Simulation modelling of mental health services … · focussing on adults of working age, and services focussing on older people – including specialist services for people with

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Norfolk and Suffolk NHS Foundation Trust

Simulation modelling of mental health services

Project Report

15

th February 2017

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CONTENTS

Page number

1 Introduction 1.1 Background 3

1.2 Purpose and structure of document 4

2 Method 5

3 Questions and scenarios arising from engagement work 9

4

Findings from simulation modelling

14

4.1 Baseline prediction 15

4.2 Scenarios tested 25

4.3 Optimisation 42

5 Discussion and Conclusions 44

Appx Time series and heat maps of optimisations 46

http://www.simpathy.org.uk/

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1. INTRODUCTION 1.1 Background

This document sets out the results of a simulation modelling project carried out by Mental Health Strategies for mental health services in Norfolk and Suffolk. Norfolk and Suffolk NHS Foundation Trust are seeking to review the organisation and delivery of various aspects of your services, focussed around the acute care pathway, and associated community services. This is in the context of both local concerns about aspects of the operation of that pathway, and emerging national guidance; for example with the implementation plan for the Five Year Forward View now explicitly seeking to end the practice of sending acutely ill patients long distances for treatment. This has been a persistent problem in Norfolk and Suffolk. As recommended by Old problems, new solutions, the Trust are now looking to undertake a robust service capacity assessment – and, potentially, to create a “step-change” in the planning and delivery of acute mental health services in Norfolk and Suffolk. The service capacity assessment will ensure that change is based on a robust and detailed model of the way services could work in future – with an aim to see an optimised balance of investment, beds and community services. The expected resource context of this project is flat resources – redistribution of resources may be identified / proposed, but the overall spend on the Trust’s mental health services will be expected to remain constant in value terms. There is, however, expected to be a net reduction in the actual amount spent on out of area placements.

The purpose of this project is therefore to provide both a body of evidence to inform local

discussions, and independent recommendations as to specific actions which could be taken.

The scope of this project was services provided by the Trust for adults of all ages registered or resident within either Norfolk or Suffolk. This has therefore included both services focussing on adults of working age, and services focussing on older people – including specialist services for people with dementia.

The scope did not include:

Services provided for children and adolescents (although the elements of young

people’s services provided for people aged 18+ were in scope) Services provided by other providers, whether local authority, other NHS, or

third/independent sector – with the exception of overspill and alternative to admission beds, which are in scope, irrespective of provider

Specialist mental health services which are commissioned via regional or national specialist commissioning arrangements

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The project’s specific objectives, at its outset, were to answer the following questions:

Question

1 How many inpatient beds should be provided for adults of all ages with mental health problems?

2 What should be the size, role and function of crisis intervention / home treatment services?

3 What should be the size, role and function of services offering a bed-based alternative to inpatient admission, including step-down facilities?

4 What should be the size, role and function of community mental health teams?

5 What would be the impact of rebalancing resources to meet anticipated demand?

6 What would be the impact of changing resources to benchmark levels?

7 What is the potential volume of discharges to social care?

In practice, a wide range of specific questions and scenarios emerged as the project progressed, some directly related to the original questions, and some developing from these discussions. This report presents the results of the analyses and scenarios which were the main focus of local attention – and which, we hope, will provide the body of evidence which enables necessary local decisions now to be reached.

1.2 Purpose and structure of document

This document sets out the results of our work. After this introduction, the document is organised as follows: Section 2 contains a brief description of the method adopted to undertake the review

Section 3 explains the questions and scenarios which arose during our workshops and

meetings with local stakeholders

Section 4 contains the main findings of the quantitative modelling analysis

Section 5 contains a discussion of the findings, and our conclusions, in the light of the work

undertaken

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2. METHOD 2.1. Engagement meetings

This section summarises how the work was carried out. The project had both qualitative and quantitative elements. The qualitative work proceeded via a wide range of engagement meetings with local stakeholders. This wide range of engagement ensured that the data analysis was informed throughout by local understandings of service opportunities and pressures, and that analytical findings were interpreted as meaningfully and appropriately as possible.

Written notes were taken during the course of undertaking face to face or telephone interviews with key stakeholders. The key themes arising from the interviews were then analysed and discussed via the Mental Health Strategies Project Team. These notes were used to inform the development of the proposed scenarios on the mental health modelling project. It should be noted that some stakeholders attended more than one workshop and some attended a workshop and were also interviewed on an individual basis. List of stakeholders interviewed

1. Alison Armstrong, Director of Operations, Suffolk, NSFT 2. Dr Larry Ayuba, Consultant Psychiatrist, NSFT (telephone interview) 3. Andy Barton, Manager, Home Treatment Team, Suffolk, NSFT 4. Maureen Begley, Commissioning Manager, Mental Health, Norfolk County Council 5. Dr Nagendra Bendi, Consultant Psychiatrist, Crisis & Home Treatment Team, Norfolk,

NSFT 6. Steve Birt, Care Pathway & Discharge Nurse, Bury St Edmunds, Suffolk, NSFT 7. David Bullivent, Interim Manager, Suffolk, NSFT 8. Julie Cave, Finance Director / Deputy Chief Executive, NSFT 9. Laz Chirimunjiri, Deputy Service Manager (Acute), NSFT 10. Jane Coates, Acute Service Manager, Woodlands, Suffolk, NSFT 11. Pauline Davies, Locality Manager, West Norfolk, NSFT 12. Dr Stephen Dye, PICU Consultant Psychiatrist, Woodlands, Suffolk, NSFT 13. Dr Luk Ho, Consultant Psychiatrist, Fermoy Unit, Queen Elizabeth Hospital, Kings

Lynn, 14. Matt Jackson, Clinical Team Leader, Woodlands, Suffolk, NSFT 15. Donan Kelly, Service Director, Suffolk NSFT (telephone interview) 16. Charlie Loades, CTL, PICU, Norfolk, NSFT 17. Dr Martyn, Crisis & Home Treatment Team, Norfolk, NSFT 18. Emma Mertens, CTL, Thurne Ward, NSFT 19. Dr Albert Michael, Consultant Psychiatrist, NSFT 20. Del Mitchell, Community Service Manager, NSFT (telephone interview) 21. Micki Munro, Manager, Older Peoples Services, NSFT 22. Dr Tony Palframan, GP Poringland, member of South Norfolk CCG 23. Kris Panvalkar, Modern Matron, Suffolk, NSFT 24. Steph Payne, Deputy Service Manager, NSFT 25. Dr Vivien Peeler, Consultant Psychiatrist, Home Treatment Team, Suffolk, NSFT 26. Dr Simi Periera, Consultant Psychiatrist, NSFT 27. Ruth Pillar, Service Manager, Older Peoples Services, Norfolk, NSFT

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28. Dr Judy Rubenstein, Consultant Psychiatrist, Later Life, Bury St Edmunds, NSFT 29. Jane Sayer, Director of Nursing, Quality & Patient Safety, NSFT 30. Mike Seaman, Acute Service Manager, NSFT 31. Michael Scott, Chief Executive, NSFT 32. Homayoun Sepehrara, Team Manager, Crisis & Home Treatment Team, Norfolk,

NSFT (telephone interview) 33. Dr Bohdan Solomka, Medical Director, NSFT 34. Dr Suzanne Stacey, Consultant Psychiatrist, Willows Ward, Woodlands, Suffolk, NSFT 35. Darren Stanton, Clinical Lead, Crisis & Home Treatment Team, Norfolk, NSFT

(telephone interview) 36. Veno Sunghuttee, Associate Director of Operations, Norfolk, NSFT 37. Dr Rosalind Tandy, GP & West Suffolk Governing Body Member 38. Dr Uju Ugochukwu, Consultant Psychiatrist, Early Intervention in Psychosis Service,

NSFT (telephone interview) 39. Dr Hugo de Waal, Consultant Psychiatrist in Old Age Psychiatry, NSFT 40. Debbie White, Director of Operations, Norfolk & Waveney, NSFT 41. Euan Williamson, Integrated Mental Health Commissioning Manager, NHS North

Norfolk CCG and Norfolk County Council 42. Matt Wilson, Interim Project Manager, NSFT 43. Karen Wood, Transformation Lead, Mental Health, West Suffolk CCG 44. Lesley Workman, Acting Service Manager, Later Life Services, NSFT

In addition, we held 6 large group events/workshops, as opportunities to discuss together both

current issues and emerging findings.

