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Joint planning in Dudley—the role of balance of care
OMEGA The
Int. JI of Mgmt Sci, Vol. 9, No. 5. pp. 501 to 508. 1981
0305-0483 81 050501-08S02 0(~ 0
Printed in Greal Britain, All rights reserved
Copyright ~ 1981 Pergamon Prcss Lid
Joint Planning in Dudley-the Role of Balance of Care IG NICHOLLS West Midlands RHA, Birmingham, UK tReceived May
1981)
Balance of Care is a computer-based policy analysis tool that has been developed to aid the joint planning of health and local authority services in England. A case study is presented on its application w i t h i n the West Midlands region of the National Health Service. As well as giving a description of the important steps in the project, the case study incorporates observations on factors which can lead to success, or failure, in the application of Operational Research concepts.
THE BACKGROUND TO BALANCE itself to be a valuable aid to national policyOF CARE makers and soon people began to consider BALANCE OF CARE (BOC) is the name coined whether it could not be equally well applied to about a decade ago for an approach to aiding the analysis of similar policy issues at a more those concerned with the development of local level. An experiment to test out this hynational policies in the fields of health and per- pothesis took place in Devon between January sonal social services. The then Secretary of and October, 1976. The results of this experiState for Health and Social Services, Sir Keith ment proved sufficiently encouraging to Devon Joseph, had recognised that, although policies County Council and Devon Area Health Authwere being developed nationally for improving ority that a full-time study was set in being to the care of separate segments of the popula- create a 'tailor-made' version of BOC for use in tion, such as the elderly and the mentally ill, Devon. This study has also been successful and there was not a satisfactory mechanism for is being carried out by the Operational considering the implications of such policies Research Unit of the Institute of Biometry and taken together. Further, it was difficult to Community Medicine of Exeter University. assess the consequences, both in terms of Accounts of the work in Devon can be found resources required and of levels of care de- in the work of Canvin and co-workers [1, 2]. livered, of alternative policies. The task of deThis paper picks up the story of BOC in veloping the relevant policy analysis tool was December, 1976, with the agreement of the Regiven to the Operational Research Service of gional Team of Officers of the West Midlands the Department of Health and Social Security Regional Health Authority (WMRHA) for a (DHSS). trial implementation of BOC in an Area BOC was first applied to the problem of Health Authority in the West Midlands region. analysing the implications of possible alterna- It is a case study on the relationship between tive policies for the care of the elderly section the operational research practitioner and two of the country's population. It met with early clients; it covers the 'selling' of the original acceptance by Ministers and senior civil ser- concept to the clients, the phased implementavants in the DHSS, and was extended to cover tion of the concept and its integration into the three other sections of the population; the clients' planning mechanisms. Before proceedmentally ill, the mentally handicapped and the ing with the story it will be necessary to physically handicapped. It continued to prove explain something of the nature of BOC itself. 501
502
Nicholls--Joint Planning in Dudley
THE BALANCE OF CARE MODEL The main feature of BOC is that it is concerned with analysing the implications of alternative patterns of care, using various combinations of health and local authority resources. For certain population groups, such as those requiring surgery, there is little scope for alternative forms of care provision. Either there are enough resources to satisfy the demand (doctors, nurses, beds and operating theatre time) or there are not. However, for other population groups, there may be many different ways of combining the available resources of health and local authorities to provide acceptable forms of care. The population groups for whom the above is true include the elderly, the mentally handicapped, the mentally ill and the physically handicapped; and it is around these that the framework of BOC has been built; firstly, a system of classifying their relevant attributes is constructed for each of these four groups. For the elderly, for example, the attributes could be their physical health, mental health, social circumstances (are they socially isolated?), the suitability of their housing and their degree of continence. These might be determined by the appropriate professional advisers as those attributes which are most significant in determining their need for services. The second task would then be to determine the resources provided by the two authorities that either are, or could be, used in providing care to the population groups involved in the study. Typical health service resources would be: geriatric medical beds; continuous nursing care beds; long stay psychiatric beds; mental handicap hospital hostel beds; group home places; psychiatric community nurses; domiciliary physiotherapists; care attendants,; home nurses; health visitors. The local authority resources included in a BOC study would certainly be drawn from the Social Services Department, and might also include some from the Housing Department, the Education Department and the Leisure Services Department. Examples would be: long-stay residential home places; sheltered housing; wheelchair properties; mobility dwellings; adult training centre places; day centre places; home helps; IBalance of Care--a user's view of a new approach to joint strategic planning by RG Borley, SH Taylor and CR West.
