1. Demand and Capacity Planning and Management MIKE.LYON@SCOTLAND.GSI.GOV.UK A rational approach to delivering the best possible clinically effective and resource efficient services taking account of clinical priorities.

2. Quotes 1 “Unlike medicine, computer networks, transportation, military etc., improvement methods in healthcare are frequently not based on scientific principles, and are nothing else but trails and errors, or benchmarking one dysfunctional organisation against another.” [Litvak] “Merely enforcing a time constraint does not necessarily confer the capacity to meet it …” [Anstey, Gifford, Litvak]

3. Quotes 2 “The real challenge is not to invent but to implement.” [International Partnership for Innovative Healthcare Delivery] “We need an honest debate” [Orthopaedic Consultant] “Only clinicians can make the service more efficient and effective” [Orthopaedic Consultant]

4. SOME GUIDANCE 1 Managing Waiting Times – a good practice guide 2003 ‘The 10 Golden Rules for Waiting Times Management’ 1.The patients’ interests are paramount. 2. Adequate services should be available to meet appropriate referrals for assessment and treatment. 3. Patients should be offered care according to clinical priority and within agreed waiting time standards.

5. SOME GUIDANCE 2 Patient Rights (Scotland) Act 2011 “It is the right of every patient that … Health Care is to be patient focused: that is to say anything done to the patient must take into account the patient’s needs, have regard to the importance of providing the optimum benefit to the patient’s health and wellbeing … in following the rights of an individual patient the rights of other patients must be taken into account … the provision of health care should be proportionate and appropriate to the circumstances of each case … have regard to the importance of securing effective and efficient use of the health service … in pursuance of the rights conferred … an eligible patient is to start to receive an agreed treatment within the maximum waiting time”

6. SELF EVIDENT FACT 1 The Treatment Time Guarantee and the Maximum Outpatient Waiting Time are scheduled care targets focused on routine patients. It follows logically that there must first and foremost be sufficient capacity to ensure clinically appropriate treatment of emergency, trauma and urgent patients.

7. SELF EVIDENT FACT 2 On the basis that the capacity requirements for clinical urgency are met, the waiting time for routine scheduled patients can only be delivered on the basis of adequate, available, well utilised, well managed and clinically effective capacity that meets appropriate demand both now and in the future (available means beds not boarded into, theatres available etc.)

8. HOW DO WE KNOW? How do we know what type of capacity we require, where it should be and how much we should have? The clinical nature of the capacity we require is being addressed through research, audit, BOA, SCOT, SOSDG, the Quality Drive … We are now commencing the discussion on where the capacity should be. We know we need more activity, how do we know how much capacity we need?

9. Lucky 7 Questions 1. Potential – do we know our capacity potential; are all resources fully utilised; are there adequate resources for each clinician? 2. Balance – does activity balance against demand, i.e. the list is not continuing to rise over time? 3. Size – is the list too big, e.g. 18 weeks work for a 12 week target (the list should rise and fall across a range to buffer variation)? 4. Queues – are we trying to manage too many queues? 5. Scheduling – are there adequate urgent slots, adequate review slots, are routine patients treated predominately in date order? 6. Variation – do we smooth variation in supply, project and resource against variation in demand, take account of winter pressures? 7. Plan – do we manage against a clear plan?

10. ASKING THE 7 QUESTIONS Any clinician can ask these questions of their own circumstances. Any clinical team or service can ask these questions. If the answers are not sufficiently positive then a waiting time target will not be rationally delivered (without excessive use of waiting list initiatives or independent sector).

11. ANSWERING THE 7 QUESTIONS There is now considerable experience in the NHS in demand/capacity planning and management and proven tools and techniques that can be utilised: Discrete Event Simulation Queuing Theory Statistical Process Control Variation Methodology DCAQ (demand/capacity/activity/queue) Commercial planning packages Operations Science

12. PLANNING AND MANAGING “It is necessary to have queue specific plans based on projected demand and planned activity, however, a plan is pointless and invisible unless it is projected forward, monitored against and corrective management action taken when required. Waiting time targets must be delivered against rational plans that are managed in real time and based on well managed adequate capacity, otherwise the target risks becoming counter-productive.”

13. SO It is rational and possible for any service to: 1.Determine the best waiting times that can be delivered with current projected demand, planned activity and scheduling practice. 2.Determine what would have to change to deliver any specific waiting time. There are tools, technics and methodologies to enable us to do so. So let’s do so.

14. National Support There will be national support to: 1.Enable optimal utilisation of capacity 2.Enable whole systems working, addressing the requirements for scheduled and un-scheduled services 3.Determine the amount of any additional non-recurrent capacity that may be required, locally and nationally (remove backlog) 4.Determine the amount of any additional recurrent capacity that may be required, locally and nationally (achieve balance) 5.Develop a national plan with actions to address Trauma and Orthopaedic capacity.

15. In conclusion If there is insufficient activity available to match additions to a list, then no waiting time target will be met. Our prime objective today is not the delivery of waiting time standards; it is the delivery of high quality orthopaedic services with sufficient capacity. Ideally, the delivery of a waiting time standard should be the by-product of a clinically effective, resource efficient and adequately resourced service.