2.2. Simulation modelling

The quantitative aspect of the work was undertaken via discrete event simulation modelling.

This approach required construction of a statistical model of the current operation of

services, identification of scenarios for change, and interactive modelling of the effects of

those scenarios to achieve the optimum use of resources. This is based, not on use of simple

averages and standardised flows, but on the creation of patient cohorts and presentations

which mimic, as far as possible, the variance between patients and patient events which

happens in real life. This proceeded via the following steps:

a) Preparation of an episode-level data schedule (i.e. a list of every contact by every

patient) for services within scope over a three year data period

b) Validation and cleansing of the data, to enable it to be used in model design. This

was done in regular discussion with Trust information and operational staff, and we

are confident that the data used in our modelling are of sufficient reliability to use

for decision-making purposes

c) Creation of a discrete event simulation model to enable forward projections to be

made.

d) Forward projections were run for five years as a baseline

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e) Via stakeholder discussions and meetings:

a. validation of the statistical inputs to the model

b. identification of “what if” scenarios – changes to services which could help

to improve flow and management of demand

c. discussion and evaluation of the modelling results

f) Between engagement activities, review and revision of the core model to ensure its

accuracy, and to test more complex combinations of scenarios

The following parameters applied to our baseline modelling, following local discussions. It

should be noted that, in this context, a “fail” is modelling terminology for an undesirable

event. The aim of the modelling process is to agree a configuration of services which is

expected to minimise the number of fails. In this project, the following have been regarded

as fails:

use of acute overspill

waiting to access services for longer than the agreed waiting time threshold for

that service

referrals to services which are already at their agreed safe caseload limit

It should be noted that, for waiting time “fails,” each individual event of excess waiting

will be regarded for modelling purposes as an individual modelling fail. This does not imply

that the service overall will be considered as having failed to meet its service target, as

there are national and local targets for many services which do not expect 100% of

demand to be met within the waiting time threshold. The waiting time targets here are

also not necessarily contractual targets; they are simply the thresholds which were agreed

for the purposes of this project.

1. The safe operating caseload limit for community teams is equivalent to the peak

caseload over the six months prior to the census date

2. The volume of demand for each service (both external referrals and internal transfers)

will follow a trend established by the most recent stable trend within the three years

prior to the modelling period – but adjusted by demographic change for the

catchment population as estimated by the ONS

3. External referrals are modelled using a Poisson distribution with mean equal to the

observed rate described above at (2)

4. The pattern of variance in lengths of stay (inpatients) and contact intensity

(community services) will follow a trend established by the most recent stable trend

within the three years prior to the modelling period

5. Length of stay distributions are generated by segmenting the set of all discharges

associated with a service into percentiles. The uppermost percentile boundary is

trimmed to ensure the mean of the length of stay distribution matches the mean of

the underlying dataset

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6. Where, due to recent service reconfigurations, historic length of stay does not

represent the expected length of stay of new patients joining the service, a length of

stay profile will be generated using the number of caseload days/occupied bed days

and discharges for the service over the most recent stable period

7. The waiting time standard for all referrals classed as emergency is 4 hours, for urgent

is 120 hours, and for all referrals classed as routine is 28 days. Referrals not assessed

in these periods will be counted as a waiting time fail

8. If demand rises above capacity for inpatient beds, an overspill fail will be created for

each bed night a patient spends in an overspill bed

9. If a resident of Norfolk is admitted to a bed in Suffolk, or vice versa, this will be

counted as an internal overspill fail

10. Capacity of overspill beds is unlimited

11. Wards are considered full once 100% capacity is reached, inclusive of leave.

12. Male patients can be admitted only to beds designated as suitable for male patients;

female patients only to beds designated as suitable for female patients.

13. All NHSE-commissioned secure services are out of scope and should not be considered

as fails

14. A bed for the “wrong” age group will always be used in preference to overspill. The

age cut-off for older people’s functional services is 70.

15. If demand rises above capacity for community services, patients will join a waiting list

until a caseload space is available. There are local clinical criteria to determine priority

access, but data is not captured on this decision in a systematic way.

16. With the exception of A&E liaison only, services must retain patients on their caseload

until the required downstream service has capacity to accept them – caseload days

attributable to such patients are counted as internal delayed transfers of care within

the model.

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3. QUESTIONS AND SCENARIOS ARISING FROM ENGAGEMENT WORK

This section presents, for clarity and completeness, a list of the main proposals arising from our engagement work. This list was subsequently discussed

both by the Mental Health Strategies project team, and with the Trust steering group, and the most promising/supported ideas taken forward to modelling.

Other proposals could of course still be considered as part of the finalisation of the modelling process.

Norfolk & Suffolk

No. Population Intervention Flow Outcome

1 Individuals with acute mental health problems

Currently the Trust has different care pathways. Common acute care pathway needed across the Trust

Greater consistency in admission rates; greater use of alternatives to admission

2 Cluster 8: Individuals with personality disorder

Develop a Personality Disorder Service as recommended in FYFV

Reduce health service usage by people with personality disorder over time

3 Older age population requiring admission

Increase the capacity for caring for individuals in later life by revising the balance of adult and later life beds. The older age population will be cared for by staff who are trained and experienced in caring for this group

Eliminate out of area admissions for older people

Norfolk


4 Individuals seeking inpatient admission in an acute bed

Ensure that access to all beds are managed via the CRHTTs and only the CRHTTs over 24 hour period. Ensure all patients are considered for Home Treatment

Increased diversion rate.

5 Individuals on acute admission wards

Stepdown facility Relieve pressure on the beds Reduction in acute admission days

6 Individuals in crisis who are being admitted at present but may be suitable for home treatment

Separate the Crisis Teams out from Home Treatment Teams. At present the CRHTTs are doing more crisis assessment work than home treatment. This is due to the number of 4 hour assessments they need to conduct and staffing issues.

Increased ability to offer Home Treatment. Fuller utilisation and protection of the ability of the CRHTTs to offer home treatment.

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7 Individuals beginning to break down

Early intervention café run with mix of statutory and peer support This could also support people with personality disorder

Admission avoidance

8 Individuals who are currently being admitted as they need to be removed from living situation

Block purchase B & B beds Establish links between CRHTTs and B & Bs Manage those admitted to a B & B as an alternative to admission via CRHTTs

Reduction in acute admission days

9 Individuals on inpatient wards At present the CRHTTs have one team member in each team doing in reach work onto the wards. There is a need to strengthen this link between the CRHTTs and the wards.

Support early discharge.

10 People requiring admission Increase the number of beds in Norwich

Reduce the number of beds on existing wards but provide more wards

Elimination of OOA

11 Cluster 8: Individuals with personality disorder

Mind run the “Wave” service in Central Norfolk. Expand service to West Norfolk, if there is clear evidence of benefit

Reduction in health service usage Shorten length of stay

12 People being referred by GPs for urgent assessment

Identify a cohort of Norfolk Consultant Psychiatrists to participate in an on call rota for GPs Change referral options GPs have to 4hrs/ 24 hours/120 hours/28 days Manage GP expectations, and skills. Explore option of GPs completing the Diploma in Mental Health (like in Sutton / SWL) Ensure CRHTTs have clear referral criteria and provide staff training to prevent them assessing all referrals. Ensure that they are adequately resourced.

Reduce the number of referrals from GPs and assessments being conducted by the CRHTTs. At present 75% to 90% are not taken onto the CRHTTs caseload Ensure that 4 hour urgent assessments are only conducted for those who are in crisis.