social workers; meals on wheels; night sitters; special schools. Having developed a classification system and a list of resources, the two need to be combined together, in order to derive the alternative forms of care that might be provided to patients with particular combinations of attributes. These alternative forms of care are known as 'packages of care', and determining them is a job which only the professional care providers themselves can undertake. Once the above structure has been established, possible alternative future health and personal social services policies can be analysed with it, and the results presented in terms of the criteria which are believed to be important by the policy-makers. A schematic representation of BOC is provided in Fig. 1. Fuller descriptions of the current formulation of BOC as a mixed integer mathematical program can be found in Coverdale and Negrine [4] and Gibbs [5]. An alternative formulation of BOC has been developed and is in its final stages of testing: reported in this issue of Omega. 1
BALANCE OF CARE IN THE WEST MIDLANDS REGION OF THE NHS The West Midlands RHA provides a number of central services for a population of about 5.1 m in the counties of Hereford and Worcester, Warwickshire, Salop, Staffordshire and West Midlands. It allocates the yearly revenue budget to the 11 Area Health Authorities (AHAs), it manages the capital building programme and is the responsible strategic planning body for the region. The OR Unit of the West Midlands RHA provides a service which at the present time is free to the customer, who can come from any discipline and any organisational level in the region. In 1976, the vast new machinery of the NHS Planning System was beginning to move, and health authorities were becoming increasingly aware of the problems they would face in developing plans with this radically new (for the NHS) methodology. Broad objectives would be stated by the DHSS, modified and amplified by RHAs and AHAs, and be received by the operational management tier, the Health Districts. The Districts would then develop their strategic plans in the light of these objectives. The
Omega, Vol. 9. No. 5
Construction of alternative ways of providing care
Local Authority services
Formulation of the model
Health Authority services
P A C K A G E S OF CARE
Classification of population
Future levels of health a nd local authority resources
B A L A N C E OF CARE MODEL
the
Estimates future population size
503
Application planning
to joint issues
INPUT POLICY OPTIONS
I
E V A L U A T I O N OF A PARTICULAR POLICY
of RESULTS~
ACCEPTANCE OF POLICY
MODIFICATION OF POLICY OPTIONS
FIG. 1. Schematic diagram of BOC.
West Midlands RHA's OR Unit saw here an opportunity to provide NHS managers with considerable support via the use of operational research methods. At the top of the list of such methods appeared BOC. In order to commit a significant proportion of the OR Unit's resources to an experimental application of BOC in the West Midlands, it was necessary to obtain the approval of the Regional Team of Officers (RTO). The RTO is the top management group within the RHA, and they are accountable to the RHA members themselves, who are appointed by the Secretary of State. The RTO is a five-person group that manages by consensus, it contains the Regional Administrator (to whom Management Services is accountable), Regional Medical Officer, Regional Nursing Officer, Regional Treasurer and Regional Works Officer (who controls the Architects, Engineers and Quantity Surveyors). In the West Midlands RHA they meet every Monday, and so on Monday, 2nd December 1976, I met them to gain their support for a trial implementation of BOC.
First Attempt--a Multi-District Area The RTO accepted my proposal and agreed on one of the four multi-district AHAs as the site of the experiment.
