ANNEX 7

BED MODELLING : FURTHER WORK

 

1.  BACKGROUND

1.1  Following the original work carried out by the North Glasgow Trust, Southern General Trust and ISD Scotland from June, 1999 to April, 2000 a number of areas of concern were identified by Trust clinicians and a further Clinical Bed Modelling Review was undertaken with them. This work was summarised in the September, 2000 Board paper in the ‘Trust Clinical’ column of the Table on page 39.

1.2  The Trust Clinical Review identified a number of issues, which were analysed in greater detail. The main findings which materially affected the number of beds required were:

    1. the originally suggested assumption that in-patients with a stay of up to 2 days would in future be treated in an ACAD setting was not valid across the whole spectrum of specialties. Detailed analysis of this cohort of patients was carried out and a sub-set of patients was identified as appropriate to transfer to an ACAD setting. The remainder of this group of patients were left in the in-patient cohort.
    2. the residual length of stay for the remaining in-patient cohort of patients (after the ACAD group had been removed) was recalculated to establish an actual Trust length of stay. This increased the average length of stay by up to 2 days for the surgical specialties. Given this recalculation the Trust length of stay could not be benchmarked against Scottish peer performance since it was no longer a like for like comparison. ISD were therefore asked to recalculate the Scottish length of stay by applying the Trust’s ACAD criteria to the Scottish data.
    3. the bed occupancy rates were re-examined and clinicians felt that there was a significant risk of bed unavailability at peak times if we planned for 85% occupancy.  80% occupancy was used in the first iteration of the clinical model. Two specialties which have predominantly 5 day week working for their wards, ENT and Ophthalmology, requested a 75% occupancy rate to ensure that peak demand could be met. Subsequently the elective and emergency workloads have now been split and the effect of allowing for differing occupancy rates incorporated into the model.
    4. a number of service re-design issues had not been taken into account in the initial work on the ‘Trust Clinical’ bed model. There have been explored in more detail in the second phase work.
1.3  The net effect of the initial Clinical Bed Model was to increase the number of beds over the original Trust\ISD model published in the Spring, mostly in the surgical specialties (around 150 more). The difference in the medical specialties was around 40 more and in orthopaedics\plastic surgery the difference was around 60.

 

2.  APPRAISAL OF INITIAL CLINICAL REVIEW

2.1  The Trust, in appraising the outcome of the initial iterations of the Clinical Model agreed that the ACAD cohort should be adjusted as suggested. They were thoughtful about the other elements in the Trust Clinical Model and put in hand work to explore how improved organisation and reasonable changes in ways of working would affect the position. In particular they looked at:
    1. splitting the elective and emergency patient cohorts and establishing their own average length of stay and occupancy levels.
    2. establishing a revised average length of stay for Scotland by applying the North Glasgow ACAD criteria to all Trusts across Scotland (as already mentioned earlier).
    3. further refining the ACAD cohort and banding their current length of stay into 0, 1, 2 day stays.
    4. establishing the current and potential Day Case rates to consistently deliver at least the targets regarded as reasonable by the Accounts Commission.
    5. investigating how much time was spent in hospital before the operation took place and considering the scope for increasing the number of patients who, with different pre-operative and pre-admission preparation, could be admitted on to the same day as their operation.
    6. linking in-patient and x-ray data to look at "lost" bed days waiting for an investigation.  Anecdotal evidence suggested that this might have considerable impact on lengths of stay and efforts were being made to quantify this.
    7. what potential there might be to smooth out peaks and troughs of activity by more effective use of theatre sessions and mixed specialty use of bed complements.
    8. review of English benchmarks for efficiency criteria to identify what the most challenging targets would be, for the purpose of comparison.

 

2.2  The North Glasgow Trust manager tasked with the work has met groups of clinicians from each specialty. ISD have provided statistical modelling support. Each specialty has been reviewed against the considerations identified above to allow the model to be refined using ‘best fit’ for that specialty. This should establish a reasonable efficiency level and consequential bed numbers, consistent with safe clinical practice and likely demand for each specialty.

 

3.  REDESIGN ISSUES

3.1  The Trust Clinical Bed Modelling review undertaken in the summer was very much focused on testing the philosophy of the initial modelling process but also exploring the possibilities for change within existing clinical frameworks. The debate must now move on to how services can be redesigned and delivered more efficiently in the context of improved facilities and better support from service departments. A range of redesign issues have been identified as a starting point for this process and others will be included as the debate continues. The main areas under review are:

    1. throughcare and early supported discharge, particularly for elderly people.
    2. immediate on-site investigations in the emergency receiving centre.
    3. fast track radiology investigations for in-patients, including out of hours.
    4. generic emergency receiving beds, outwith specialty specific bed complements.
    5. pre-assessment services ensuring the maximum number of same day elective admissions : operations.
3.2  It has not been possible within the timescales for this second phase clinical review to explore all of these issues for each specialty across North Glasgow. For the purpose of establishing suggested bed numbers for each specialty at this stage a token "efficiency gain" factor has been used, which will be refined in the light of further analysis with clinicians. Each in-patient episode has been reduced by 0.5 days to represent the high probability that such redesign issues will have the effect of reducing lengths of stay.