13 Individuals with enduring mental health problems who

Reinstate Assertive Outreach Teams Reduction in admissions?

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are difficult to engage

14 Individuals who are in contact with the Police

Place Street Triage Nurses on the streets with the Police as opposed to in the Control Room

May reduce the number of detentions under S136

15 Individuals with dementia Improve the consistency of the DISTs to prevent admission. Review the fact that they have no medical or clinical psychology input

Increase the ability of the DISTs to prevent admissions across the Trust

16 Individuals with dementia requiring short-term care

Secure contract for two alternative to admission beds for people with dementia.

Prevent inpatient admission

17 Young people with dementia Provide beds for young people with dementia Provision which specifically meets the needs of

this patient group. They are being admitted to adult acute at present.

18 Individuals in the CMHT caseloads

Offer enhanced opening hours 8am to 8pm or 10pm and weekends

Reduce out of hours admissions and presentations to CRHTTs and A & E

19 Homeless people in Norfolk

The Trust used to have a Homeless Team. There is a need to address the needs of this group. Hostels have closed which used to house them. Proposed interventions include a)Re open hostels b)Day Centre c)Some form of community engagement with this group to identify deterioration in mental health early on

Tailored provision to meet the specific needs of the homeless – possibility to reduce admissions?

20 People waiting for CMHT allocation

CMHTs in West Norfolk are able to accept referrals but have a list of patients waiting to be allocated. Some are managed by the CRHTT in the meantime. They are reviewing team members caseloads and are about to start using a caseload management tool

Eliminate waiting list for allocation – free up capacity in CRHTTs

21 Individuals with mental health problems

Have one large wider Community Mental Health Team linking up with MCPs

Improved patient flow due to a reduction in the number of different community teams and interfaces

22 People at risk of suicide Provide low level psychiatric support. There is a gap between the Wellbeing Service, the counsellors employed by GP practices and what is on offer via the mainstream

Reduction in referrals to mainstream mental health services by offering more low level psychiatric support in primary care

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mental health services. Suicide rate in Norfolk & Suffolk is high. GP referrals to MH are only accepted 20% of the time. GPs are left to manage risk the rest of the time.

Suffolk

No. Population Intervention Flow outcome


Remove the AAT and manage SPOA via IDTs Reduce duplication between AAT and IDT


Merge AAT, Home Treatment Team and Liaison Psychiatry

Reduce interfaces and improve communication and patient flow

25 Individuals on the IDT caseload who are becoming unwell

Strengthen the ability of the IDTs to work via the FACT model and be more responsive

Prevent some admissions to hospital as this will enhance the ability of the IDTs to intervene early on

26 Individuals in crisis Remerge the Crisis element and Home

Treatment element of the former CRHTT

27 Individuals on acute admission wards in Suffolk

Ensure Norfolk Social Care staff respond to emails, attend meetings and address the needs of all Norfolk patients in Suffolk beds as a priority

Reduce the length of stay of Norfolk patients in Suffolk beds

28 Individuals with dual diagnosis (mental health and substance misuse) in Suffolk

Address lack of substance misuse and dual diagnosis services in Suffolk

Enhance the ability of people with dual diagnosis to receive support

29 Individuals with dementia Strengthen the ability of the DIST to be able to prevent admission to hospital

Prevent admission to hospital in some instances

30 Individuals with dementia Consider how to locally manage the needs of elderly people with dementia who require PICU

Prevent OOAs or ensure that OOA placements for this patient group are commissioned in a more planned way

31 Individuals with personality Develop a Crisis House run by the Trust Reduction in inpatient admissions

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disorder offering a max of 72 hour admission for social or practical reasons. The CRHTTs could manage the person whilst in the Crisis House

32 Individuals with dementia Enable GPs to have swift access to a Psychiatrist or Clinical Psychologist for people with dementia

Improved flow via community teams


Decrease the number of inpatient beds– this will enable Consultants to see patients more frequently whilst they are on the ward which in turn will help facilitate discharge.

Increase in the number of times patients are assessed by the Consultant Psychiatrist on the inpatient wards. May lead to shorter LOS


There is one crisis bed in Bury St Edmunds. This works well. There is a need to increase this to two beds.

Reduction in inpatient admissions

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4. FINDINGS FROM SIMULATION MODELLING

This section presents the findings of the quantitative element of our work, the simulation modelling. Our presentation starts with the baseline prediction – what would happen if the service simply continues as currently planned. It then presents the individual results of the key scenarios tested. Next, various possible optimised scenarios are described based on combinations of the scenarios. Each of the scenarios is numbered and summarised, for ease of overall reference; all are five-year projections. The results of modelling work of this nature should always be interpreted with a measure of caution. The findings here do not represent what is certain to happen; they present what is predicted to happen if the scenarios here do in fact happen, and if no other significant events emerge during the planning period. There is also always the risk of random variation, although the numbers here are sufficiently large that this need not be a major concern. Modelling results should therefore be taken only as one source of evidence in the local decision-making process, to sit alongside local knowledge of the strengths of weaknesses of services, and of the local community’s needs and aspirations.

4.1 Baseline prediction In order to identify potential issues of capacity and flow with the proposed locality model over the next five years, and to allow a basis of comparison for our scenario work, we first generated a ‘base model’. The modelling assumptions and results of the base model simulation are shown below. In the results table, and throughout this section, terms should be understood as follows: Total Fails: the total number of over-capacity, overspill, and waiting time fails as described below. Note that these are the total numbers over the 5 year modelling period, not per year. Over Capacity Fails: the number of times a patient is referred to a service within the model’s scope which is over its operational capacity at the time of the referral, where that service is not permitted to run a waiting list Waiting Time Breaches: the number of times a patient remains on the waiting list of a service for longer than the specified maximum waiting list for that service External overspill admissions: the number of times a patient is admitted to a bed/service of a nature which is provided by the Trust, but to a different provider Overspill bed days: the number of bednights occupied by patients residing in the trust patch in beds provided by other providers as acute overspill. Each 1825 OBDs represent, on average, a whole bed occupied throughout the five-year modelling period. These are broken down into the various functional service types Implied number of beds (mean): the mean number of overspill beds occupied at any one time during the modelling period

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BASELINE MODEL

In both the baseline model, and all of the scenarios, we have assumed that the population will change in accordance with the ONS’s projections for demographic growth. The baseline model below shows that, on this assumption, but with no other changes to services – and with existing service trends continuing:

• Inpatient services will be under pressure in both Norfolk and Suffolk in both working age and older adult services.

• In Norfolk, most overspill is predicted in working age adult acute and dementia inpatient services. In Suffolk, most overspill is predicted in older adult and rehabilitation services.

Metric (over 5 year simulation) Baseline

Activity

…total caseload days 27,055,950

…total contacts 319,366

…total occupied bed days 621,621

…total new episodes 244,716

Fails - Norfolk 14,902

…over capacity fails 426

…waiting time fails 12,360

…overspill fails 2,116

Fails - Suffolk 3,805

…over capacity fails 7

…waiting time fails 3,027

…overspill fails 772

Overspill - Norfolk

…total bed days 66,663

…total implied beds 36.5

…implied beds - working age (inc. asst) 17.6

…implied beds - PICU 1.8

…implied beds - older adult functional 3.3

…implied beds - dementia 12.7

…implied beds - other 1.2

Overspill - Suffolk

…total bed days 36,625

…total implied beds 20.1

…implied beds - working age (inc. asst) 8.1

…implied beds - PICU 0.6

…implied beds - older adult functional 2.7

…implied beds - dementia 3.5

…implied beds - other 5.2

Significant waiting time fails are predicted for the following services. Fail rates are shown in brackets in each case:

• Coastal IDT - Coastal CLL (92.1% fails)

