The Dynamics of Care: Understanding People Flows in Health and Social Care

Foreword
Preface
Acknowledgements
	Acknowledgements by Eric Wolstenholme
	Acknowledgements by Douglas McKelvie
	Joint Acknowledgements
Contents
About the Authors
1 The Challenges Facing Health and Social Care and the Relevance of Dynamic Models
	1.1 Overview
	1.2 Case Study—Mrs. Jones
	1.3 The Challenge
	1.4 What to Do?
	1.5 A Way Forward—From Mrs. Jones to Dynamic Models
	1.6 The Scope and Insights
	1.7 System Dynamics
	1.8 Systems Thinking
	1.9 Systemic Versus Systematic Thinking
	1.10 Systems Messages
	1.11 The State of Health and Social Care Worldwide
	1.12 The Restructuring Cycles of Health and Social Care
	1.13 Wicked Problems in Health and Social Care
	1.14 Delayed Hospital Discharges
	1.15 Access to Mental Health Services
	1.16 A Word on Software, Modelling, Access to Models and Mathematics
	1.17 Overview of the Book
	References
Elements of System Dynamics Important to Health and Social Care Modelling
2 The Dynamics of Treatment and Capacity
	2.1 A Simple One-Stock Map of a Hospital Treatment Pathway
	2.2 An Exercise in Thinking Through Time with Stocks and Flows
	2.3 A Two-Stock Hospital Model with a Capacity Constraint
	2.4 Simulation Experiments on the Two-Stock Hospital Model
	2.5 Redesigning Policies
	2.6 Systems Notes
	2.7 Changes to the Length of Treatment
	2.8 The Importance of the Two-Stock Hospital Model
	2.9 Different Types of Capacity
	2.10 A Word on Variation and Costs
	2.11 Concluding Remarks
	Appendix: The Answer to the Exercise in Fig. 2.2
	References
3 Performance Measurement—The Fallacy of Waiting Time Targets
	3.1 The Relationship Between Capacity and Waiting Times
	3.2 The Two-Stock Hospital Model
	3.3 Other Implications
	3.4 The Arbitrariness of Waiting Times
	3.5 The Infeasibility of Implementing a Relationship Between Capacity and Waiting
	3.6 Conclusions
	References
4 The Shape of Illness and the Impact of Interventions
	4.1 Introduction
	4.2 Population Dynamics (Ageing Chain)
	4.3 Health Condition Dynamics (What Shape Is the Condition?)
		Acute, Episodic Conditions
		Long Term Conditions (Degenerative)
		Long Term Conditions (Not Degenerative, Improvement May Be Possible)
		Chronic Illness with Acute Episodes
		Lifelong Conditions—Physical and Learning Disabilities
	4.4 Combining Population Ageing Dynamics and Health Condition Dynamics
	4.5 Models that Are Not Condition-Based
	4.6 The Purpose, Nature and Intended Impact of Interventions
		Basic Assessment and Treatment
		Care Interventions
		Management of a Condition
		Prevention
		Screening
	4.7 Towards a Taxonomy?
	4.8 Conclusions
	References
5 Feedback Dynamics
	5.1 Feedback
	5.2 Reinforcing and Balancing Feedback Loops
	5.3 Revealing Feedback Loops on a Stock-Flow Map
	5.4 Causal Loop Maps
	5.5 Summary of the Rules for Drawing Feedback Loops
	5.6 Multiple Feedback Loops, Unintended Consequences and System Archetypes
	5.7 Problem Archetypes
	5.8 Solution Archetypes
	5.9 The Four Problem/Solution Archetypes
	5.10 Underachievement Archetype
	5.11 An Example of the Underachievement Archetype in Health and Social Care
	5.12 Out-of-Control Archetype
	5.13 Examples of the Out-of-Control Archetype in Health and Social Care
	5.14 Conclusions
	References
6 Applying System Dynamics
	6.1 An Overview of the Process of Building and Validating System Dynamics Models
	6.2 The Author’s Approach to Group Model Building and Modelling as Learning
		‘Service Design’ and Group Model Building
	6.3 Other Modelling Approaches
	6.4 Other Approaches to Health and Social Care Analysis
	6.5 The Authors’ Positioning of System Dynamics for Health and Social Care Modelling
	6.6 Big Data
	6.7 System Dynamics Software
	References
Projects for Dynamically Balancing Health and Social Care Capacities
7 Hospital Delayed Transfer of Care (Delayed Discharges)
	7.1 The Issue
		Proposed Solutions
		The Contribution of System Dynamics to the Issue
	7.2 A Two-Capacity Patient Pathway Model
		Data
			Design of Experiments—Dynamic Equilibrium
			Simulation Results
	7.3 The 2004 National Model of Delayed Hospital Discharge
		Data and Experiments
		Example Results from the Delayed Hospital Discharge Model
	7.4 Conclusions from the 2004 Delayed Hospital Discharge Model
		Impact of the National Delayed Hospital Discharge Model
			Concluding Remarks
	References
8 Integrated Care
	8.1 Integrated Care
	8.2 Modelling Integrated Care (the ‘Balance of Care’)
		Integrated Care, Delayed Discharge and the ‘Balance of Care’
	8.3 Running the Integrated Care Model
		Base Run
		Adding Emergency Bed Capacity (the ‘+Beds’ Scenario)
