Simulation for Strategic

Planning – the Scenario

Generator
An Introduction
October 2009
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A software tool developed by the Institute comprising
• A healthcare demand model
• A representation of a whole health and social care delivery
system based on pathways of care
• A powerful simulation facility
Simulation

A technique that aims to imitate, abstract and

represent a system, process or behaviour
for specific analytical, decision support or
learning purposes
Simulation for strategic planning

Will it work?
it’s too risky
to test live Will it impact
How might
demand elsewhere in
change over our system?
time?

What is the
optimum
cost /
capacity
Model trade-off?
of
care
 Simulation does not predict

but

• it should aid understanding

• help you ask better questions
• anticipate effects of change

however

the answer is still a local matter

SG ages the modelled population year
on year, taking into account births,
deaths and life expectancy. Other
projected changes such as migration
can be also modelled. This has been
used to examine the long-term impact
on healthcare in areas of high
population growth (e.g. Milton Keynes).
Changes to the health system care
pathways can also be modelled
alongside population changes,
permitting any number of “what if”
scenarios to be run.
West Essex PCT used SG to examine the
workforce implications of acute care models
including GP diversion, Walk-in Centres and
polyclinics to handle a large (100,000)
population influx over the next 10 years.
Using the BAEM workforce model and the
activity and cost data from SG it was possible
to predict the numbers of staff required by
location and their costs.
East Riding of Yorkshire PCT modelled the
activity and costs arising from falls and
compared current provision with a
proposed new service that includes an
ambulance diversionary pathway to reduce
hospital admissions, and three tiers of
preventative and rehabilitatory assessment.
They were able to investigate the impact of
the ageing population, to compare
scenarios of various degrees of success in
diverting cases from A&E as a result of the
diversionary pathway and to identify the
costs and activity of the various steps in the
existing and new pathway. This aided
understanding of the proposed pathway
and its patient flows; enabled them to
demonstrate the potential benefit of
implementing various aspects of the falls
pathway, to identify the likely workforce
consequences, make sounder investment
plans and have greater confidence in the
business planning and commissioning of
the new elements of the service
Typical uses of Scenario Generator
Population growth
Viability of existing
hospital services as a
result of shift to primary
care
Testing capacity plans
Care pathways (incl.
falls, stroke, major
trauma)
Remodelling
unscheduled care,
admission avoidance
Polyclinics
A behavioural simulation was conducted to
test the shift of care closer to home (the
King’s Fund See-Saw event). Key
stakeholders were brought together to
negotiate a five year strategy to shift care in
a fictitious health community. They agreed to
move 10% of care from hospital to the
community. Simulation then demonstrated
that the intended shift would result in one of
the hospitals being non-viable. This insight
led stakeholders to negotiate some very
different models of care delivery.
South Central SHA used SG to model and
gain consensus on a stroke pathway that
was based on national and local best
practice and evidence.
The pathway model was then applied to their
PCT communities, taking into account
current resources and activity. Scenarios
demonstrating beneficial outcome from
thrombolysis, specialist stroke units and
early supported discharge were well
received and used to support business
cases for introduction of the new services
Greenwich PCT has an annual population
growth of 1.2%, high birth rate & inward
migration, high admission rates, and above
average outpatients. They wanted to
explore implications for their own PCT of
the Healthcare for London plan, in
particular to anticipate polyclinic activity.
10 year simulations were run using the
generic healthcare model with local
configuration, comparing scenarios from
London Plan.
SG helped the PCT to test assumptions in
the London Plan and assess the
consequences for their PCT. It caused
them to question the volume of polyclinic
activity, its impact on care pathways and its
affordability
 Functional model

Results include:
Changes to: •Activity & cost for each step
•Population •Average & peak capacity
•Demography •Transaction time
•Prevalence Scenarios •Queues

Changes to:
Events •Referral
patterns
•Capacity
Population Mental Health •Duration

Urgent Whole
Demographic Simulation
weighting system results
Planned model

Prevalence Maternity

Service Pathway
points, flows Constrained
& waits models resources
Pathway display
How Scenario Generator Can examine activity across
supports the WCC the whole healthcare delivery
system locally and how it
Commissioning Cycle might respond to changing Allows multiple scenarios
demand or to different service of changing demand or
models. SG has a visual service delivery to be
pathway modeller that allows modelled and compared.
Can review demand existing and proposed new
arising from changing These can be used to
services to be mapped. test/check assumptions in
population and disease proposed service models
prevalence (population
growth is modelled)

Service delivery models

can be modelled within SG
as one or more pathways
applicable to different
disease groupings (e.g.
stroke, falls, urgent care)