Since BOC was still an experimental tool, the OR Service of the DHSS was prepared to provide support to an application in the West Midlands. Accordingly, arrangements were made to meet the Area Administrator and Area Medical Officer, and the Director of Social Services from the local authority. Meetings with the former revealed few problems and enthusiastic support was obtained. However, when we met the Director of Social Services, he expressed serious reservations about a fundamental assumption of BOC, that it was possible to consider the needs of a particular population group, such as the physically handicapped, in terms of a classification of attributes as described above. The Director of Social Services was unable to accept this, and stated his view that each Social Services client had individual characteristics which could not adequately be catered for when clients were grouped together. In addition, he was confident that his strategic plans were well enough developed, and he doubted that BOC could offer any help to him. These views naturally presented us with a difficult problem of differing levels of enthusiasm for BOC from the two authorities. A rather uneasy compromise was offered by the Director of Social Services, who recognised the
504
Nicholls--Joint Plannin# in Dudley
potential value of BOC to his Area Health Authority colleagues, and agreed to proceed with the study, whilst reserving the right to dissociate his Department from necessarily accepting the results of the study. This compromise was accepted and negotiations progressed during 1977, until the time came for us to seek the support of the Psychiatric Division (the group of all consultant psychiatrists practising in the Area). We met the Chairman of the Division, who chose to describe BOC personally to the rest of. the Division. They decided that they did not wish to participate in the study, having been adversely influenced in their decision by the particular formulation of the mental illness part of the model that had been described to them. Recognising that an alternative formulation had been developed in Devon, we invited the leader of the OR project team in Devon, Mr R Canvin, to meet the Chairman of the Psychiatric Division and a consultant colleague, together with the Area Administrator and Medical Officer. The results of this meeting were encouraging; the alternative formulation was liked, and a further consideration of the proposal would be made by the Division. Eventually their decision was relayed to the Area Team of Officers: although one psychiatrist was not interested in BOC, the others would co-operate, provided that an additional appointment of a research registrar be made, specifically to be concerned with BOC. This was a precedent that the Area Team of Officers could not afford to set and, very reluctantly, they decided to terminate the proposed BOC study in their Area.
port. This proved to be the most crucial step in what became our successful second attempt to implement BOC. With him we arrived at a short-list of four potential AHAs. We discussed these with the Regional Administrator and Regional Medical Officer and Dudley, a singledistrict Area, was unanimously placed at the top of the list. Following meetings with the Director and Deputy Director of Social Services, and with the Area Medical Officer, it became clear that the support o f two key groups would be necessary before BOC could proceed. On the one hand were the staff of Social Services, and on the other were the consultant medical staff. Our approaches to these two groups were very different. About 15 representatives of the different levels within the staff of Social Services met members of the OR team to hear BOC explained to them. Following this meeting, we wrote up the details of our oral presentation in a paper which the staff could then consider at length. They subsequently asked for two further meetings to clarify various points in what we had said, and we discovered our first potential stumbling block. A major worry was becoming evident amongst the middle managers, in that their staff were already under pressure to cope with the very heavy workload on the Department. BOC represented an additional workload which would place further pressure on Social Services. In debating this quite reasonable concern of the middle managers, the structure of our implementation became clarified. What the OR project team were hoping for was an agreement to move straight into the building of a tailor-made verSecond Attempt--a Sin#le-District Area, Dudley sion of BOC for Dudley. However, this was The DHSS OR Service were still willing to effectively asking the two authorities to invest provide support to an application of BOC in significant amounts of time and effort from the the West Midlands, and I and members of my professional care providers in the development staff agreed that we should have one more try. of a tool of unproven value. As a result of the We discussed the likely AHAs that might worries expressed by the Social Services satisfy the relevant criteria of interest in devel- Department it seemed to us sensible to offer a oping their joint planning, good relationships two-stage implementation process. In the first with their corresponding local authority and stage all we should attempt to do would be to important planning issues to resolve. In these offer a demonstration of the potential value of discussions we included a number of RHA staff BOC to Dudley. We would do this by using and one in particular, the Specialist in Com- the model developed for Devon and insert into munity Medicine with responsibility for health it the data on population numbers and information (SCM), was very interested in our resources for Dudley. This would have the proposals and wished to offer his personal sup- advantages of:
Omega, Vol. 9, No. 5
--speed, since the process should last no longer than six months; --simplicity, since the emphasis would be on the potential value of the tool, rather than the intricacies of its construction: --safety, since very little effort would be required from health or local authority staff, and almost all the risk would be carried by the OR project staff. At the end of this first phase, the two authorities would have a much sounder basis on which to assess whether they wished to give a commitment to the development of a tailormade version of BOC for Dudley which would be Phase 2. Our approach to the consultant medical staff was equally important, but, on the advice of the Area Medical Officer, was handled entirely by him. He ensured that the subject of BOC was tabled at all the critical meetings in the Area's medical machinery and he, personally, gained acceptance for it. The process of gaining support for BOC in Dudley lasted from October, 1977 to May, 1978, when we again called our colleague from Devon, Mr Canvin, to describe BOC in Devon to a meeting attended by the Area Team of Officers and the Director and Deputy Director of Social Services. His eloquence won the day and Phase l had begun.