 

4.  DAY SURGERY RATES

4.1  In defining the "ACAD cohort" (patients currently with a short in-patient length of stay who will in future be treated in an ACAD) some specialties appeared constrained by existing anaesthetic protocols. Following the report from the ACAD visit to the USA it is clear that this issue should be systematically reviewed. Its potential impact is not yet quantifiable in terms of bed numbers.

4.2  There are however some specialties who do not yet achieve the existing Accounts Commission targets for day surgery rates. This is sometimes for operational reasons within their theatre sessions or because some of the procedures have either moved to an Out-patient setting or are no longer performed. Nevertheless there will be further progress in this area, and the revised clinical model has used the Accounts Commission target as the benchmark for each specialty as the minimum level of day surgery.

 

5.  RESULTS

5.1  Having established the revised average length of stay for Scotland and quantified the value, in bed days, for each of the efficiency criteria in 2.1, a computer model has been set up which allows different scenarios to be run for each specialty. As further discussion takes place the parameters can be altered in the model, allowing a ‘what if’ scenario to be used. The best fit, as established so far by the planning team is set out for each specialty on the attached sheets to provide a platform for further debate.

5.2  The process adopted since the summer requires a highly participative approach in discussing how the specialty-specific variables should be pitched for this next stage in planning. It needs to be tested further in North Glasgow but also needs to be introduced into discussion in South Glasgow.

5.3  It should also be noted that eventually, in real life, specialties and services need to inhabit wards in hospitals. Although we shall be building hundreds of new beds in new buildings, there will still be beds in use in those existing wards that continue in use (such as Gartnavel ward tower block, the GRI Queen Elizabeth Building, new Maternity block and new Emergency Receiving\Plastic Surgery block). These existing wards do not have identical or standard bed complements. New wards in the new buildings constructed later in this decade may have varying standard sizes between one site (or part of it) and another. This means that in matching specialties or services to real wards bed numbers may turn out to be slightly higher or lower than stipulated in a statistically derived bed model. The variances are unlikely to be significant however.

6.  POPULATION CHANGE AND CROSS-BOUNDARY FLOWS

6.1  Predicting bed numbers for the future requires some modelling of expected population change and cross-boundary flows to be incorporated. The September, 2000 Board paper, in referring to this issue said:

"The GGNHSB population profile for the future is expected to decline although the rate of decline is susceptible to two relatively new factors:

  1. a concerted effort by the Glasgow Alliance to reduce decline through the creation of New Neighbourhoods (at Drumchapel and Ruchill) and a continuing improvement in housing and infrastructure.
  2. the expectation that Glasgow will be home for several thousand asylum seekers.

The Government population prediction used by the Arbuthnott Report in its calculations of funding used a 1994-based population projection which showed Greater Glasgow having a population of 893,000 in the year 2000, declining to 852,000 by 2010, a decline of 41,000 (or 4.6%). One might expect that due to the new factors referred to earlier the rate of decline might be rather slower.

Age structure has a particular impact on planning services for children, adolescents and the elderly, although in Greater Glasgow as much attention has to be given to its locally distinctive health status and patterns of illness. The impact of deprivation and social inclusion worsens many adults’ health much earlier in their lives than elsewhere.

The impact of the scale of expected population change is marginal at the level of our strategic planning. It does not affect:

It will affect the number of beds provided, and that will need to be picked up by Trusts at the next stage of Outline Business Case planning. Even so, population change is only one factor in determining bed numbers.

As far as changes in flows of patients are concerned, we are already aware that Lanarkshire Health Board wish to see some changes affecting their residents.  Discussions with Lanarkshire Health Board and the acute hospital Trusts concerned are still underway but it is anticipated that over a three year period from 2001\2 there will be fewer patients coming to Glasgow hospitals from the Cumbernauld, Wishaw, East Kilbride, Hamilton and Monklands areas. These changes have been translated into estimated numbers of cases.

In advance of definitive agreement being reached we cannot be precise about impact, but it might help to illustrate the impact by reference to a range of specialties affected. The numbers that follow are illustrative only:

In year one 2,200 fewer cases to North Glasgow, 1,100 fewer to South.
In year two 3,400 fewer cases to North Glasgow.
In year three 2,400 fewer cases to North Glasgow.

The impact on bed requirements depends on the mix between in-patient cases and day cases (which is not yet clear). If this followed the normal current ratio of cases to in-patient (1 : 3), then 1,100 fewer patients in South Glasgow might equate to 275 day cases, 825 in-patients. If those in-patients had average lengths of stay of as much as 5 days (which is relatively high), that equates to 4,125 bed days or around 13 beds at 85% occupancy. Clearly the potential impact is higher in North Glasgow, where a similar illustrative calculation results in an impact of some 96 beds (at a 5 day average length of stay). Clearly if the ratio of day cases to in-patient care is different or length of stay were less than 5 days – which is likely – then the impact on bed numbers is likely to be less than this.