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• West Norfolk Adult - Adult CMHT (90.9% fails) • Central Norfolk Adult - South AFI (73.6% fails) • Central Norfolk Adult - North AFI (70.9% fails) • West Norfolk DCLL - DCLL CMHT (42.5% fails) • Bury South IDT - Adults Bury South IDT (34.3% fails) • Ipswich IDT - Youth Ipswich IDT (30.4% fails) • Central Norfolk Adult - South City AFI (27.4% fails) • GYW DCLL - Waveney Memory Treatment (25.0% fails) • Bury South IDT - Youth Bury South IDT (24.8% fails) • Ipswich IDT - Adults Ipswich IDT (19.6% fails) • GYW CFYP - Early Intervention (18.2% fails) • GYW Adult - Waveney Adult Community (17.2% fails) • Bury South IDT - Bury South CLL (13.2% fails) • GYW CFYP - Eating Disorders (9.2% fails) • West Norfolk CFYP - Early Intervention (4.9% fails)

4.1.1 Baseline trends It is important to understand the expected volatility in the pattern of inpatient pressure. The sample charts below, based on a single run of our model, but typical of the pattern we observed, show the number of overspill beds required each day over the modelling period. For Norfolk, where assessment beds are distinguished from working age adult acute beds, the modelling estimate is that there will mostly be sufficient beds, but there will be regular peaks where demand will exceed capacity:

Baseline Results – Norfolk Assessment Beds

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This volatility can be understood more fully in the following heat map. This shows the overall results of multiple runs of our model. With 16 beds, for example, on every time we ran the model, excess demand for this service was observed on at least 5% of days. On 16% of runs of the model, excess demand was observed on at least 10% of days. These permit the Trust to consider your baseline appetite for risk. If, for example, a 5% excess demand rate is considered acceptable, the current bed numbers and configuration would be sufficient. To reduce this to a probable 1% excess demand rate would require 20 beds, with existing bed use trends.

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Occupied Beds Beds

1% 2% 5% 10% 15% 20%

Beds 1 day 18 days 37 days 91 days 183 days 274 days 365 days

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14 100% 100% 100% 100% 100% 100% 46%

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17 100% 100% 100% 54% 0% 0% 0%

18 100% 100% 86% 0% 0% 0% 0%

19 100% 86% 14% 0% 0% 0% 0%

20 100% 14% 0% 0% 0% 0% 0%

21 100% 8% 0% 0% 0% 0% 0%

22 92% 0% 0% 0% 0% 0% 0%

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Baseline Results – Norfolk Working Age Beds

For working age acute beds in Norfolk, the picture is of significantly more persistent excess demand:

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120

140

Oct

-16

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Ap

r-1

9

Jul-

19

Oct

-19

Jan

-20

Ap

r-2

0

Jul-

20

Oct

-20

Jan

-21

Ap

r-2

1

Jul-

21

Occupied Beds Beds

15th February 2017

19

The heat map for Norfolk working age adult acute beds shows that, in the baseline, as many as 110

beds would be required to achieve a 1% of days overspill rate. The existing bed numbers, with no

mitigations, look certain to produce routine overspill.

Baseline Results – Suffolk Assessment Beds For Suffolk’s assessment beds, the sample runs show that these bed numbers appear adequate on

average, but will experience regular peaks of demand which will exceed capacity:

1% 2% 5% 10% 15% 20%


92 100% 100% 100% 100% 100% 100% 100%

94 100% 100% 100% 100% 100% 100% 70%

96 100% 100% 100% 100% 100% 70% 32%

98 100% 100% 100% 100% 100% 41% 8%

100 100% 100% 100% 100% 54% 8% 0%

102 100% 100% 100% 95% 16% 0% 0%

104 100% 100% 100% 38% 0% 0% 0%

106 100% 100% 78% 8% 0% 0% 0%

108 100% 84% 38% 8% 0% 0% 0%

110 100% 46% 14% 0% 0% 0% 0%

0

5

10

15

20

25

30

35

Oct

-16

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Ap

r-1

9

Jul-

19

Oct

-19

Jan

-20

Ap

r-2

0

Jul-

20

Oct

-20

Jan

-21

Ap

r-2

1

Jul-

21

Occupied Beds Beds

0

5

10

15

20

25

30

35

Oct

-16

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Ap

r-1

9

Jul-

19

Oct

-19

Jan

-20

Ap

r-2

0

Jul-

20

Oct

-20

Jan

-21

Ap

r-2

1

Jul-

21

Occupied Beds Beds

15th February 2017

20

The heat map for Suffolk’s assessment beds shows that 16 beds are certain to produce persistent

excess demand. At least 22 beds would be required to reduce the number of expected excess

demand days to, probably, no more than 5% of days:

Baseline Results – Suffolk Working Age Beds

For working age adult beds in Suffolk, there appear mostly to be sufficient beds, but there are

regular peaks of excess demand.

0

5

10

15

20

25

30

35O

ct-1

6

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Ap

r-1

9

Jul-

19

Oct

-19

Jan

-20

Ap

r-2

0

Jul-

20

Oct

-20

Jan

-21

Ap

r-2

1

Jul-

21

Occupied Beds Beds

1% 2% 5% 10% 15% 20%


16 100% 100% 100% 100% 100% 100% 100%

17 100% 100% 100% 100% 100% 100% 68%

18 100% 100% 100% 100% 100% 38% 14%

19 100% 100% 100% 100% 46% 5% 0%

20 100% 100% 100% 78% 5% 0% 0%

21 100% 100% 100% 22% 0% 0% 0%

22 100% 100% 62% 5% 0% 0% 0%

23 100% 70% 14% 5% 0% 0% 0%

24 100% 30% 5% 0% 0% 0% 0%

25 70% 5% 5% 0% 0% 0% 0%

0

10

20

30

40

50

60

70

80

90

Oct

-16

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Ap

r-1

9

Jul-

19

Oct

-19

Jan

-20

Ap

r-2

0

Jul-

20

Oct

-20

Jan

-21

Ap

r-2

1

Jul-

21

Occupied Beds Beds

15th February 2017

21

The heat map for working age adult beds in Suffolk suggests that at least 75 beds would be required,

on current use trends, to reduce expected overspill days to below 5%.

For remaining bed types, we give the heat maps below, in each case highlighting the bed numbers

which would be required, on current use trends, to reduce expected overspill days to below 5%:

0

10

20

30

40

50

60

70

80

90O

ct-1

6

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Ap

r-1

9

Jul-

19

Oct

-19

Jan

-20

Ap

r-2

0

Jul-

20

Oct

-20

Jan

-21

Ap

r-2

1

Jul-

21

Occupied Beds Beds

0

10

20

30

40

50

60

70

80

90

Oct

-16

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Ap

r-1

9

Jul-

19

Oct

-19

Jan

-20

Ap

r-2

0

Jul-

20

Oct

-20

Jan

-21

Ap

r-2

1

Jul-

21

Occupied Beds Beds

1% 2% 5% 10% 15% 20%


61 100% 100% 100% 100% 100% 100% 100%

63 100% 100% 100% 100% 100% 100% 95%

65 100% 100% 100% 100% 100% 86% 30%

67 100% 100% 100% 100% 86% 22% 8%

69 100% 100% 100% 86% 30% 8% 8%

71 100% 100% 100% 54% 8% 8% 0%

73 100% 92% 62% 14% 8% 0% 0%

75 100% 62% 46% 8% 0% 0% 0%

77 100% 46% 14% 0% 0% 0% 0%

79 92% 30% 0% 0% 0% 0% 0%

15th February 2017

22

Baseline Results – Norfolk PICU Beds To reduce expected excess demand days to and expectation of below 5%, on current use trends, 17

Norfolk PICU beds would be required.

Baseline Results – Norfolk Functional Beds (Older People) To reduce expected excess demand days to and expectation of below 5%, on current use trends, 25

Norfolk functional illness (older people) beds would be required.

Baseline Results – Norfolk Dementia Beds To reduce expected excess demand days to and expectation of below 5%, on current use trends, 86

Norfolk dementia beds would be required.

