Impact case study database

Cardiff researchers formed strategic alliances with multiple Welsh NHS health boards to engage healthcare professionals with Operational Research (OR). Application of the research outlined in Section 2: 1) provided healthcare decision-makers with reliable modelling data to better provide service to patients, while training NHS staff to further improve their data analysis services. Through this engagement, the research led to: 2) improved hospital designs; 3) increased efficiency of frontline mental health services; and 4) reduced instances of painful pressure ulcers.

4.1 Setting up dedicated modelling units in NHS Health Boards

Harper is a founding Director of the Health Modelling Centre Cymru (hmc²), which works with clinicians and NHS managers to apply modelling techniques to healthcare settings. In 2014, hmc² partnered with the Aneurin Bevan Continuous Improvement Unit (ABCi), which provides mathematical modelling capability for the Aneurin Bevan University Health Board (ABUHB). To support this work, the Cardiff team established the Mathematical Modelling Unit within ABCi, additionally training NHS staff in how to apply OR models to develop and test alternative approaches to healthcare management. Trish Chalk, Clinical Futures Lead at ABCi said of the partnership: “ This unique and innovative partnership has delivered considerable impact in developing and applying OR methods for improving our NHS services and patient outcomes” [5.1].

In addition, hmc² initiated the novel researchers-in-residence programme in partnership with NHS Wales, supporting both Aneurin Bevan and Cardiff and Vale University Health Boards, which collectively serve over 1.1 million people. This programme embedded modelling techniques within the improvement work undertaken at the health boards, for example: modelling the dynamics of day surgery flow and clinic flow at Royal Gwent Hospital to advise on capacity needs and to reduce patient waiting times; analysing the effect of individuals presenting in A&E under the influence of alcohol and to subsequently contribute to planning of a mobile emergency unit in Cardiff city centre on Friday and Saturday nights to alleviate pressures on A&E and limit disruptive behaviours towards staff [5.2]; and development of a text mining tool to analyse a backlog of more than half a million outpatient letters, saving £630,000 that had been reserved for manual data entry [5.3]. Judith Paget, Chief Executive of the Aneurin Bevan University Health Board, praised the collaboration and the outcomes upon the work of both health boards: “ The modelling unit’s work has led to better planning and better analysis: far better decisions are made as a result of the input of the modellers” [5.4].

In 2015, the collaboration between Cardiff research and NHS practice was recognised by the Times Higher Education Awards and received the award for ‘Outstanding Contribution to Innovation and Technology’ [5.5]. The panel noted that “ such mathematical modelling has never been used before in the UK healthcare system” and that the judges were “ impressed by the range of innovations achieved in a subject area not renowned for this type of collaboration” [5.5, p.31 ]. Harper also received the Companion of OR award from the Operational Research Society, the panel noting that his work has “ a vision for sustained impact” and that the ABCi Mathematical Modelling Unit be “ praised and aspired to by the health OR community” [5.6].

4.2 Improving the design and operation of hospitals

ABCi approached Cardiff University in 2016 requesting mathematical modelling support in the early-stage design of a proposed new hospital near Cwmbran, South Wales, which would serve a population of over 600,000. The E-HOSPITAL framework was used to assess the potential capacity and required capabilities of the hospital and optimise the flow of patients, reduce unnecessary surgical cancellations, reduce waiting times, and plan for safe care.

The ABCi unit specifically highlighted the role of the software in the development of the hospital plans: “ Dr Gartner and the team at Cardiff University School of Mathematics have been fundamental in helping us to design the new hospital using the E-HOSPITAL platform” [5.1]. The proposed design, including the Cardiff-recommended structural changes, became the confirmed plans for the Grange University Hospital, a new 470-bed hospital supported by a £350M investment from Welsh Government. The hospital opened ahead of schedule on 17 November 2020 to assist the South Wales response to both Covid-19 and winter health pressures [5.7].

Trish Chalk, Clinical Futures Lead at ABCi outlined the value of the E-HOSPITAL platform: “Our provision was 32 operating theatres. Using E-HOSPITAL, you have helped us to identify smarter and more efficient scheduling of operating theatre sessions such that the total number of staffed operating rooms across ABUHB has been reduced by 2” [5.1]. Chalk confirmed that this equates to a saving for the Health Board of around £900,000 each year, totalling £2.7M to date. Through early identification of surplus requirements, and the associated costs in staffing operating theatres, the Health Board was able to reallocate resources previously earmarked for the surplus theatres: “ A substantial saving which means we can reinvest these funds into other aspects of our services” [5.1]. The modelling was praised not only for the improved efficiency in financial costs, but also for maintaining the proposed level of service to the local population despite the reduced number of operating theatres: “ It should be noted that this reduction has been made possible even whilst accommodating for growth in demand” [5.1].