Comparing predicted and Specific local resources

observed over time and using can be configured (e.g.
the model to understand how stroke unit, A&E units,
and where the system out-patient department,
behaved differently from the community hospital,
predicted. diagnostics) and linked to
steps on existing and new
pathways

Using the pathway modeller as a Running simulations on

tool for building clinical developed models will reveal
consensus, a simple and potential bottlenecks, potential
straightforward way of designing queues and delays. Output from
and sharing models for the simulations can be used to
delivery of care along pathways inform spatial modelling (e.g.
best location for new facilities)
How Scenario Generator supports WCC Competencies
1. Locally lead the NHS
SG can be used as a communication tool, provides a
consolidated whole-system view of the health and social care
economy, offers a transparent way of developing and sharing
service models
2. Work with community partners
SG provides a common platform on which to share service
models between community partners thereby increasing
knowledge transfer
3. Engage with public and patients
4. Collaborate with clinicians
Being based on clinical pathways, the service delivery models
are easily understood by clinicians and managers. SG is a
powerful tool for increasing clinical engagement when used as
a part of a multi-disciplinary planning process
5. Manage knowledge and assess needs
SG is a powerful modelling and simulation environment tailored
to the needs of healthcare strategic planning. It has a
population and disease modelling component and a service
delivery model based on pathways of care. It provides
analytical rigour to process mapping and whole-system
performance, supports a comprehensive map of local service
provision and analysis of current and future population trends.
SG supports predictive modelling, process mapping, scenario
planning and needs analysis
6. Prioritise investment
SG incorporates tariff costs of services in support of
investment planning. It supports process mapping,
predictive modelling, what if scenarios, simulation, service
costing, strategic planning.
7. Stimulate the market
SG can map current service provision, models and
simulates the impact of commissioning decisions and
strategies on current provision, increases understanding
of the local system.
8. Promote improvement and innovation
SG is a powerful tool for sharing new service model
proposals with clinicians, other staff and patient groups, it
offers transparency since assumptions are clearly
identified and models can be used to inform service
specifications. New ideas for service redesign can be
modelled and simulated very quickly.
9. Secure procurement skills
SG can reduce risk of failure of contracts through
better understanding and communication of the
desired service through prior modelling and
simulation.
10. Manage the local health system
11. Make sound financial investments
SG provides an analysis of the overall cost of
delivering modelled services, to better inform financial
analyses of new services.
 BCBV metrics
Opportunity Locator Role for Scenario Generator
Priority Selector
… & other Institute products

Finding
quick wins
Planning Engaging /
Marketing

Project Delivery for

Commissioners
Choosing
options
Designing
Prioritise Implementin
Commissioning g
Opportunities
Commissioning Patient
Pathways
Quic Experience-based Design
kSetting
direction Understandin
g
current state

Measurement for
Thinking Envisioning Improvement Monitoring
Differently
The ‘Plan Do Study Act’ of Modelling
Define
problem

Design
Select initial
approaches model

80% of the
Develop
benefit of
concept simulation Validate
DoDo
other is in this
analyses
analyses
process
P
Refine A D Simulate
Draw
S
conclusions