Phase one--demonstrating the potential of BOC To manage this first phase we needed a representative, but small, group of officers from the two authorities. This became known as the Joint Management Team and was composed of the following people:
All meetings were attended by the OR project team, which included staff from the W M R H A OR Unit and from the OR Service of the DHSS. The meetings were chaired by me. A very tight timescale was set for the completion of this first phase of the study, and it was the project team that set it rather than the Joint Management Team (JMT). With the first meeting held in late September of 1978, we had the target of completing the computer runs of the model and commencing the writing up of the results by the following January. In order to achieve our target we needed to accept the model as formulated for Devon, with the Devon care providers' views on acceptable alternative forms of care without any modification, and collect data which represented the numbers of patients/clients in Dudley who fell into the various categories. Obviously, we were unable to undertake any surveys to supplement available local data, and, where there were gaps in what was routinely recorded, it was necessary to use existing surveys. There were two such surveys which were very valuable to us, one was a survey undertaken by the local authority in the early 1970s, and the other was a well-known national survey [6] on the handicapped and impaired. The JMT meetings worked extremely well and both the members of the JMT and the OR project team became very 'task-oriented', with the result that the target was only missed by two weeks. Thus, in mid-January, 1979, we began to write up the results of our efforts. Basically, what we had done was to undertake. three successive runs of the model. Run 1--1978. The aim of this run was to simulate the existing allocation of resources as a basis for comparison, but this had the additional value of indicating existing imbalances
Dudley Metropolitan District Council
Dudley Area Health Authority
Deputy Director of Social Services,
Specialist in Community Medicine (Social Services), Divisional Nursing Officer, (Community), Sector Administrator (Community).
Assistant Director of Social Services, (Fieldwork), Principal Administrative Officer, (Social Services), Assistant Director of Finance. 2
505
2 (at some meetings the G r o u p Accountant (Social Services) deputised for this officer).
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Nicholls--Joint Planning in Dudley
in the levels of service provided to different sections of the community (notably the younger physically handicapped and the elderly handicapped) and those resource areas which would be most cost-effective for expansion. Run 2--I 983 'most likely'. In this second run, we modelled Dudley five years into the future when the first phase of the new district general hospital was due to open. We attempted to reflect the most likely pattern of resource provision as indicated by the two authorities' forward plans. The two main results from this run were that the planned increase in meals on wheels appeared to be considerably in excess of what was required, and that for some patient groups, the level of services was likely to decline in comparison with 1978. Run 3--1983 'optimistic'. Following the second run, a number of modifications were made to the pattern of resource provision (for example a residential home for the elderly was deleted and one for the mentally handicapped put in its place). The result was that, although the level of meals on wheels provision had been reduced, it was still too high, but it was now possible to maintain the levels of care achieved in 1978, although not to improve upon them. This last point was particularly important. The effect of an ageing population appeared to be that, even with increased levels of resource, standards of service would only stand still, and they were not particularly high in 1978. Although these results obviously had to be interpreted with great caution, and were really only intended to be illustrative of BOC's capabilities, actions were taken by the two Authorities as a result of their production. Our report [-3] was discussed with members of the AHA's Area Management Team in March, 1979, and with the local authority Chief Officers in April. The joint planning machinery of the two authorities takes place via meetings of the two sets of chief officers, the so-called Joint Care Planning Team (JCPT) and meetings of councillors and health authority members, the Joint Consultative Committee (JCC). We subsequently pre~ented our results to these two bodies. At all these meetings we were seeking support for a move into phase two of the study, where we would build a tailor-made version of BOC for Dudley. This step would involve both authorities investing sig-
nificant amounts of time and effort of various individuals and groups, and would commit them to an 18-month development programme. The results of the first phase study were sufficiently convincing for there to be complete agreement that the second phase should begin straight away.