What is more problematic is the loss of income from Lanarkshire. Because the bed numbers impact will be scattered in small numbers between different specialties and different hospitals it will be difficult for the Trusts to reduce their costs. This means prices to GGNHSB (mostly) and other Health Boards are likely to rise. The withdrawal of income is estimated at:

2001\2 £2.2 million
2002\3 £2.9 million
2003\4 £3.9 million

 and the impact has to be factored into GGNHSB’s financial planning."

6.2  In their subsequent work on bed numbers the North Glasgow Trust have calculated that the combined impact of population changes and reduced cross-boundary flow from Lanarkshire would account for a bed reduction of 63 beds. This is after an assumed growth of 5% in general medical emergency admissions has been factored into the model.

6.3  Some work has been done to test whether the original ‘nil’ growth assumption for specialties other than general medicine was reasonable. Data for the period 1995\6 to 1999\2000 were examined as follows:

    1. General surgery – virtually no change in total bed days over the period.
    2. Vascular surgery – no evidence of an increasing trend.
    3. ENT – showed a sharply decreasing trend.
    4. Ophthalmology – the previous decrease in activity appears to have levelled off in 1998\9.
    5. Urology – some slight fluctuations which have stabilised in the last three years.
    6. Nephrology – evidence of fluctuations year on year but between 1995\6 and 1998\9 the total stays rose by 5.2%. It would be appropriate to consider some growth for the future.
    7. Respiratory medicine – the activity and bed days rose in 1995\6 and 1996\7. Since then the increases levelled off and there is no evidence of a continuing rise.
6.4  In the next stages of work we will want to re-test the assumptions around cross-boundary flow, population change (absolute levels and in terms also of changing age profile) and differences in future growth trajectories in medical emergency admission rates.

6.5  The North Glasgow modelling will also need to be adjusted to take account of future changes of flows within Glasgow, such as:

    1. what happens if most orthopaedic emergencies in West Glasgow in future flowed to the Southern General?
    2. what numbers of emergency flows might there be from south-east Glasgow to GRI when the Southside A & E service moves westwards away from the Victoria Infirmary?
    3. flows in gynaecology in-patient cases as a result of merging the West Glasgow and South Glasgow gynaecology in-patient services at the Southern General.
6.6  Finally the work will need to consider what the implications are of any specific waiting times targets established in the Scottish Health Plan.

 

NORTH GLASGOW TRUST

BED MODELLING SUMMARY AS AT 13th DECEMBER, 2000

Specialty

Current
beds

Spring 2000

Consultation Model

North Glasgow

Clinical Model

 

1. ENT

32

8

20

 

2. General Surgery

373

263

303

See separate sheets ‘General Surgery’ and ‘Vascular Surgery’.

3. Ophthalmology

22

6

15

 

4. Urology

82

41

63

 

5. ITU

17

17

18

This certainly needs revisiting. GGNHSB expects I.T.U. bed provision to increase further.

6. Gynaecology

75

32

28

Work sheet includes West Glasgow gynaecology which in future is proposed to be located in South Glasgow (=12 beds. Hence North Glasgow future requirements would be 28 beds).

SURGICAL SUB TOTAL

601

367

447

 

7. Cardiology

103

66

76

Needs revisiting to consider need to include expected future growth in activity.

8. Clinical haematology

26

24

30

 

9. Communicable

diseases

32

24

23

 

10. Dermatology

20

18

20

To be reviewed further in the light of emerging proposal to create single Dermatology Unit for whole of Glasgow.

11. Gastroenterology

-

8

18

Beds currently counted within general medicine.

12. General medicine (including

endocrinology)

417

504

420

North Glasgow Clinical model assumes growth of 5% p.a. in activity. Effect offset by reductions in cross-boundary flow and by target reduction of 0.5 days in average length of stay. See sheet for details.

13. Homoeopathy

15

15

12

 

14. Nephrology

61

62

68

Needs revisiting to consider possible future growth in activity.

15. Respiratory medicine

90

69

82

 

16. Rheumatology

39

38

41

 

MEDICAL SUB TOTAL

803

828

790

 

17. A & E

22

0

7

 

18. Orthopaedics

172

122

143

Work sheet includes all West Glasgow emergency cases. In future many would go to Southern General. Numbers need review.

19. Plastic Surgery

76

42

50

(Work sheet does not yet incorporate current Canniesburn data)

20. Burns

22

15

15

No work sheet yet produced.

ORTHO\PLASTIC SUB TOTAL

292

179

215

 

21. Oncology

141

130

130

Needs further review. Two work sheets ‘Medical Oncology’ and ‘Clinical Oncology’ suggest 110 beds in total but with number of cancer cases increasing and new treatments we do not expect 110 beds to be enough.

22. Cardiothoracic

94

94

94

Work sheet suggests 81 but existing capacity likely to be needed to future improve waiting times.

TOTAL

1931

1598

1676

 

Not included in these tables are Geriatric Medicine – Assessment and Rehabilitation – see working sheet for details.

 

Last modified: August 15, 2002

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