"We need to acknowledge capacity and demand is complex" (Part one)

Gareth Jenkins is a partner at Changeology Group. For the past 15 years, Gareth has worked in health and social care both as an NHS employee and external consultant. Specialising in transformation, change, performance improvement and productivity, he has worked across the UK and Ireland delivering better outcomes for staff and patients. Changeology have been working with the Better Care Fund (BCF) Support Programme to deliver improvement support in systems. This is the first of a two part blog.

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One of the primary challenges across health and social care is to try and supply suitable capacity to meet the ever-increasing demand for services.  

The dictionary suggests that demand is 'a need for something to be sold or supplied' while capacity is 'the amount that can be held or produced by something.' While being a relatively rudimental explanation, and non-specific to care provision, it is nonetheless easy to understand. So why is this seemingly such a complex issue? And what exactly is 'it'?
Semantic satiation is at large here, I fear. Such is the regularity of the term ‘capacity and demand’ or ‘demand and capacity’ that we have ended up with a term that has lost all meaning. For far too many people this now means little more than a data return or spreadsheet, rather than being a fundamental part of a working system. 

Working 'it' out

For the last 15 years, I have been working in and around the public sector in the UK and Ireland and 'it' has been a common factor, everywhere.  

There is always this focus on 'how can we get the data and information together' to come up with a plan or model. Some places start with a blank canvas, some with their previous year’s iteration, and some with a new heralded template or model.  

On reflection, a better question may be 'why' rather than 'how'?  Is it to better commission services or to better run services, or both?

Knowing ‘what the demand is’ is difficult but can be done. Understanding ‘what the current capacity is’ can be done but is not easy.  So what?  Knowing something is all well and good but what do we do with that information?  

We know what the emergency department wait time is. We maybe know what our utilisation in theatres is. Do those numbers drive changes in behaviour or are they just an indicator of performance? 

Due to the advent of smartwatches we now know what our heart rate is at any time of day - amongst other things – are we changing behaviours or just vaguely interested? It is what action is taken that is crucial here; unless information is used as a driver for action then it merely becomes a ‘thing.’

Instead of “it” being the zenith of one’s efforts it could well be seen as the nadir.

Don't believe in the simple fix

While the aforementioned definitions may be simple, it would be reckless to suggest that modelling demand in the care sector is straightforward:

  • When does demand start?
  • When does it end?
  • When does it relate to service A and then service B, and then so on?

There are a number of quality reports and documents which detail the need for calculating demand effectively (Alireza Ghorbani, John Bolton, the King’s Fund) and while it is not a simple fix, it can be done.  

But the trick is not to make it an unconnected exercise; demand fluctuates and changes on a constant basis. And similarly with capacity – machinery and equipment can have downtime, human resources have shift patterns, absence and annual leave.

All of these factors (and many more) can change, quite literally, like the weather. So, unless demand is being perpetually monitored and measured, it is almost impossible to know exactly what capacity is required to meet it.

I have seen capacity calculated as the number of WTE multiplied by a number of hours or days – at a certain level that can be factual, although perhaps not very useful. 

The skillset, disciplines and experience of said capacity has to be counted, and then what proportion of their working time one expects them to be available for certain demands. On top of that we need to understand other factors like:

  • what shift patterns they have been allocated?
  • what leave they have booked in?
  • where are they based?
  • what is their mode of travel?
  • how is that affected by the time of day?
  • do they have an existing caseload and crucially what workload is contained within that caseload? (because each person on that caseload will likely have unique needs or demands) and so on. 

In much the same way, someone may have done some research and decided that Service A will receive 150 referrals in a particular month – in order to balance capacity against that demand we need to understand a range of things:

  • when that demand is arriving?
  • what day of the week?
  • what time of day?
  • what level of urgency?
  • what social/environmental/clinical needs do they have amongst a raft of other factors?

So regardless of our desire to make it simple, it is not.  To see capacity and demand as a number is to oversimplify the inherent complexity of health and social care services and it leads to a borrowed wisdom surrounding the efficacy of certain services which invariably leads to frustration amongst the staff (and patients) on the frontline.

From the inside, out

Equally, there is a balance to be struck. 'Paralysis by analysis' can come into play; you can make demand and capacity calculations so complex, that they become unwieldy and difficult to use.

This is just as problematic as over-simplifying the nuances of services and trying to make entire services boil down to a single number.  Both challenges are far more likely to occur if the planning is done from ‘outside’ or ‘above’, even if by a proclaimed expert or someone using a ‘tool.’ 

Invest time and expertise into the operational teams and they will provide robust, accurate and considered information which will be much more useful for planning, commissioning and service configuration.

When trying to provide support to an organisation around marrying capacity and demand the focus must be on the actions required to change and balance each side of the equation. These metrics should not be calculated, or presented for a whole organisation unless it has been worked up from a granular level, because it is at that level where the changes will need to be taken.

Even if changes made are macro-level strategic ones, they will have little or no effect unless the strategy is cascaded down through organisations to change behaviours throughout.

This is the first of a two-part blog. The second part will be published shortly. Please keep an eye on our BCF Support Programme for updates.