1% 2% 5% 10% 15% 20%


10 100% 100% 100% 100% 100% 100% 100%

11 100% 100% 100% 100% 100% 92% 78%

12 100% 100% 100% 100% 86% 78% 46%

13 100% 100% 100% 86% 70% 22% 0%

14 100% 95% 86% 70% 22% 0% 0%

15 100% 86% 70% 46% 0% 0% 0%

16 100% 70% 54% 0% 0% 0% 0%

17 86% 46% 22% 0% 0% 0% 0%

18 62% 24% 0% 0% 0% 0% 0%

19 46% 0% 0% 0% 0% 0% 0%

1% 2% 5% 10% 15% 20%


17 100% 100% 100% 100% 100% 100% 100%

18 100% 100% 100% 100% 100% 100% 86%

19 100% 100% 100% 100% 92% 78% 49%

20 100% 100% 100% 100% 78% 49% 32%

21 100% 100% 100% 86% 49% 24% 0%

22 100% 100% 95% 62% 16% 0% 0%

23 100% 95% 86% 32% 0% 0% 0%

24 100% 78% 54% 16% 0% 0% 0%

25 95% 49% 32% 8% 0% 0% 0%

26 86% 32% 16% 8% 0% 0% 0%

1% 2% 5% 10% 15% 20%


70 100% 100% 100% 100% 100% 100% 100%

72 100% 100% 100% 100% 100% 100% 100%

74 100% 100% 100% 100% 100% 100% 76%

76 100% 100% 100% 100% 100% 68% 35%

78 100% 100% 100% 100% 68% 35% 19%

80 100% 100% 100% 84% 27% 19% 11%

82 100% 92% 84% 43% 19% 11% 11%

84 100% 76% 68% 27% 11% 5% 0%

86 84% 51% 43% 11% 5% 0% 0%

88 76% 43% 19% 11% 5% 0% 0%

15th February 2017

23

Baseline Results – Norfolk Step Down Beds To reduce expected excess demand days to and expectation of below 5%, on current use trends, 10

Norfolk step-down beds would be required.

Baseline Results – Suffolk PICU Beds To reduce expected excess demand days to and expectation of below 5%, on current use trends, 14

Suffolk PICU beds would be required.

Baseline Results – Suffolk Functional Beds (older people) To reduce expected excess demand days to and expectation of below 5%, on current use trends, 22

Suffolk functional beds for older people would be required.

1% 2% 5% 10% 15% 20%


5 100% 100% 100% 100% 100% 100% 100%

6 100% 100% 100% 100% 100% 92% 68%

7 100% 100% 100% 100% 76% 30% 22%

8 100% 100% 100% 68% 22% 0% 0%

9 100% 84% 59% 14% 0% 0% 0%

10 100% 51% 14% 0% 0% 0% 0%

11 76% 5% 0% 0% 0% 0% 0%

12 51% 0% 0% 0% 0% 0% 0%

13 5% 0% 0% 0% 0% 0% 0%

14 0% 0% 0% 0% 0% 0% 0%

1% 2% 5% 10% 15% 20%


7 100% 100% 100% 100% 100% 100% 100%

8 100% 100% 100% 100% 100% 100% 100%

9 100% 100% 100% 100% 100% 92% 51%

10 100% 100% 100% 100% 76% 38% 22%

11 100% 100% 100% 84% 30% 14% 8%

12 100% 92% 84% 35% 8% 0% 0%

13 100% 68% 59% 8% 0% 0% 0%

14 92% 51% 30% 0% 0% 0% 0%

15 84% 8% 0% 0% 0% 0% 0%

16 59% 0% 0% 0% 0% 0% 0%

1% 2% 5% 10% 15% 20%


16 100% 100% 100% 100% 100% 100% 100%

17 100% 100% 100% 100% 100% 92% 59%

18 100% 100% 100% 100% 92% 54% 22%

19 100% 100% 100% 84% 59% 8% 0%

20 100% 92% 92% 59% 0% 0% 0%

21 100% 84% 76% 14% 0% 0% 0%

22 84% 76% 30% 0% 0% 0% 0%

23 76% 30% 5% 0% 0% 0% 0%

24 76% 14% 0% 0% 0% 0% 0%

25 46% 0% 0% 0% 0% 0% 0%

15th February 2017

24

Baseline Results – Suffolk Dementia Beds

To reduce expected excess demand days to and expectation of below 5%, on current use trends, 35

Suffolk dementia beds would be required.

Baseline Results – Suffolk Rehabilitation Beds To reduce expected excess demand days to and expectation of below 5%, on current use trends, 20

Suffolk rehabilitation beds would be required.

These are baseline assessments; we now turn to consider mitigation scenarios which have arisen for

these various pressures.

1% 2% 5% 10% 15% 20%


25 100% 100% 100% 100% 100% 100% 100%

26 100% 100% 100% 100% 100% 100% 92%

27 100% 100% 100% 100% 100% 92% 78%

28 100% 100% 100% 100% 92% 84% 62%

29 100% 100% 100% 100% 84% 62% 38%

30 100% 100% 100% 92% 62% 46% 38%

31 100% 100% 84% 68% 54% 30% 14%

32 100% 84% 84% 62% 38% 14% 0%

33 100% 84% 84% 38% 14% 0% 0%

34 92% 84% 68% 22% 0% 0% 0%

1% 2% 5% 10% 15% 20%


10 99% 100% 100% 100% 100% 100% 100%

11 100% 100% 100% 100% 100% 100% 100%

12 100% 100% 100% 100% 100% 92% 92%

13 100% 100% 100% 92% 92% 92% 92%

14 100% 92% 92% 92% 92% 92% 76%

15 92% 92% 92% 92% 76% 76% 70%

16 92% 84% 84% 76% 70% 62% 46%

17 76% 70% 70% 70% 46% 38% 30%

18 70% 70% 70% 62% 30% 30% 22%

19 70% 62% 54% 38% 30% 22% 8%

15th February 2017

25

4.2 Scenarios tested Scenario 1 – Standardise acute pathways

There is considerable variation between areas of Norfolk and Suffolk, in terms both of the way the acute pathways are organised, and the rates of

admission observed. This appears difficult to attribute solely to local variance in need. There appears to be a high level of correlation between wards’

physical location and admission rates:

15th February 2017

26

This correlation is also observed, albeit slightly more weakly, in beds for dementia (above) and for functional illness in older people (below):

15th February 2017

27

The tables below show the recent trends in admission rate per capita, by locality and bed type, over the past three years:

15th February 2017

28

Working Age adult admissions

County / CCG

Admissions Oct 2013-Sept

2014


2015


2016

Total Admissions

(3 years) Population

(18-64)

Admissions per 100,000 population

(3 yrs) Norfolk 1,358 1,510 1,440 4,308 571,063 754

NHS Norwich CCG 380 494 490 1,364 126,084 1,082 NHS Great Yarmouth and Waveney CCG 363 389 330 1,082 119,199 908 NHS West Norfolk CCG 251 246 229 726 96,249 754 NHS North Norfolk CCG 145 144 179 468 91,943 509 NHS South Norfolk CCG 219 237 212 668 137,588 486

Suffolk 835 756 850 2,441 361,111 676 NHS West Suffolk CCG 366 311 333 1,010 131,394 769 NHS Ipswich and East Suffolk CCG 469 445 517 1,431 229,717 623

Working age adult bed days

County / CCG

OBDs Oct 2013-Sept

2014

OBDs Oct 2014-Sept

2015

OBDs Oct 2015-Sept

2016 Total OBDs (3

years) Population

(18-64) OBDs per 100,000 population (3 yrs)

Norfolk 47,637 47,718 44,766 140,121 571,063 24,537 NHS Norwich CCG 15,560 15,437 15,566 46,563 126,084 36,930 NHS Great Yarmouth and Waveney CCG 13,172 11,565 7,979 32,716 119,199 27,447 NHS West Norfolk CCG 6,571 9,146 7,515 23,232 96,249 24,137 NHS North Norfolk CCG 5,484 4,578 6,046 16,108 91,943 17,520 NHS South Norfolk CCG 6,850 6,992 7,660 21,502 137,588 15,628