The Cardiff team also applied E-HOSPITAL to identify cost savings for University Hospital Munich. The platform was able to determine the optimal mix and inventory control of disposable and reusable bronchoscopy devices, eliminating the need for single-use disposable bronchoscopy devices. Dr Günther Edenharter, Specialist in General Medicine at University Hospital Munich, stated: “ Before your [Dr Gartner]’s work, we disposed of 950 units per year. Thanks to your work, we have removed entirely the need to dispose these units” which has “resulted in substantial environmental and economic savings” [5.8]. CO₂ emissions have been reduced by six tons each year together with annual cost savings of €182,350 (around £152,252).

4.3 Supporting mental health outreach teams

Cardiff research supported the provision of mental health services across South Wales, focussing on Assertive Outreach Teams (AOTs). AOTs are a novel patient-led service which enable mental health professionals to identify and more readily respond to the needs of severely mentally ill adults, placing them on an appropriate care pathway to avoid progression of the patient’s condition to the point of hospitalisation. At Aneurin Bevan University Health Board, however, AOTs were perceived as a costly service with poorly understood benefits; these were due to be cut.

Modelling and statistical analysis work from the Cardiff group quantified the benefits achieved by AOTs, which supported the business case made to the health board to continue to fund these teams. The Cardiff team developed a caseload management tool, incorporating clinical, demographic and staffing variables, such as medical history, specific patient needs, staff skill-mix, resource levels and availability, and geospatial demand and travel times. This enabled AOTs to better coordinate complex caseloads with further benefits for patients and the health board, as noted below [5.9]. Dr Izabela Spernaes, ABCi Mathematic Modelling Unit Lead, explained that AOT services were at great risk of closing and that “the analysis and modelling provided by the School of Mathematics resulted in significant benefits of AOT services” [5.9]. The benefits identified as a result of the Cardiff research include [5.9]:

• “Improved patient outcomes measured by a reduction in the Adult Camberwell Assessment of Need (CANSAS) per patient by an average of 51%.” The CANSAS measures severe needs for mentally ill adults across a range of physiological and psychological factors, such as psychological distress, self-care, and physical heath.

• A reduction in “ineffective and unnecessary acute hospital admissions by 79%.” Acute admissions are those which require diagnostic tests, treatment, and follow-up care. There was also a 66% reduction in the number of crisis admissions (hospital stays when the patient is highly vulnerable) from 2.76 stays on average per patient to 0.93 . The mental wellbeing benefits to the patients are difficult to quantify, but savings to the NHS Board were calculated at £7.3M per annum from crisis admission reduction alone.

• “A 65% reduction in time taken off work by patients due to severe mental health episodes.” Days off due to severe mental health episodes went from an average of 41.8 days per patient per year to 14.6 days.

4.4 Reducing pressure ulcers

Pressure ulcers, which can occur when patients spend significant time in bed, are painful, impair mobility, and diminish a patient’s quality of life. Low staff morale has been identified as causing lapses in care, leading in increased instances of pressure ulcers (among other unintended consequences), which then further decreases staff morale, generating a negative feedback loop. Pressure ulcers are also costly to health boards; for example, pressure ulcers costed Aneurin Bevan University Health Board more than £500,000 per annum in compensation to affected patients.

To address this problem, Cardiff researchers embedded within ABCi developed a comprehensive simulation (system dynamics) model of the health board’s Unscheduled Care (USC) system. This modelled staff wellbeing and its impact on clinical performance and identified that current measures being implemented by the Trust would not be sufficient to reduce health acquired pressure ulcer incidences at the Royal Gwent Hospital.

The model was used to identify negative feedback loops, including understanding and quantification of dependencies between staff behaviours and factors, such as resource utilisation, morale, sickness rates and use of agency staff. Consequently, joint learning sessions with Cardiff University researchers and ABCi staff were developed to help Unscheduled Care staff understand the complex dynamics of the health system. In addition, spreadsheet-based monitoring tools were developed together with a Consultant Clinical Psychologist in order to track staff wellbeing. These interventions helped prevent negative feedback loops occurring and transformed patient care from potentially harmful to safe [5.10]. As a result, “ within two years, up to ten frontline teams prevented (at least) 265 pressure ulcers and averted more than £1.5 million in cost while securing better quality care for patients and improved patient experience” [5.10]. The approach won the NHS Wales Award 2019 in the category Improving Patient Safety.

In summary, Cardiff research into mathematical modelling techniques was used by Welsh NHS Health Boards to improve patient outcomes and the delivery of services. Close collaboration through the Cardiff-NHS Wales innovative researchers-in-residence programme, and via international partnership with University Hospital Munich, enabled efficient design of hospitals, improved the efficiency and effectiveness of mental health outreach teams, and reduced pressure ulcers. This led to direct cost savings of at least £12.1M for the NHS, as well as ~£150,000 savings for the University Hospital Munich hospital in Germany.