Synergia - Design Realise Sustain

Issue

Many Boards have invested in better and larger facilities only to find that their estimates for demand have fallen well short of reality; the new facilities that they thought were going to be sufficient for ten years are already overflowing. Now they are faced with the requirement for further investment in dialysis facilities and no confidence that their investments will be sufficient.

The rising tide of chronic conditions, resulting in renal failure and ultimately the need for dialysis, is becoming a major concern for DHBs who want a robust planning process to support the design of a sustainable renal service which gives them greater ability to predict and manage demand and thereby manage costs more effectively. They know they have to invest but they do not want to be on the back foot, responding to continual demands for new staff and new facilities.

To solve this problem Synergia utilised dynamic simulation modelling techniques to provide a robust analysis of what was driving demand and what options the DHB had to manage it. The modelling not only provided a robust tool to forecast demand under a range of scenarios but also a tool to understand the nature of the service and how it could be redesigned to meet both clinical and management requirements.

The DHB had made significant improvements in its service over the last few years, extending its dialysis facilities and recruiting more staff. However, the service was stretched with staff focusing on day-to-day coping strategies, moving and shifting patients to free up machines for unexpected arrivals and/or acute emergencies. Little if any development work was being undertaken as staff had no free time to do it. They were acutely aware that care was sub-optimal. It was a service on the 'backfoot' coping with the demand, but only just. Adequate facilities quickly became inadequate and an unplanned request for additional facilities was made. An unhappy Board had little choice but to fund the request but demanded that the situation be addressed so that they would not be faced with more unpleasant surprises. There was a strong desire to ‘get on the front foot’ and develop a plan that was based on a robust and realistic understanding of demand and the resources needed to manage it.

Solution

The Approach

A commonly held view is that the rise in prevalence of chronic kidney failure, combined with the ageing population will require more in-centre facilities to be built to meet this demand. Before accepting this view we developed a better understanding of demand. To do this we used System Dynamics modelling to develop a clear picture of the dynamics involved in chronic kidney disease, the decline into chronic kidney failure and the impact of service design on both.

Synergia worked with the renal clinicians, staff from the planning section and business analysts who had access to the renal service’s clinical and financial data, to build this model. The aim was to develop a clear, robust picture of the renal service and how it was likely to evolve under current policies and practices. We began with a qualitative model that described the key factors involved in driving renal demand within the DHB. This included the obvious impact of age and deprivation levels but also highlighted the importance of managing renal disease, along with the aggravating factors, as these have a significant impact upon the dependency levels of patients arriving at the service. This in turn has a major impact upon the treatment, or modality options, available. As patients arrive sick and dependent the numbers requiring supported in-centre service grew proportionally.

With this background a detailed quantitative model was developed utilising data from the local service, the ANZDATA database – the major renal database in Australasia - and international literature. The first model ran scenarios based on a continuation of current policies and practices. The results were not good; demand would continue to rise, albeit starting to rise at a slower rate over the next 10 years, and in-centre facilities would have to be expanded to cope. However, the modelling did provide some hope, highlighting a number of other plausible futures with different patient and service outcomes. The modelling clearly showed that the need for in-centre facilities, as opposed to other options such as home dialysis or peritoneal dialysis, which were less expensive and, for most patients, clinically superior, was driven as much by the nature of the service as by the demographics of the population. This meant that something could be done. Even if the overall demand was out of the DHBs control, at least in the short to medium term, they could choose how to respond to that demand and in doing so drastically alter the future clinical and financial future of the service.

What became clear in this work was that patients were being treated in-centre because there were limited resources being applied elsewhere. The resources needed to support the training required for home and community options were being absorbed by the response to the rising in-centre demand. Links with the primary sector were far from optimal and patients were being seen by the renal service far later than was needed. As a result they were sicker than they should be and the dialysis options were limited. When a patient is sick, frightened and having to go on dialysis at short notice it is not a good time to talk about training and having dialysis at home. Furthermore, dialysis patients require minor surgery to provide access for the dialysis machine to circulate their blood. As patients were arriving late and access was hard to get on a timely basis a large number of them were being given temporary and even emergency access. Not a good start to a process that you were going to have to put up with for around five hours, three days a week for the rest of your life. It was great to have it all done for you. Thinking about having to do this at home, and being trained to do so was, for many patients far too difficult. Having the process all done by the nurse is a lot easier. Once patients start on fully supported in-centre care it is difficult to encourage them to change – even though it can be much better for them.

So, the more the service ran to keep up, the more the service filled up its in-centre facilities. What the process of modelling showed was that the future of the service was, to a large extent, in their control and that a better understanding of the dynamic interplay between demand and service design could provide options that were better for the patients, better for staff and better for the financial management of the Board.

Outcome

Synergia’s approach, using system dynamics modelling, led to a greater understanding amongst management and clinical staff of what was driving demand and what options the DHB had to develop different responses. This led to a better understanding of the impact of managing aggravating factors, managing renal disease, and investing in primary care, on the dialysis volumes and the dialysis treatment options. The outputs of the model suggested that whilst the total demand volumes would be very difficult to change in the medium term, changing the renal service practices within the hospital and in their relationships with the primary sector could have a significant impact upon the level of dependence exhibited by patients and consequently the modality choices available to them.

The modelling was also used to develop future scenarios based on different mixes of these intervention strategies. As a result the DHB discovered that they could have a major impact on the volume and type of dialysis treatments for their patients and that simply increasing in-centre facilities was not the only option. This understanding had consequences worth millions of dollars for the DHB.

From a service on the ‘back foot’ they are now a service with a sense of control over their destiny. Their particular concerns are understood and their approach is being supported. Over the next decade the demand for renal dialysis services will increase and unless the health system is going to limit access renal services will need to be expanded. However, this work has shown that despite the ageing population it does not mean a continual increase in expensive in-centre facilities.

The use of simulation modelling increased understanding and blew away a number of untested myths about the growth in demand and the service responses required. Good service design, and an understanding of the characteristics of demand within a given population can lead to far more innovative options that are less expensive and, most importantly, far better for patients.