Suffolk 31,872 31,458 30,502 93,832 361,111 25,984 NHS West Suffolk CCG 10,636 11,978 12,944 35,558 131,394 27,062 NHS Ipswich and East Suffolk CCG 21,236 19,480 17,558 58,274 229,717 25,368

15th February 2017

29

Older adult admissions (functional)

County / CCG


2014


2015


2016

Total Admissions


(65+)


(3 yrs) Norfolk 111 114 88 313 239,615 131

NHS Norwich CCG 21 28 28 77 35,587 216 NHS Great Yarmouth and Waveney CCG 28 26 20 74 53,424 139 NHS West Norfolk CCG 20 23 11 54 44,740 121 NHS North Norfolk CCG 24 20 8 52 49,226 106 NHS South Norfolk CCG 18 17 21 56 56,638 99

Suffolk 113 92 80 285 135,853 210 NHS Ipswich and East Suffolk CCG 70 62 54 186 87,630 212 NHS West Suffolk CCG 43 30 26 99 48,223 205

Older adult bed days (functional)

County / CCG

OBDs Oct 2013-Sept

2014

OBDs Oct 2014-Sept

2015

OBDs Oct 2015-Sept

2016 Total OBDs (3

years) Population

(65+) OBDs per 100,000 population (3 yrs)

Norfolk 7,209 7,018 6,732 20,959 239,615 8,747 NHS Norwich CCG 1,713 1,930 2,647 6,290 35,587 17,675 NHS Great Yarmouth and Waveney CCG 1,848 2,152 1,238 5,238 53,424 9,805 NHS North Norfolk CCG 1,535 1,060 684 3,279 49,226 6,661 NHS South Norfolk CCG 970 852 1,638 3,460 56,638 6,109 NHS West Norfolk CCG 1,143 1,024 525 2,692 44,740 6,017

Suffolk 8,846 7,314 8,094 24,254 135,853 17,853 NHS Ipswich and East Suffolk CCG 4,737 3,965 4,751 13,453 87,630 15,352 NHS West Suffolk CCG 4,109 3,349 3,343 10,801 48,223 22,398

15th February 2017

30

Dementia Admissions

Dementia bed days

County / CCG

OBDs Oct 2013-Sept

2014

OBDs Oct 2014-Sept

2015

OBDs Oct 2015-Sept

2016 Total OBDs (3

years) Population

(65+) OBDs per 100,000 population (3 yrs)

Norfolk 26,674 25,249 22,831 74,754 239,615 31,198 NHS Great Yarmouth and Waveney CCG 13,848 11,609 9,408 34,865 53,424 65,261 NHS Norwich CCG 2,660 4,290 4,387 11,337 35,587 31,857 NHS North Norfolk CCG 4,405 3,960 4,006 12,371 49,226 25,131 NHS South Norfolk CCG 4,498 4,727 4,248 13,473 56,638 23,788 NHS West Norfolk CCG 1,263 663 782 2,708 44,740 6,053

Suffolk 4,619 5,497 4,576 14,692 135,853 10,815 NHS Ipswich and East Suffolk CCG 3,321 3,508 2,638 9,467 87,630 10,803 NHS West Suffolk CCG 1,298 1,989 1,938 5,225 48,223 10,835

County / CCG


2014


2015


2016

Total Admissions


(65+)


(3 yrs) Norfolk 168 102 106 376 239,615 157

NHS Norwich CCG 33 23 19 75 35,587 211 NHS Great Yarmouth and Waveney CCG 47 24 35 106 53,424 198 NHS South Norfolk CCG 35 27 24 86 56,638 152 NHS North Norfolk CCG 33 20 16 69 49,226 140 NHS West Norfolk CCG 20 8 12 40 44,740 89

Suffolk 55 61 40 156 135,853 115 NHS Ipswich and East Suffolk CCG 40 45 25 110 87,630 126 NHS West Suffolk CCG 15 16 15 46 48,223 95

15th February 2017

31

South Norfolk has the lowest use of working age inpatient beds across the Trust, both in terms of admissions and occupied bed days. West Norfolk has, overall, the lowest use of older adult inpatient beds.

In this scenario we consider the impact of rolling out the acute model from those parts of the patch across the whole trust. Given that this would be a large change, we present two versions of this, one where the full impact can be achieved, and another where only 50% of the impact can be achieved.


Standardise acute pathways

(100% impact)

Standardise acute pathways

(50% impact) Activity

…total caseload days 27,055,950 27,002,334 27,038,735 …total contacts 319,366 319,917 320,152 …total occupied bed days 621,621 354,815 438,849 …total new episodes 244,716 237,430 241,309

Fails - Norfolk 14,902 14,834 14,222 …over capacity fails 426 434 495 …waiting time fails 12,360 13,613 12,258 …overspill fails 2,116 787 1,469

Fails - Suffolk 3,805 3,226 2,628 …over capacity fails 7 23 8 …waiting time fails 3,027 2,868 2,451 …overspill fails 772 335 168

Overspill - Norfolk …total bed days 66,663 6,561 33,850

…total implied beds 36.5 3.6 18.5 …implied beds - working age (inc. asst) 17.6 0.6 14.7 …implied beds - PICU 1.8 1.8 2.1 …implied beds - older adult functional 3.3 0.0 0.7 …implied beds - dementia 12.7 0.0 0.0 …implied beds - other 1.2 1.1 1.1

Overspill - Suffolk …total bed days 36,625 14,306 8,850


15th February 2017

32

Scenario 2 – Remove assessment ward

In this scenario we have redesignated the assessment wards in both Norfolk and Suffolk as working age adult assessment and treatment wards. We have assumed no change to overall inpatient episode LOS as a result of this change.

This has a small positive impact in terms of reducing overspill. This arises from the fact that a bigger bed pool is more able to withstand natural variation in demand from day to day.


Redesignate Assessment

Beds Activity

…total caseload days 27,055,950 27,060,136 …total contacts 319,366 320,364 …total occupied bed days 621,621 616,115 …total new episodes 244,716 244,783

Fails - Norfolk 14,902 14,673 …over capacity fails 426 389 …waiting time fails 12,360 12,483 …overspill fails 2,116 1,802

Fails - Suffolk 3,805 3,242 …over capacity fails 7 10 …waiting time fails 3,027 2,714 …overspill fails 772 519

Overspill - Norfolk …total bed days 66,663 60,068

…total implied beds 36.5 32.9 …implied beds - working age (inc. asst) 17.6 13.8 …implied beds - PICU 1.8 2.0 …implied beds - older adult functional 3.3 3.4 …implied beds - dementia 12.7 12.6 …implied beds - other 1.2 1.1

Overspill - Suffolk …total bed days 36,625 29,919


15th February 2017

33

Scenario 3 - Crisis Cafes

In this scenario we have set up two Crisis Cafés, adopting the Surrey model, whereby all referrals are gatekept by the Trust, but the actual service is operated in partnership with a voluntary organisation, with significantly extended hours of operation. In Surrey, there was evidence that Crisis Cafés resulted in a reduction of adult inpatient admissions by up to 33%. We have conducted a sensitivity analysis based on the proportion of this reduction that could be achieved across Norfolk and Suffolk, discounting the effect by 20%, 50% and 80%. We have also limited the effect of this scenario to the populations of Norwich and Ipswich, where we have assumed the two services would be based. With this limitation, this shows a small beneficial effect, overall.

