Collaborative Programme MENTAL HEALTH Collaborative Programme Demand, Capacity, Activity & Queue Welcome. Introduce yourself. 1

Disgruntled referrers Agitated managers Dissatisfied patients Is your service unwell? Do you recognise any of the following symptoms? Tired clinicians Disgruntled referrers Agitated managers Dissatisfied patients Growing waiting lists Failed waiting list initiatives Increasing workload No time to organise or think ahead Becoming hopeless Set the scene. Do you recognise any of the following symptoms? These are not uncommon. 2

Take a moment to imagine a service where… Your service is without a waiting list There are no unnecessary delays before service users are seen Clinicians are able to focus their energy on treating people Take a moment to imagine a service where there is no waiting list – either for assessment or for treatment. Imagine a service where there are no unnecessary delays before service users are seen, and where clinicians are able to focus their energy on treating people rather than eg in meetings, chasing pieces of paper, spending days on the phone etc. 3

Improve the health of your service by using DCAQ This presentation:- introduces Systems Improvement thinking; explores reasons why queues might exist, and; defines DCAQ in the Mental Health context. Help is at hand. Read slide. 4

Systems Thinking To firstly set the scene for Demand and Capacity work, it helps to start thinking of services as systems. It’s useful to think about services as systems, and to recognise that what each service or system delivers is the result of how it has been designed, rather than a product of the people who are tasked with working in it. If you sort the system out, then you improve what it can deliver, and you might just make it easier to work in. If you are trapped in a badly designed system, it can be very frustrating as you try your best to deliver high quality care when the system is working against you. 5

Systems Improvement Understand Design Build Relationships Use Information Systems improvement can be broadly described in four key stages: Understand your system – what’s working and what isn’t. Design a better one Implement what you’ve designed – so get those ideas from around the table into your working practices Evaluate whether what you’ve designed and implemented has had the desired or predicted effect. To apply this approach in health care, we need to take this further. First, recognise that relationships run through and hold together our systems of care – relationships between parts of your processes, the way the team works well together and where it could work better, and perhaps most importantly, the relationship between the patient and care provider. The systems approach comes from industry and to successfully apply it in healthcare, we need to be mindful of the importance of relationships in bringing about improvement. Second, use information to help you to understand the system, to design a better one, to implement and evaluate the impact of the change. This provides real focus and direction in systems improvement. We will now look at one specific use of information in systems improvement. Implement Evaluate 6

DCAQ Demand Capacity Activity Queue 7 DCAQ - What is it? A technique which: Helps you to understand why queues form Helps you to understand the volume work that is asked of your service, and its capacity to respond to that volume Looks at the flow of patients through your system Allows structured measurement of demand and capacity Presents potential solutions (scenario modelling) to demand and capacity problems. Activity Queue 7

Traditional Responses Queue Management Systems Perspective Traditional Responses Training Waiting List Resource Initiatives Systems Perspective Process Variation Waste If you have waiting lists for parts of your service then you may have considered or been involved in some of the traditional responses to waiting lists: Training – train staff to do things more quickly. WLI – Time-limited and focussed resource to clear a backlog. Doesn’t address underlying reasons for backlog. Usually, problem resurfaces soon after it’s been “solved”. Resource – we don’t have enough staff, so get more in. Taking a systems perspective takes the emphasis away from the people working in the system, and places it on the system itself. Processes – look at your processes. Do they flow? Are they patient-centred? Do they allow you to deliver quality in the best way possible. Could they be designed differently in a way? Variation – what variation exists within your system? Are you aware of it? Have you measured it? Do you adapt to it accordingly? Is there anything you can do to minimise the effect of it? Waste – What waste exists within your system? Waste can take many forms. For example, waiting, lost slots, under-utilised staff, unnecessary appointments and so on. Look to minimise waste wherever possible. Addressing queues from a systems perspective is longer-lasting and shines a light on things you can do within your existing resource frameworks that will improve access for patients.