Phase two--delivering the goods For the W M R H A OR project team, we were very much now on our own. The level of support that could be provided by the DHSS OR Service had decreased to a mainly advisory service, and the experience of our colleagues in Devon was only of limited value. The nature of the task that faced us was twofold. Firstly, we had to bring together four groups of advisers, drawn from the caring professions, to develop the parts of the model concerned with the four population groups (elderly, mentally ill, mentally handicapped, younger physically handicapped). Secondly, we had to ensure that BOC became an integral part of Dudley's joint planning machinery: if it was a parallel exercise to the conventional methods of planning then it was almost certainly doomed to fail. It needed acceptance and commitment. In achieving this second aim we were helped greatly by the AHA's General Administrator (Planning) and the Assistant Director of Finance from the local authority who produced a paper for the JCPT, suggesting the creation of a 'Joint Strategy Group' (JSG). Whilst each authority had a second-in-line officer planning group, the J C P T did not, and they proposed that there should be one, called the JSG, with second-in-line officers from the two authorities on it. Its role would be primarily advisory to the JCPT, but it would have one executive responsibility and that would be to run BOC. This proposal was accepted and the JSG came into being in the autumn of 1979. At the same time we were bringing together nominations for membership of the four advisory teams. In November, 1979, these teams had their first meetings, which usually last about an hour, and take place over lunch to minimise the disruption to the members' other work. Membership of a typical group includes a consultant, a hospital nurse, a community nurse and one or two representatives of the local authority, such as a senior social
Omega, Vol. 9, No. 5
worker, an occupational therapist, the home help supervisor or a member of the Housing Department. There have been four tasks facing the teams of advisers: la) Construction of a classification system. This is the basic building block of BOC. Each team took the system developed in Devon, and considered it in the light of their own experience. In all cases significant modifications to the classification have been made. (b) Determination of resources to be included. Inevitably, the resources available in Dudley have differed from those included in the Devon model and an eye has had to be cast to the future to see what new resources might be worth including as possibilities for new patterns of care. (c) Creation of packages of care. For each category of patient within the classification system the advisers have had to consider all the various ways in which the resources might be used to provide alternative patterns (or 'packages') of care. This, without doubt, has been the most difficult task for the advisers, since, not only have they had to consider which resources to group together, but they have also had to determine the amounts of each resource to be included in each package. (d) Acquisition of the relevant data on patient numbers in each category and resource levels. This task has posed a considerable problem for the project team, because of the many sources of data, the large volume of coding onto data collection sheets necessary, and the checking of the data that is required, and the formulation of the model. Of these tasks, the first two are complete, the third is complete all but for one patient group, and we are well advanced into the collection of data. At the time of writing, June 1981 is the predicted date for completion of Phase 2. D u r i n g the last year, the JSG has become increasingly involved in the development of the structure of the Phase 2 model, and in the formulation of the questions which it will be used to investigate. Its members are also giving considerable thought to its impact on the two
507
authorities' information and planning systems and to the maintenance in the future of BOC as an effective tool for policy analysis in Dudley. BOC has acted as a catalyst in throwing into relief the information requirements of an effective planning and policy-analysis tool, and much of the OR project team's work after Phase 2 is complete will be in turn!ng it into a routine tool with the necessary information systems in support. A further development, recently begun, is the extension of the model to cover other groups in the population. The first of these is children, and two groups of advisers have been created to consider local authority services for 'children in care' and health services for 'handicapped children'. W H A T HAS OUR I N V O L V E M E N T W I T H BOC T A U G H T US'? Although the BOC study in Dudley is far from over, it is already possible to see a number of issues which it has brought to the surface about successful (and unsuccessful) OR, and about issues facing the NHS.