Metric (over 5 year simulation) Baseline Crisis Café

7% Crisis Café

17% Crisis Café

26%

Activity …total caseload days 27,055,950 27,032,652 27,048,977 27,045,920

…total contacts 319,366 319,719 320,439 319,875

…total occupied bed days 621,621 618,544 604,434 598,452

…total new episodes 244,716 244,603 244,288 243,848

Fails - Norfolk 14,902 15,568 14,837 14,854

…over capacity fails 426 438 468 430

…waiting time fails 12,360 13,129 12,641 12,876

…overspill fails 2,116 2,001 1,727 1,548

Fails - Suffolk 3,805 3,389 3,586 3,242



…overspill fails 772 734 659 631

Overspill - Norfolk …total bed days 66,663 64,824 58,630 54,724

…total implied beds 36.5 35.5 32.1 30.0

…implied beds - working age (inc. asst) 17.6 16.4 13.5 11.0

…implied beds - PICU 1.8 1.9 1.8 1.8

…implied beds - older adult functional 3.3 3.5 3.4 3.4

…implied beds - dementia 12.7 12.7 12.5 12.5

…implied beds - other 1.2 1.0 1.0 1.2

Overspill - Suffolk …total bed days 36,625 35,690 31,696 32,178







15th February 2017

34

Scenario 4 – Step-down beds

In this scenario we have considered adding 12 extra step down beds across the Trust to accommodate those working age patients with the longest lengths of stay. This would significantly reduce working age overspill in both Norfolk and Suffolk.

Metric (over 5 year simulation) Baseline 12 extra step

down beds Activity








15th February 2017

35

Scenario 5 – Split crisis assessment and home treatment team

In Norfolk, the CRHTs perform both a crisis assessment and home treatment function. In this scenario we have considered the impact of splitting these functions into two separate resources. This has little impact on service utilisation. The number of over-capacity fails increases slightly due to two points of failure in the system. This finding suggests that local home treatment services are already adequately resourced, in that ringfencing the home treatment staffing complement produces no obvious flow benefit.

Metric (over 5 year simulation) Baseline Split CRHT in

Norfolk Activity








15th February 2017

36

Scenario 6 – Extra crisis bed in Suffolk

The addition of an extra crisis bed in Suffolk reduces working age adult overspill by around one bed.

Metric (over 5 year simulation) Baseline Extra Crisis

Bed Activity








15th February 2017

37

Scenario 7 – Community personality disorder team

In this scenario, we consider the impact of setting up a specialist personality disorder service. Patients are assumed to be retained within the service for between two and three years.

If the service can be created out of new resources, this appears beneficial, both in terms of reducing community fails and overspill. The service would need to carry a caseload of around 1,500 patients in Norfolk and 800 patients in Suffolk.

If the service is required to be carved out of existing community resources, the case is far less clear. Increased pressure on adult CMHTs (Norfolk) and IDTs (Suffolk) would significantly increase the number of waiting time fails.


Personality Disorder Service

(new resource)

Personality Disorder Service

(carve out) Activity

…total caseload days 27,055,950 29,685,576 24,700,983 …total contacts 319,366 296,878 193,563 …total occupied bed days 621,621 590,066 589,178 …total new episodes 244,716 236,643 220,274

Fails - Norfolk 14,902 6,097 16,771 …over capacity fails 426 342 330 …waiting time fails 12,360 4,267 15,061 …overspill fails 2,116 1,488 1,380

Fails - Suffolk 3,805 2,323 9,515 …over capacity fails 7 3 5 …waiting time fails 3,027 1,790 8,962 …overspill fails 772 530 548

Overspill - Norfolk …total bed days 66,663 53,633 52,841


Overspill - Suffolk …total bed days 36,625 27,715 28,345


15th February 2017

38

We have also modelled the combination of crisis cafes and PD service together. This produces the

following results:


Crisis Café 7% and PD

Service


Service


Service

Activity …total caseload days 27,055,950 29,661,135 29,717,291 29,690,690

…total contacts 319,366 297,056 297,646 297,938

…total occupied bed days 621,621 580,375 572,482 565,218

…total new episodes 244,716 236,715 236,280 236,021

Fails - Norfolk 14,902 5,842 4,895 5,735



…overspill fails 2,116 1,282 1,132 989

Fails - Suffolk 3,805 2,332 2,266 2,204



…overspill fails 772 491 462 457

Overspill - Norfolk …total bed days 66,663 47,980 44,460 40,666







Overspill - Suffolk …total bed days 36,625 26,753 25,532 25,350







These two scenarios together produce a substantial improvement in overall flow, but do not wholly

remove the risks of fails.

15th February 2017

39

Scenario 8 – Eliminating fails in community teams

We are here investigating the actions which would be required to eliminate fails in each of the Trust’s community teams. There are four variables: capacity

of the team, the mean days between contacts (contact intensity), the mean episode length, and the number of referrals. The table below shows the

adjustment which would be required in each variable to eliminate fails. Each is considered independently. It will be seen that, for the large majority of

services, relatively small adjustments in current arrangements could be sufficient to align capacity and demand, on current pathway patterns.

Capacity Mean days between

contacts Mean length of episode (days) Referrals per year

Service Current New Current New Current New Current New

Bury North IDT - Adults Bury North IDT 354 387 38 42 351 321 344 315

Bury North IDT - Bury North CLL 320 341 52 55 177 166 558 523

Bury North IDT - Bury North Enhanced Community 185 185 48 48 336 336 158 158

Bury North IDT - Youth Bury North IDT 87 87 35 35 221 221 84 84

Bury South IDT - Adults Bury South IDT 406 476 36 42 373 318 392 335

Bury South IDT - Bury South CLL 360 410 48 55 224 197 553 486

Bury South IDT - Bury South Enhanced Community 247 247 49 49 616 616 86 86

Bury South IDT - Youth Bury South IDT 133 153 47 54 490 426 97 84

Central IDT - Adults Central IDT 310 310 29 29 429 429 238 238

Central IDT - Central CLL 166 175 43 45 279 265 187 178

Central IDT - Central Enhanced Community 161 191 41 49 369 311 140 118

Central IDT - Central Youth 43 48 24 27 276 247 46 41

Central Norfolk Acute - CRHT - HTT 161 161 9 9 26 26 1,338 1,338

Central Norfolk Acute - Psych Liaison 59 59 11 11 6 6 1,116 1,116

Central Norfolk Adult - North Adult Community 675 675 24 24 734 734 253 253

Central Norfolk Adult - North AFI 292 356 29 35 182 149 626 514

Central Norfolk Adult - North City AFI 239 270 21 24 130 115 654 579

Central Norfolk Adult - South Adult Community 1099 1099 26 26 908 908 321 321

Central Norfolk Adult - South AFI 348 436 38 48 155 124 872 696

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Central Norfolk Adult - South City AFI 294 367 27 34 130 104 834 668

Central Norfolk CFYP - Early Intervention 212 224 21 22 499 472 140 133

Central Norfolk CFYP - NDD Adult Cent Nor ST209 47 47 107 107 404 404 24 24

Central Norfolk CFYP - Youth Minor 8 8 398 398 87 87 8 8

Central Norfolk DCLL - DIST 9 17 7 13 17 9 126 67

Central Norfolk DCLL - DIST Community 81 93 4 5 22 19 945 823

Central Norfolk DCLL - DIST MA Cent Nor ST204 61 81 28 37 30 22 612 461

Central Norfolk DCLL - North DCLL 725 814 40 45 158 140 1,625 1,447

Central Norfolk DCLL - North Memory Med 181 219 63 76 183 151 339 280

Central Norfolk DCLL - South DCLL 673 740 39 43 131 119 1,731 1,575

Central Norfolk DCLL - South Memory Med 89 108 48 58 137 113 192 159

Central Norfolk SPOA - SPOA 24 24 1080 1,080 8 8 347 347

Coastal IDT - Adults Coastal IDT 411 428 34 35 641 615 234 225

Coastal IDT - Coastal CLL 275 353 66 85 446 347 257 200

Coastal IDT - Enhanced Community Coastal IDT 208 208 47 47 386 386 122 122

Coastal IDT - Youth Coastal IDT 116 116 42 42 126 126 76 76

East Suffolk - DIST 74 86 5 6 33 28 598 515

East Suffolk - HTT - Assessment 58 58 1 1 2 2 543 543

East Suffolk - HTT - HTT 58 58 2 2 20 20 624 624

East Suffolk - Psychiatric Liaison 77 77 14 14 13 13 1,381 1,381

GYW Adult - Access and Assessment GYW 305 323 28 30 21 19 4,476 4,226

GYW Adult - Adult Liaison JPUH 50 50 21 21 30 30 311 311

GYW Adult - GY Adult Community 877 934 40 43 512 481 621 583

GYW Adult - Waveney Adult Community 851 934 35 38 447 407 724 660

GYW CFYP - Early Intervention 124 139 25 28 423 377 103 92

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GYW CFYP - Eating Disorders 19 22 12 14 423 365 13 12