Queues can exist for variety of reasons time Demand Target Capacity Queues can exist for a number of reasons: Historical backlogs – your system may be in balance but is living with the legacy of an old way of working or has an old queue that has never been cleared. Demand exceeds supply. This might be the first notion as to why a system has queues. But is often not the case. Average capacity and average demand can be matched and still a queue can grow, if there is a mismatch in variation between capacity and demand, as this chart demonstrates. DCAQ work will allow you to identify which (or how many!) of these applies to your service.

Demand in Mental Health services Systems Perspective The amount of time needed to manage those referrals that chose to use your service Ask what they think demand is. In acute setting, where the time taken to treat or perform a procedure does not vary widely, then you can quickly ascertain demand. Is the number of referrals you get. In MH however, calculate the number of referrals that choose to use the service and multiply it by the time needed to treat. This is necessary because time needed varies due to severity, complexity, diagnosis etc. It may be necessary to look at demand for different streams of service users, split by the time they will require. For example, low intensity and high intensity psychological therapies may differ significantly and may have to be grouped as such.

Systems Perspective There are Different Types of Demand Actual Demand Created Demand Failure Demand Hidden Demand There are different types of demand. Actual Demand (what we are asked to do) Created Demand (what we choose to do above what is needed) Failure Demand (have to do it again as didn’t get right first time) Hidden Demand (need is there but it doesn’t present to us at moment) Total Demand = Actual + Failure + Created + Hidden So what? It is useful to think of demand in this way because it shows that there are things we can do which will influence some of these types. Therefore, if we can influence it, we can manage demand. We are not simply at its mercy, although it may feel like it sometimes. DCAQ work will give you lots of ideas about how might do this along the way. Influence and manage the Demand for your service

What might influence Demand? Referral pathways Opt-in and booking systems Allocation mechanism(s) Streamline the process Reduce waiting lists Do things right first time Prevention and service user education Review and discharge protocols For example Lots of aspects of how you set out your system can and does influence your demand. This list is not exhaustive. As we work through the DCAQ work, things will emerge which you feel might improve the service’s capacity to respond to the demand it faces. Be aware of this as we go through the work. 12

Capacity in Mental Health services How much work you can do in a given time period Can measure it in different ways e.g. How many service users you can see How many hours you have available for face to face work Capacity can be described as how much work you can do in a given time period. It can be measured in a number of ways. It’s how much work you can do in a given time period IF THE WORK IS THERE TO BE DONE and if you have the staff, resources and rooms to do it. Do you know what the capacity of your your service is? Do you know your own capacity? COULD USE CAPACITY CALCULATOR HERE. Given what we know about the variation in demand, we would encourage you to measure capacity as how many hours you have available for face to face work. 13

Ideas to extend Capacity Reduce process steps Optimise how long each step takes Distribute work to appropriate staff Redesign roles Additional investment There are lots of ways you can extend your capacity. Reduce the number of steps in your care delivery where possible. More steps equals more resource required and is harder to ensure quality the more steps you have. Optimising how long each step takes. This is the shortest time possible which delivers the desired outcome. Think about which staff members are most appropriate for each step and each piece of work that your service does. Where you have bottlenecks in your system, ensure you make the most of the scarce resource you do have by allowing them to focus on what only they can do. Think about the potential of redesigning roles. This is about achieving the best system balance possible. For example, you might consider taking some of the routine admin away from clinical staff and using administrative staff to do it. A number of boards have put in place self-help coaches to provide low intensity interventions to those presenting with depression within primary care. This has reduced workload coming into specialist services - so is an example of better skill mixing. Only when you have done all of the above, will you be in a position to put forward a request for additional investment. In the current climate, you simply will not get resource through additional investment without having done so. DCAQ work will help you to think about these options in the context of YOUR service. 14

So What Now? Time to get started! 15 There’s no time like the present to begin work on diagnosing what could be improved in your service or system. DCAQ work may just make it a healthier system to work in and a healthier service for your service users to pass through. 15