Easy

Why is forward planning such a slog in the NHS? Fundamentally, all we are doing is this:

1. Take what happened last year
2. Add a bit
3. Adjust for any specific pathway and demand management changes
4. Apply some agreed performance assumptions using well-known equations
5. Output the results as activity, capacity and money.
6. Profile it all into a monthly plan.

Hard

The first thing that makes it difficult is the sheer volume of numbers involved. Your plans need to break everything down at least by specialty (treatment function code), or by HRG chapter, or even by HRG. Then you need to separate out emergency spells, elective spells, A&E, first outpatients, etc. And you need to split it by commissioner or provider, and possibly by provider site as well. All in all, you are looking at dozens of service lines at least, and quite possibly hundreds.

The second problem is that different kinds of data come from different places in different formats (including notes of meetings and scraps of paper). Some of the performance assumptions are broad-brush, some are detailed, and some are exceptions to a general rule. They somehow need knitting together into a single planning model. And they keep changing: time goes by and more recent activity data becomes available; performance assumptions and pathways are negotiated and amended; new guidance comes down from the Department of Health (and in future the Commissioning Board).

The third problem is that some of the historical data is prone to errors: activity is not completely or correctly coded, there are delays in recording events on the system, there are duplicates and omissions, and changing customs and practices cause coding drift and other systematic error. To some extent, these errors can be detected and corrected automatically; in many cases they can’t.

The fourth problem is that well-known equations do not exist for some of the workings. Waiting time standards of the form “90% of patients must be treated within 8 weeks” have historically been a high-profile example; the standard is easy to state, but to model it properly you need to take in the effect of clinical urgency, cancellations, whether you are running a fully-booked or partially-booked system, and other factors. If you try to simplify the problem by assuming that current practice reflects how things ought to be, then you are ignoring (often substantial) opportunities to improve.

There are similar problems with monthly profiling: you can profile non-elective work based on historical patterns; but what agreed methods are there for profiling inpatient elective work around peaks in non-elective demand, when the 18-week waiting time limit means that you can’t slow down surgery very much over the winter?

The fifth problem is that you probably have the wrong tools for the job. The suggested tool for presenting your plans is usually a spreadsheet, and (despite the well-known problems with spreadsheet errors, and their limitations when it comes to iterative calculations) they are the cultural default.

Important

How much does this matter? Aren’t these plans just shelfware? Feeding the beast, and all that?

Actually, no. Although your painstakingly-crafted plans may end up on the shelf afterwards, there are two good reasons why the effort is important:

1. The planning process causes lots of conversations to happen that do change the way healthcare is delivered, and the numbers make sure those conversations are tough enough.
2. The financial squeeze is now adding urgency: PCTs will not be allowed to create a legacy of debt for future GP consortia, continually-rising demand is no longer affordable, and hospitals have a capacity overhang from the boom years… and so back to point 1 above.

It is natural when planning to focus on the correctness of the calculations. The complexity of the process can make this all-consuming.

But it is equally important to make sure that everyone else involved can keep track of the performance and pathway assumptions being used. Why? Because when clinicians and managers make changes to healthcare in real life, they are implementing changes to these assumptions.

Of course the calculations must be right, and the “bottom line” results are crucial in showing how much further negotiation will be needed. But it is also worth paying attention to the presentation of those key assumptions. If other people can easily see what they are, what they mean, and how they change during negotiations, then better decisions will be made about them, and the planning process will be a more powerful force for improvement in the real world.