Using simulation modelling to determine future capacity requirements in Cumbria CCG
The project focussed on services for adults of all ages provided by the Cumbria Partnership NHS Foundation Trust only.
Our main findings were:
- Neither the number of beds provided, nor lengths of stay in those beds, appear unusually high, based on national benchmarking data. On the full range of evidence here, there seems to be no convincing case that bed numbers could be cut further beyond those proposed, nor that efficiencies in throughput could release significant new capacity.
- Rates of admission are however somewhat high, based on national benchmarking data. This is probably unsurprising, as there are few alternatives to inpatient admission offered in Cumbria.
- There is no evidence that lengths of stay within the county are being elevated by admissions to non-local services at present. We therefore can reasonably disregard this risk in future modelling.
- DTOCs are creating a significant pressure within older people’s organic services – 25% of the bed capacity on Ruskin has been attributed to DTOCs in recent months.
- If the current strategic option 3 is pursued, and no mitigation steps are taken in developing alternatives to admission, we think there is a significant risk that overspill demand will rise over the coming years – potentially to as many as 17 beds being typically required at any one time.
- A range of mitigations are possible – a crisis café, crisis houses, and intensive support service for people with dementia, more home treatment. We are conscious, however, that the number of “divertable” patients is not large at any one time. Taken together, we estimate that such alternatives to admission could bring the risk of overspill demand down to a typical level of 4 beds. In practice, such a level could well be managed by occasional use of leave.
- There is no reason from a patient-flow perspective to prefer a 1,2, 3 or 4 site option. This will need to be considered from the perspectives of estates feasibility, cost, and patient access.
- Resources for these services are closely matched to current capacity and demand levels. There is little scope for retraction of revenue resources without some reductions in expected service provision – or an acceptance of increasing waiting times to access services.
What would we do in this situation? The overall level of bed provision appears comparable to that elsewhere in the country – although we are conscious that many places are experiencing bed pressures at present, and this benchmark may therefore be a low one. But there is a clear service and clinical aspiration across the country to provide the least intensive service which is consistent with safe and effective care. We therefore think that the number of beds proposed could and should be made to work.
The number of sites will be driven by cost and access considerations, rather than patient flow. But we note that the sites on which services may be concentrated in future (Carlisle and Barrow) have tended to have longer lengths of stay, and higher readmission rates. It will be important that practices from other sites are not lost, and learning and practice are merged between units – rather than simply existing practice at Carlisle and Barrow being extended to a wider group of patients,
If the proposed number of beds is to work, investment will be needed in alternatives to admission. There is a good case for the development of a crisis house in each of the Kendal and Whitehaven areas. These need not be large; a unit of 2-3 beds in each case would meet the plausible level of demand. It might be operationally practicable for either or both units also to offer a form of crisis café function – offering support and supervision without actual admission – in order to ensure a viable and cost-effective service. Such services could be provided in partnership with a voluntary sector organisation, but it is important that they be gatekept by existing crisis services, to minimise the likelihood of their attracting new admissions/service users, who would otherwise not have been admitted anywhere.
Investment in home-based support as an alternative to admission could also be beneficial, but may be difficult to implement in practice. We estimate a Cumbria-wide caseload of only 7 for an intensive home support service for people with dementia; and there has been uncertainty in local discussion as to the need for and viability of an expanded home treatment service for functional illnesses. It may be that marginal investments in existing teams, with an expectation of managing at least some more challenging clients, may be the most operationally realistic.
There does appear to be a case for adjusting the numbers of beds provided for each speciality, within the overall pool. If 72 functional illness beds could be provided for adults of working age, this would be expected to require overspill on only 1-2% of days, assuming mitigations are implemented. The proposed 18 beds for older people with functional illness appears appropriate. The consequence of this adjustment would be only 22 beds for organic illnesses. This is too few as it stands, but we note the level of DTOCs being experienced. It appears that current planning is assuming that these will continue. There may in practice be a choice for local agencies between funding some additional capacity within the Trust to enable this to be managed as at present – of the order of the 26 currently proposed; or addressing the DTOC issue such that this is no longer required. With minimal DTOCs, and some capacity for intensive home support, 22 beds could be sufficient.
It is important to stress that, even if all of this is done, we still anticipate that there will be days on which demand for some services may exceed capacity. We anticipate that the usual operational disciplines will therefore still be required to manage such peaks – but that, with the mitigations in place, these should be small and seldom.
Although it has not been the main focus of this project, we should note here the situation of non-psychotic community services. Across the county, we see little prospect of the proposed 15 day waiting standard being met for very large number of patients. Meeting that standard will require either an increase in resources in such services, or a reduction in the referrals being made to them.