		Adding Home Care Capacity (the ‘hc’ Scenario)
		Adding Care Home Capacity (the ‘ch’ Scenario)
		Adding Intermediate Care (the ‘ic’ Scenario)
		Adding Care Home Support (the ‘chs’ Scenario)
		Adding All Capacity Increases (Except Emergency Hospital Beds)
	8.4 Conclusions
	Appendix: The Challenge of Modelling Integrated Care—Transparency, Allocation and Alternative Pathways
		Transparency
			Allocation of People Waiting to Capacity Restricted Services
			Alternative Pathways
	References
9 Implementation of a Stepped Care Approach to Depression Services
	9.1 Introduction
	9.2 The NICE Guidelines for Depression and Implementation Issues
	9.3 Using a System Dynamics Modelling Approach to Avoid Unintended Consequences in the Implementation of Stepped Care for Depression Services
	9.4 Description of the Model
	9.5 What the Model Enabled
	9.6 Using the Model to Support Implementation of the Guidelines—Running a Series of Model-Supported Collaborative Workshops
	9.7 Factors Emerging from the Collaborative Process
	9.8 Conclusions
	References
10 Towards a Dynamic Theory of How Hospitals Cope in Times of High Demand
	10.1 Introduction
	10.2 An Overview of Hospital Patient Pathways
	10.3 The Coping Strategies
	10.4 Unintended Consequences of the Coping Strategies for Patients
	10.5 The Coping Strategy Archetypes
	10.6 Unintended Consequences of the Coping Strategies on the Performance of Hospitals
	10.7 Identifying Solutions
	10.8 Concluding Remarks
	References
From Cost Benefit Analysis to Dynamic Impact Assessment as a Means of Understanding Complexity
11 Dynamic Impact Analysis for Mental Health Reform
	11.1 Introduction
	11.2 The Original Cost Benefit Hypothesis
	11.3 The Enhanced Cost Benefit Analysis
	11.4 The System Dynamics Model
	11.5 Issues Raised in the Treatment and Recovery Sector
	11.6 Issues Raised in the Labour Market Sector
	11.7 Issues Raised in the Therapist’s Sector
	11.8 Model Experiments
	11.9 Results from Running Experiments to Show the Benefits of the ‘Fully Operational’ CBT Programme
	11.10 A Mixed Programme
	11.11 Summary of First Insights from the System Dynamics Model
	11.12 Results from Running Experiments to Show the Benefits of a Phased Build up to Full Operation of the CBT Programme Over 7 Years
	11.13 Summary of Further Insights from the System Dynamics Model
	11.14 Sensitivity Results
	11.15 Conclusions on the Content of the CBA
	11.16 Conclusions on the Use of System Dynamics to Supplement CBA
	References
12 Planning Investment in Alcohol Services
	12.1 Context and Client
	12.2 The Problem
	12.3 Method
	12.4 Description of Model
	12.5 Typical Model Behaviour
	12.6 Making Sense of the Findings
	12.7 Wider Applications
		Costs and Benefits
		Non-treatment Approaches to Tackling Alcohol Consumption
	12.8 Making the Model Usable
	12.9 Conclusion
	References
13 The Impact of Diagnosis Targets for Long-Term Conditions: Dementia
	13.1 Introduction
	13.2 Prevalence and Incidence—A Simple Model Structure
		Data Consistency
	13.3 Developing the ‘Condition Flow Chain’ and Triangulating Missing Data
	13.4 Diagnosis and Diagnostic Capacity
	13.5 Broader Impact on the Social Care System
	13.6 Conclusions
	13.7 Footnote
	References
14 Making Predictive Risk Assessment ‘Dynamic’: The Underlying Churn Effect
	14.1 Introduction
	14.2 The Problem—Lack of Impact of Local Implementation of Case Management to Identify Those at Risk of Hospital Readmission
	14.3 The Model
	14.4 Population Module
	14.5 Service Module 1—Use of Hospital
	14.6 Service Module 2—New Case Management Service
	14.7 Finance Module
	14.8 Model Findings
	14.9 Conclusions/Summary
	References
Health and Social Care Workforce Projects
15 Classic Workforce Projects
	15.1 Introduction (UK Perspective)
	15.2 Basic Workforce Model
	15.3 Elaborations on the Simple Workforce Model
	15.4 Developing a New Profession
	15.5 Modelling a Trainer Workforce
	15.6 Workforce Model for One Type of Occupation Including Progression and Ageing
		Modelling the Supply of Specialists
		Modelling Demand for Consultants and Middle Grade Doctors
	15.7 Conclusions
	References
16 Using a Control Theory Approach to Workforce Planning
	16.1 A Control Theory Workforce Model
	16.2 Staffing a Start-up Organisation
	16.3 Conclusions
17 Workforce Projects to Assist Health and Social Care Integration
	17.1 Model 1—Modelling Health and Social Care Integration Workforce Change
	17.2 Model 2—Care Workforce in the Context of the Wider Economy
	17.3 Conclusions
	Reference
18 A Summary of Systems Messages and Insights
	18.1 Summary of the Book
	18.2 Concluding Messages
	18.3 A Final Word
Glossary