdown, rates of outpatient and inpatient activity reduced dramatically. But referrals also reduced. Patients stayed away from - or were unable to book an appointment with - their GP. The number of patients waiting for treatment fell from 4.4m at the end of February to 3.8m at the end of May. A considerable referral backlog is building up in the community and in GP practices. Services are planning the dark. Modelled results are sensitive to factors we know little about To produce estimates of the future waiting list size, our model requires a set of assumptions. Supplying these assumptions is a sobering process. There are many factors where our estimates are speculative. How quickly will GPs clear the referral backlog? How many symptoms will clear before the referral takes place? How will theatre productivity be affected by infection control measures? How many patients will refuse appointment slots? When will these patients feel more comfortable entering a hospital? Analysis and research needs to be directed towards these uncertainties. In the meantime any plans should incorporate sensitivity analyses allowing these values to vary within plausible ranges. Waiting lists may yet reach unprecedented levels Despite these uncertainties, we can use a set of realistic assumptions and observe the model outputs. This process indicates that waiting lists could double or even triple by the end of March 2021. This accumulation takes place over three phases. In phase 1, referrals are supressed at something like the same level as hospital activity resulting in small changes to the waiting list. The second phase sees the waiting list grow rapidly as the referral backlog is cleared and hospital activity begins to increase. The third phase sees sustained waiting list growth. The referral backlog is cleared, and referral rates return to pre-covid levels. Meanwhile hospital activity plateaus at a level below pre-covid level as a result of infection control measures. Hope of a rapid return to pre-covid waiting lists is misplaced One of the values of simulation models is that they allow us to ask questions that could never be entertained in real life. So we asked: by how much would hospital resources (staff, beds, diagnostics and theatres) need to be increased to return the waiting list to pre-covid levels by the end of the financial year? The answer is that a step change of around 80% in resource levels would be required. The answer’s lack of realism is instructive in itself. So too was the fact that different resource types - staffing levels, theatres, beds, diagnostic capacity - needed to be increased simultaneously. There is simply no rapid way back to pre-covid waiting lists. Feel free to use or adapt our model We are part of the NHS analytical community. So our model is freely available for non-commercial use. It is part of a broader collaborative effort to coordinate covid-related analytical outputs. We want it to be widely shared and we hope it is of value for local planning. There are many different questions about the impact of Covid on waiting lists for planned care. No single model can address all questions well. The chances that our model will coincide with the exact questions local teams might have are slim. So here too are suggestions for using our work to support your own: As a point of reference. It’s often useful to see how someone else has approached a similar problem. You can compare approaches and consider the strengths and limitations of the two methods, the assumptions made, the simplifications applied, the model functionality etc. As a source of assumptions. One of the key challenges when modelling the outcome of some future scenario is to parameterise your model with assumptions about the timing and scale of certain impacts. No-one can know these with any certainty. So our assumptions can be a useful reference point. As a source of data (or data wrangling code). We have assembled large quantities of data. This data wrangling process is time consuming. You might therefore want to use these datasets as inputs into your own model(s), or adapt the data wrangling scripts (r and t-sql) to produce your own bespoke data tables. To run specific scenarios supported by the model. Our model allows parameters to be adjusted to create new scenarios. You may wish to run locally relevant scenarios within our models. As a starting point to develop a more complex model. It may be that with some additional variables or functionality, our model might be able to address some new questions that are relevant in your area. Feel free to use our model as a starting point and add complexity and functionality as required.