Salesmanship and inter-personal relationships Many of OR's potential customers, and not an insignificant number of its practitioners, see OR as essentially a highly-technical, mathematical subject with a repertoire of mathematical tools at its disposal. We have long believed, in my own OR unit, that OR is much more than that narrow view implies. An essential quality in a successful generalist OR practi.tioner must be 'salesmanship'; there is no point in being able to solve a problem if you cannot sell that solution to the client. Salesmanship is also about credibility; the OR practitioner must be able to convince the client that he is competent to work on the problem in the first place. Such skills are difficult to teach, but they are critical in studies like BOC, where you are asking the client to place a lot of faith in your ability to deliver what you promise. Part of the skill of salesmanship, and an important element in establishing and maintaining a good working arrangement with the client, is an understanding of the mechanisms of inter-personal relationships and group dynamics. Group working in the JMT, its successor the JSG, and in the four advisory teams,
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Nicholls--Joint Plannin9 in Dudley
has been a key part of the BOC study. Fortunately, most members of the WMRHA OR Unit have had training in these topics.
Planning the early stages of a study From what has been said earlier in this paper it is evident that our plans to gain the necessary commitment in the multi-district AHA were defective. We did not think through the mechanics of the process properly, nor did we identify the importance of a committed doctor to work alongside with us in the 'selling' phase. BOC as a catalyst There is good evidence that, despite its undoubted imperfections, BOC is the most useful tool yet developed to aid policy-makers in the health and personal social services with their joint planning. It represents such a jump in sophistication in comparison with existing methods, that it inevitably highlights weaknesses in the information systems of authorities. This should be seen as a benefit, rather than as a disadvantage, since BOC provides a sound reason for wishing to improve these systems, because it provides a mechanism to make proper use of information for decision making. BOC is also acting in this catalytic fashion in the effect that it has had on the planning machinery in Dudley. It is providing a vehicle for joint planning to become a worthwhile and effective activity. However, it should be recognised that in one sense BOC is making the decision-maker's task that much harder than previously, because the implications of his possible decisions are made quite explicit, and he is now required to re-consider his value judgements on, for example, the importance of services to one patient group as compared with another. The wider application of BOC Given that BOC has been successfully applied nationally and in Devon, and that ira-
plementations are in progress in, at least, Dudley, Cornwall, East Sussex and Wiltshire, the NHS and local authorities will soon need to consider its wider application. If the decision is taken to apply it widely, this will be great news for those involved in its development, but where do we find the OR practitioners to implement it'? ACKNOWLEDGEMENTS It is the hope of the author that the reader will have found this case history interesting and, to some extent, thought-provoking; however, any views expressed in it are entirely his own, and are not necessarily the policy nor the practice of the bodies listed below, whose support for this piece of work is gratefully acknowledged: West Midlands Regional Health Authority, Dudley Area Health Authority, Dudley Metropolitan District Council, the OR Service of the DHSS.