Consult

Act upon
outputs
How to set about using Scenario
Generator

• Have some idea of the problem you are addressing

• Identify your principal customer / stakeholder
• Draw together a core team
– leadership – a champion senior clinician or executive manager
– service design / improvement lead
– commissioning lead
– public health lead / analyst
– information analyst
• Develop a collaborative approach
• Work within an overall change programme
 Ashton, Leigh and Liverpool PCT Scenario Generator County Durham PCT
North of Tees PCT
Wigan PCT Manchester PCT
Blackburn & Darwen
PCT
Greater Manchester CBS
North Lancashire tPCT
PCT Licencees Northern Specialised Services
South of Tyne & Wear PCT
Blackpool PCT
Bolton PCT
North West Specialised
Commissioning Team
May 2009 Bradford & Airedale PCT
Calderdale PCT
Bury PCT Oldham PCT Doncaster PCT
Central Lancashire Salford PCT East Riding PCT
PCT Stockport PCT Hull PCT
Cumbria PCT Thameside & Glossop Kirklees PCT
Halton and St Helens PCT Leeds PCT
PCT Trafford PCT North Lincolnshire PCT
Heywood Middleton Warrington PCT N.Yorks & York PCT
& Rochdale PCT West Cheshire PCT Rotherham PCT
Knowsley PCT Wirral PCT Wakefield PCT
Derbyshire County PCT
Birmingham CBSA Leicester City PCT
Birmingham E&N PCT Leicestershire PCT
Coventry PCT Lincolnshire PCT
Dudley PCT Nottingham City PCT
Herefordshire PCT Nottinghamshire County tPCT
North Staffs PCT
Sandwell PCT Bedfordshire PCT
Solihull Care Trust Cambridgeshire PCT
South Birmingham PCT E & N Hertfordshire PCT
South Staffordshire PCT Luton PCT
Stoke on Trent PCT Northamptonshire PCT
Telford & Wrekin PCT Peterborough PCT
Walsall PCT S.W.Essex tPCT
Warwickshire PCT Suffolk PCT
Wolverhampton PCT West Essex PCT
Worcestershire PCT
Barking & Dagenham Lambeth PCT
Berkshire East PCT PCT Lewisham PCT
Berkshire West PCT Barnet PCT London
Buckinghamshire PCT Bromley PCT Commissioning
Milton Keynes PCT Camden PCT Support Service
Oxfordshire PCT City & Hackney tPCT London Specialised
Portsmouth City tPCT Croydon PCT Commissioning
Southampton PCT Ealing PCT Group
Strategic Decision Support Service Enfield PCT Newham PCT
Greenwich PCT Redbridge PCT
Bath & NE Somerset PCT Hammersmith & Richmond &
Bristol PCT Fulham PCT Twickenham PCT
Devon PCT Haringey PCT Southwark PCT
Dorset PCT Harrow PCT Sutton & Merton
Gloucestershire PCT Havering PCT PCT
Brighton & Hove PCT
North Somerset PCT Hillingdon PCT Tower Hamlets PCT
East Coast and Kent ECT PCT
Plymouth PCT Islington PCT Waltham Forest PCT
East Sussex Downs & Weald PCT
Somerset PCT Kensington & Wandsworth PCT
Medway PCT
South Gloucestershire PCT Surrey PCT Chelsea PCT
Swindon PCT West Kent PCT Kingston PCT
Torbay CT West Sussex PCT
Wiltshire PCT
For further information

simulation@institute.nhs.uk

www.institute.nhs.uk/scenariogenerator

www.scenario-generator.com
Some case studies ...
Case Study: East Riding PCT
Falls and Osteoporosis Pathway

Scenario Generator was used to:

• model the activity and costs arising from falls in the current health
care provision;
• model the proposed new service which includes an ambulance
diversionary pathway to reduce hospital admissions, three tiers of
preventative and rehabilitatory assessment;
• investigate the impact of the ageing population;
• compare scenarios of various degrees of success in diverting cases
from A&E as a result of the diversionary pathway;
• identify the costs and activity of the various steps in the existing and
new pathway
East Riding PCT Falls and
Osteoporosis Pathway ctd.

Benefits
• aid understanding of the proposed pathway and its patient flows;
• demonstrate the potential benefit of implementing various aspects of
the falls pathway;
• identify the likely workforce consequences;
• provide an indication of current costs of falls and the likely cost
savings as a consequence of the new pathway
• greater confidence in the business planning and commissioning of
the new elements of the service
• application of Scenario Generator to other initiatives in which new
models of care are being developed (unscheduled care strategy)
Case Study: Modelling a polyclinic
ala Healthcare for London

A London PCT with:

• Population 228,200
• 1.2% growth per annum
– High birth rate + inward migration
• High admission rates, mainly explained by high
maternity episodes
• Slightly above SHA average for outpatients
Healthcare for London – new models

For inpatients
41% of future activity will take place in major acute hospitals
20% in elective care centres
29% in local hospitals
10% of admissions managed at home or no longer commissioned

Polyclinics will handle

50% of A&E activity
40% outpatients
70% primary care consultations
“conversion factor” for 10% admissions avoided
 How did Scenario Generator help?

• 10 year simulations run using generic healthcare

model, local configuration and assumptions from
London Plan
• Quick and clean(ish) - 2 days to model impacts
and produce results
• Structured problems and concepts
• More in depth exploration of potential impacts of
London Plan assumptions for one PCT
• Question over volume of polyclinic activity
• Impacts on care pathways
• Affordability over time
 Case Study: Stroke Pathway –
South Central SHA

• Initial pathway based on Map of Medicine

• Engagement with Stroke Metrics project
• Input from Vascular Network
• National Stroke Strategy, National Sentinel Audit
• Outcomes data from Oxfordshire studies (OXVASC– Dr Peter
Rothwell)
• NICE and DH tariff costings

Courtesy of Andrew Hughes

Pathway model
Pathway - lower
 PCT 1

Baseline estimates taken from Sentinel Audit 2006 and

Asset tool:

