Why Are We Needed
Today’s NHS has set itself clear goals and values: to maximise service quality, safety, equity and patient outcomes at lower cost. The mechanism for delivery is a market involving multiple players. Some, such as GP consortia, are inexperienced. All (policy makers, commissioners and providers) lack knowledge of what works best within a complex, diverse, health and social care system. They also lack the tools and expertise to use that knowledge effectively.
System simulation and modelling have successfully been used in other sectors in realising the above. As a group of senior academics heavily engaged with industrial, business, medical, commissioning and community groups, we believe we can apply such methods to health and social care. Properly developed and embedded, we believe this will support integrated and evidence-based practice. The 20:20 Vision is a coherent set of connected ideas using simulation and modelling to improve the delivery of healthcare through better risk and process management.
Slow NHS adoption of modelling and simulation
There have been many initiatives to introduce a more process oriented view of care delivery to the NHS. The Modernisation Agency and the National Programme for IT are two initiatives in the past 10 years that aspired to transformational change. They left a legacy of some notable successes. However, these were mixed with a failure to delivery sustainable and radical change.
The literature shows that, as compared to sectors such as business and commerce and the military, healthcare papers report many fewer cases of impact or follow through to modelling or simulation studies. There may be cultural factors that have isolated those with the skills in simulation, modelling, risk management, design, and so forth, from those delivering the care.
That said, there are many examples of systems thinking, management science and risk management being applied to healthcare and delivering improved outcomes with significant savings. However, most of these are on either a small scale – a clinic, an ambulance service – or at a strategic planning level.
A key challenge for the NHS is, firstly, to prove that root-and-branch applications of modelling and simulation – consistently across an entire health service and integrated between the various levels of policy, commissioning and operations – can deliver benefits sustainably and at a macro-scale.
The second challenge is to see these methods, including simulation and modelling, driven by clinicians and healthcare managers to plot a migration pathway that embeds these methods deeply in the culture without detriment to the existing service outcomes and within a context of continuous improvement. In other sectors, this has been shown to be possible.
Interestingly, the metric-driven approach of the past decade means that much more data is available on how aspects of the system perform. This, in turn, makes it easier to contemplate management science, systematic risk management, and endemic modelling and simulation as a basis for redesigning systems and services at every level.
Create Capability, Capacity and Credibility
The NHS does not readily use risk-managed, modelled or simulated methods to develop processes, plan pathways, or in its processes of care delivery. World Class Commissioning called for modelling without achieving systematic adoption. Not surprisingly, the NHS also lacks expertise and capacity to use and apply such methods. Finally, a credibility gap and lack of awareness exist around the use of such approaches.
The Cumberland Initiative’s solution:
- A comprehensive base of evidence (from ‘good news’ stories to robust studies) to promote adoption
- Training –half days, immersive fellowships, medical school modules – to embed competence at scale
- A research cohort of sufficient mass to provide critical support across the healthcare system.
Develop Evidence of What Works
Controlled trials are as old as the NHS and have transformed the selection of drugs and devices. Today’s infrastructure includes academic medical schools, the FDA, the Cochrane Collaboration, and in the UK, the HTA and NICE. Nothing comparable exists for evidence related to care delivery or patient experience. There is little consensus as to what constitutes evidence. Britain also lacks systems to relate evidence to setting measures or measuring performance. This is a huge gap in our understanding and practice.
The Cumberland Initiative’s solution:
- A taxonomy and literature for experiential and operational evidence that parallels evidence-based medicine
- A systematic understanding of how such evidence should be applied in all aspects of operations, commissioning and policy, and to the setting of measures.
Lead Systems Understanding
Healthcare systems are not machines. However, they need mechanisms for action-at-a-distance whereby information collected and decisions taken in various places can be coordinated and applied to actions or decisions in other places and involving other people. As with any complex system, healthcare services frequently exhibit unexpected behaviour. We need key changes in order to design and plan for radically improved performance.
The Cumberland Initiative’s solutions:
- A systems-level understanding of care delivery that connects all scales of delivery to all levels of control
- A consistent set of perspectives, methods and tools, to enable staff at all levels to operate and commission with confidence, all within a consistent policy framework.
Support Risk-managed Decision-making
At any stage of a system’s life-cycle, decisions must be taken. Beds will close and services will be closed down but there is no way to anticipate the implications fully. In this light, there are some key requirements to allow radical redesign of healthcare systems
The Cumberland Initiative’s solutions:
- Robust decision support tools – starting with the best that now exist
- A new generation of planning and support tools and methods to predict outcomes and manage risk.