REFERENCES 1. CANVINRW, HAMSONJ, LYONS J & RUSSELLJC (1978) Balance of Care in Devon: joint strategic planning of health and social services at AHA and County level. Htth soc. Serv. JI 88, C17 C20. 2. CANVINRW & WALKERCL (1976) A model to support the planning of the provision of health and personal social services resources: a case study. Paper Fair, Euro II, Stockholm. 3. CLARK A, NICHOLLS IG, ROYSTON GHD & WEIR M (1979) Balance of Care in Dudley--A Report on the Phase 1 Study. We~t Midlands RHA & Operational Research Service, DHSS. 4. COVERDALEIL & NEGRINE SM (1978) The Balance of Care project: modelling the allocation of health and personal social services. JI Opl Res. Soc. 29(11), 1043-1054. 5. GIBBS RJ (1978) The use of a strategic planning model for health and personal social services. JI Opl Res. Soc. 29(9), 875-883. 6. HARRISAI (1971) Handicapped and Impaired in Great Britain. HMSO. 7. NICHOLLSIG (1981) Strategic planning of health and personal social services in Dudley experiences with the Balance of Care model. Proc. of the Second International Conference on Systems Science in Health Care, Montreal, 1980. Pergamon Press, Toronto. In press.
IG Nicholls. Operational Research Unit, West Midlands Regional Health Authority, 326 High Street, Harborne, Birmingham, B17 9PX.
ADDRESS FOR CORRESPONDENCE:
Int. JI of Mgmt Sci, Vol. 9, No. 5. pp. 501 to 508. 1981
0305-0483 81 050501-08S02 0(~ 0
Printed in Greal Britain, All rights reserved
Copyright ~ 1981 Pergamon Prcss Lid
Joint Planning in Dudley-the Role of Balance of Care IG NICHOLLS West Midlands RHA, Birmingham, UK tReceived May
1981)
Balance of Care is a computer-based policy analysis tool that has been developed to aid the joint planning of health and local authority services in England. A case study is presented on its application w i t h i n the West Midlands region of the National Health Service. As well as giving a description of the important steps in the project, the case study incorporates observations on factors which can lead to success, or failure, in the application of Operational Research concepts.
THE BACKGROUND TO BALANCE itself to be a valuable aid to national policyOF CARE makers and soon people began to consider BALANCE OF CARE (BOC) is the name coined whether it could not be equally well applied to about a decade ago for an approach to aiding the analysis of similar policy issues at a more those concerned with the development of local level. An experiment to test out this hynational policies in the fields of health and per- pothesis took place in Devon between January sonal social services. The then Secretary of and October, 1976. The results of this experiState for Health and Social Services, Sir Keith ment proved sufficiently encouraging to Devon Joseph, had recognised that, although policies County Council and Devon Area Health Authwere being developed nationally for improving ority that a full-time study was set in being to the care of separate segments of the popula- create a 'tailor-made' version of BOC for use in tion, such as the elderly and the mentally ill, Devon. This study has also been successful and there was not a satisfactory mechanism for is being carried out by the Operational considering the implications of such policies Research Unit of the Institute of Biometry and taken together. Further, it was difficult to Community Medicine of Exeter University. assess the consequences, both in terms of Accounts of the work in Devon can be found resources required and of levels of care de- in the work of Canvin and co-workers [1, 2]. livered, of alternative policies. The task of deThis paper picks up the story of BOC in veloping the relevant policy analysis tool was December, 1976, with the agreement of the Regiven to the Operational Research Service of gional Team of Officers of the West Midlands the Department of Health and Social Security Regional Health Authority (WMRHA) for a (DHSS). trial implementation of BOC in an Area BOC was first applied to the problem of Health Authority in the West Midlands region. analysing the implications of possible alterna- It is a case study on the relationship between tive policies for the care of the elderly section the operational research practitioner and two of the country's population. It met with early clients; it covers the 'selling' of the original acceptance by Ministers and senior civil ser- concept to the clients, the phased implementavants in the DHSS, and was extended to cover tion of the concept and its integration into the three other sections of the population; the clients' planning mechanisms. Before proceedmentally ill, the mentally handicapped and the ing with the story it will be necessary to physically handicapped. It continued to prove explain something of the nature of BOC itself. 501
502
Nicholls--Joint Planning in Dudley