• Assume 40% rehab in specialist stroke rehab unit (need

to clarify with stroke nurse)
• No thrombolysis offered currently in local trust (in current
Trust business case) – assume 0% as baseline
• No early supported discharge team currently in place at
local acute trust

PCT currently redesigning stroke pathway – draft pathway

completed in July

Courtesy of Andrew Hughes

 Outcomes

Baseline Intervention
Activity Cost Activity Cost
Inpatient Strokes acute costs (+ early rehab) 375 £937,500 374 £935,000
Maximum acute bed occupancy 16
Thrombolysis add costs @ 4% ischaemic 0 £0 15 £12,210

Baseline of Rehabilitation
Activity ALOS Est bed days Max bed occupancy
Stroke unit rehabilitation 140 22 3080 13
Other rehabilitation 171 26 4446 20
7526 33
Early supported discharge team in place
Activity ALOS Est bed days Max bed occupancy
Stroke unit rehabilitation 186 22 4092 14
Other rehabilitation 38 26 988 7
Early supported discharge 85
Reduction in average bed days: 2400

Outcomes
Baseline Intervention Reduction
Expected institutionalisation 65 55 -15%
Expected early deaths after treatment 87 80 -8%

Courtesy of Andrew Hughes

 PCT 2

Baseline estimates taken from Sentinel Audit 2006,

Asset tool and local pathway:

•Assume 50% rehab in specialist stroke rehab unit

(need to clarify with stroke unit)
•No thrombolysis offered currently in catchment
hospitals – assume 0% as baseline
•No early supported discharge team currently exist for
catchment hospitals

PCT has Stroke pathway based from 2006 from acute

provider. Limited commissioning understanding in
PCT

Courtesy of Andrew Hughes

 Outcomes

PCT 2 – Stroke care: Population 500k

Baseline Intervention
Activity Cost Activity Cost
Inpatient Strokes acute costs (+ early rehab) 501 £1,252,500 501 £1,252,500
Maximum acute bed occupancy 20
Thrombolysis add costs @ 4% ischaemic 0 £0 14 £11,396

Baseline of Rehabilitation
Activity ALOS Est bed days Max bed occupancy
Stroke unit rehabilitation 224 22 4928 16
Other rehabilitation 184 26 4784 22
Total 9712 38

Early supported discharge team in place

Activity ALOS Est bed days Max bed occupancy
Stroke unit rehabilitation 234 22 5148 17
Other rehabilitation 50 26 1300 9
Early supported discharge 127
Reduction in average bed days: 3203

Outcomes
Baseline Intervention Reduction
Expected institutionalisation 89 72 -19%
Expected early deaths after treatment 107 101 -6%

Courtesy of Andrew Hughes

 Key learning

• Need to have defined questions before start the modelling process

• Need a direct customer, either commissioner or provider: facilitates
better engagement and interest

Courtesy of Andrew Hughes

See-Saw Simulation – King’s Fund

• Behavioural simulation looking at care outside hospital

• Scenario Generator modelled the impacts of decisions made in year
1 into year 5
• Powerful impact of the data on the ability of the group to make
decisions
• Publication available on King’s Fund website
Simulating Population Growth

• Scenarios can be modelled for population growth

• SG ages the population year on year adding births and taking away
deaths
• Projections function allows inward migration to be modelled in
addition to natural population growth
• Changes to the health system care pathways can be modelled within
same scenarios
• ….any number of “what if” scenarios
Link to Implications for Estates
and Workforce

• SG results expressed in terms of activity by individual pathway

steps, and aggregated steps and costs (with inflation)
• Users need to be able to translate this into potential requirement for
estates and workforce
• Currently developing work to use the HUDU tool standard calculation
to look at spatial requirements
• Users could then map requirements to actual estate, through
SHAPE/other GIS tool
• Currently exploring the potential of the electronic staff record to
generate workforce requirements arising from future possible
scenarios
 Case Study: West Essex PCT

• Redesigning urgent care

• High level use of A&E attendance
• Walk-in Centre at the front end
• Increasing population – 100,000 expected in next 10 years
• Developing polyclinics to cope with new population
• Reducing use of A&E over time

• Planning for a workforce to work flexibly at varying levels of acuity

over next 10 years
• But new services increase demand….
 A Workforce Scenario

• Decide on area of service

• Draw model
• Run over 5 and 10 years to look at possible levels of activity
• Look at workload of staff teams, and use to define capacity
• What are the implications for future workforce?
• What are the implications for cost?
• What are the opportunities for skill mix to manage activity?