GYW CFYP - Youth Adult 275 291 25 26 269 254 336 318

GYW DCLL - DIST 37 45 3 4 39 32 261 215

GYW DCLL - GY Memory Treatment 171 171 34 34 99 99 479 479

GYW DCLL - OP CMHT Carlton Court 227 227 42 42 248 248 284 284

GYW DCLL - OP CMHT Northgate 131 135 37 38 154 149 239 232

GYW DCLL - OP Liaison JPUH 19 31 11 18 16 10 356 218

GYW DCLL - Waveney Memory Treatment 384 451 60 70 188 160 732 623

Ipswich IDT - Adults Ipswich IDT 600 668 37 41 498 447 444 399

Ipswich IDT - Enhanced Community 270 287 31 33 265 249 340 320

Ipswich IDT - Ipswich CLL 204 204 70 70 294 294 178 178

Ipswich IDT - Youth Ipswich IDT 82 111 36 49 292 215 101 74

Suffolk - Access and Assessment Suffolk 1052 1052 44 44 39 39 8,180 8,180

West Norfolk Acute - CRHT - HTT 100 128 6 8 40 31 709 554

West Norfolk Acute - MH Liaison 20 20 26 26 9 9 379 379

West Norfolk Adult - Adult CMHT 628 808 54 69 268 208 878 682

West Norfolk CFYP - CFYP Over 18s 89 98 46 51 116 106 243 221

West Norfolk CFYP - Early Intervention 63 73 38 44 411 355 49 42

West Norfolk DCLL - DCLL CMHT 100 128 227 291 152 119 239 187

West Norfolk DCLL - DCLL DIST 37 48 7 9 26 20 371 286

West Norfolk DCLL - DCLL Memory 338 353 77 80 142 136 748 716

West Suffolk - DIST 120 139 14 16 56 48 632 546

West Suffolk - HTT - Assessment 70 70 1 1 2 2 289 289

West Suffolk - HTT - HTT 70 75 5 5 43 40 395 369

West Suffolk - Psychiatric Liaison 81 81 26 26 29 29 541 541

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4.3 Optimisation

Clearly, many combinations of the above scenarios, and others, could be made. We have firstly

drawn out the following as potentially the most plausible, individually useful, and consistent with

what we understand to be local strategy and intentions. We have produced both conservative and

optimistic optimisations, assuming in each case:

Conservative

• Standardisation of acute care pathway at 50% impact (for both working age and older people)

• Introduction of crisis cafes at 17% impact, for Norwich and Ipswich only

• Redesignating assessment beds as working age assessment and treatment beds

• Adding an additional crisis bed in Suffolk

Optimistic

• Standardisation of acute care pathway at 100% impact (for both working age and older people)

• Introduction of crisis cafes at 26% impact, for Norwich and Ipswich only

• Addition of 12 new step-down beds

• Redesignating assessment beds as working age assessment and treatment beds

• Adding an additional crisis bed in Suffolk

In each case, we add an additional scenario, in which the length of community episodes is reduced,

as in the table in scenario 8 above, to bring capacity and demand better into balance.

It will be seen that the range of scenarios identified here is modelled to produce a very substantial

improvement in the match between inpatient capacity and demand. For community services, the

table in scenario 8 above also gives cause for optimism that relatively small changes in practice could

bring about a much better match.

Appendix A sets out full time series and heat map results of the effects of these optimisations.

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More conservative optimisation

More conservative optimisation

with community LOS

adjustment More optimistic

optimisation

More optimistic optimisation

with community LOS

adjustment

Activity …total caseload days 27,055,950 27,066,011 25,103,873 27,024,891 25,118,314

…total contacts 319,366 320,113 302,254 320,363 302,542

…total occupied bed days 621,621 439,141 437,699 318,144 319,164

…total new episodes 244,716 240,807 242,697 236,662 239,213

Fails - Norfolk 14,902 12,587 744 14,052 178

…over capacity fails 426 408 6 409 2

…waiting time fails 12,360 11,422 29 13,483 17

…overspill fails 2,116 758 710 160 159

Fails - Suffolk 3,805 2,949 190 2,539 169

…over capacity fails 7 6 10 7 9

…waiting time fails 3,027 2,854 89 2,441 72

…overspill fails 772 89 90 91 88

Overspill - Norfolk …total bed days 66,663 20,193 20,048 3,484 3,537

…total implied beds 36.5 11.1 11.0 1.9 1.9

…implied beds - working age (inc. asst) 17.6 8.6 8.6 0.0 0.0

…implied beds - PICU 1.8 0.7 0.7 0.7 0.7

…implied beds - older adult functional 3.3 0.7 0.6 0.1 0.1

…implied beds - dementia 12.7 0.0 0.0 0.0 0.0

…implied beds - other 1.2 1.1 1.1 1.1 1.1

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Overspill - Suffolk …total bed days 36,625 9,129 9,189 9,741 9,400

…total implied beds 20.1 5.0 5.0 5.3 5.2

…implied beds - working age (inc. asst) 8.1 0.0 0.0 0.0 0.0

…implied beds - PICU 0.6 0.8 0.8 0.8 0.8

…implied beds - older adult functional 2.7 0.0 0.0 0.0 0.0

…implied beds - dementia 3.5 0.0 0.0 0.0 0.0

…implied beds - other 5.2 4.2 4.2 4.5 4.3

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5. DISCUSSION AND CONCLUSIONS This is a highly complex modelling project, which is considering and generating a very wide range of both quantitative and qualitative evidence. Assembling this report has necessarily been a task of editing down this range of materials, in an effort to provide a presentation of reasonable length, but sufficient to enable both understanding and discussion of the issues at hand. Mental Health Strategies would be pleased to provide further copies of or access to the many analyses we have generated through the course of the project. Our main conclusions from our analysis are as follows:

1. Probably the main message to emerge from this project relates to the range of variance we found across Norfolk and Suffolk: in service models, in referral and admission rates, in the operation of community teams. There are clearly opportunities to spread learning and practice within the Trust, in ways which could improve services’ efficiency and effectiveness.

2. The current number of inpatient beds could be sufficient, if issues of clinical variance (primary and secondary care) are addressed, and if some adjustments are made to the pattern of alternatives to admission. We would certainly be pursuing these opportunities, and observing their effect, prior to any additional investment in general admission beds.

3. Crisis cafes and a small number of additional step-down beds may offer the most useful means of offering alternatives to admission. This may require some pump-priming of resources in the first instance.

4. If the processes of offering alternatives to admission and reducing unjustified variance prove successful, it is conceivable that some reductions in general admission beds may be possible in due course. This cannot, however, be planned with any confidence or certainty at present.

5. We are unsure whether the locally perceived benefits of offering distinct assessment beds for adults of working age outweigh the disadvantage of them operating as a further carve-out in the local bed pool. We suggest that serious consideration should be given to considering all working age adult beds as equivalent.

6. It appears likely that a community personality disorder service would be a useful addition to the local service model. It is however unclear whether resources are likely to be available to support investment in such a service, or whether it would be considered sufficiently important to redirect resources in this way.

7. We would encourage discussion of the actions possible to bring community teams’ activity more in line with anticipated demand.

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Documents

Simulation modelling of mental health services … · focussing on adults of working age, and services focussing on older people – including specialist services for people with