THE BALANCE OF CARE MODEL The main feature of BOC is that it is concerned with analysing the implications of alternative patterns of care, using various combinations of health and local authority resources. For certain population groups, such as those requiring surgery, there is little scope for alternative forms of care provision. Either there are enough resources to satisfy the demand (doctors, nurses, beds and operating theatre time) or there are not. However, for other population groups, there may be many different ways of combining the available resources of health and local authorities to provide acceptable forms of care. The population groups for whom the above is true include the elderly, the mentally handicapped, the mentally ill and the physically handicapped; and it is around these that the framework of BOC has been built; firstly, a system of classifying their relevant attributes is constructed for each of these four groups. For the elderly, for example, the attributes could be their physical health, mental health, social circumstances (are they socially isolated?), the suitability of their housing and their degree of continence. These might be determined by the appropriate professional advisers as those attributes which are most significant in determining their need for services. The second task would then be to determine the resources provided by the two authorities that either are, or could be, used in providing care to the population groups involved in the study. Typical health service resources would be: geriatric medical beds; continuous nursing care beds; long stay psychiatric beds; mental handicap hospital hostel beds; group home places; psychiatric community nurses; domiciliary physiotherapists; care attendants,; home nurses; health visitors. The local authority resources included in a BOC study would certainly be drawn from the Social Services Department, and might also include some from the Housing Department, the Education Department and the Leisure Services Department. Examples would be: long-stay residential home places; sheltered housing; wheelchair properties; mobility dwellings; adult training centre places; day centre places; home helps; IBalance of Care--a user's view of a new approach to joint strategic planning by RG Borley, SH Taylor and CR West.
social workers; meals on wheels; night sitters; special schools. Having developed a classification system and a list of resources, the two need to be combined together, in order to derive the alternative forms of care that might be provided to patients with particular combinations of attributes. These alternative forms of care are known as 'packages of care', and determining them is a job which only the professional care providers themselves can undertake. Once the above structure has been established, possible alternative future health and personal social services policies can be analysed with it, and the results presented in terms of the criteria which are believed to be important by the policy-makers. A schematic representation of BOC is provided in Fig. 1. Fuller descriptions of the current formulation of BOC as a mixed integer mathematical program can be found in Coverdale and Negrine [4] and Gibbs [5]. An alternative formulation of BOC has been developed and is in its final stages of testing: reported in this issue of Omega. 1
BALANCE OF CARE IN THE WEST MIDLANDS REGION OF THE NHS The West Midlands RHA provides a number of central services for a population of about 5.1 m in the counties of Hereford and Worcester, Warwickshire, Salop, Staffordshire and West Midlands. It allocates the yearly revenue budget to the 11 Area Health Authorities (AHAs), it manages the capital building programme and is the responsible strategic planning body for the region. The OR Unit of the West Midlands RHA provides a service which at the present time is free to the customer, who can come from any discipline and any organisational level in the region. In 1976, the vast new machinery of the NHS Planning System was beginning to move, and health authorities were becoming increasingly aware of the problems they would face in developing plans with this radically new (for the NHS) methodology. Broad objectives would be stated by the DHSS, modified and amplified by RHAs and AHAs, and be received by the operational management tier, the Health Districts. The Districts would then develop their strategic plans in the light of these objectives. The
Omega, Vol. 9. No. 5
Construction of alternative ways of providing care
Local Authority services
Formulation of the model
Health Authority services
P A C K A G E S OF CARE
Classification of population
Future levels of health a nd local authority resources
B A L A N C E OF CARE MODEL
the
Estimates future population size
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Application planning
to joint issues
INPUT POLICY OPTIONS
I
E V A L U A T I O N OF A PARTICULAR POLICY
of RESULTS~
ACCEPTANCE OF POLICY
MODIFICATION OF POLICY OPTIONS
FIG. 1. Schematic diagram of BOC.
West Midlands RHA's OR Unit saw here an opportunity to provide NHS managers with considerable support via the use of operational research methods. At the top of the list of such methods appeared BOC. In order to commit a significant proportion of the OR Unit's resources to an experimental application of BOC in the West Midlands, it was necessary to obtain the approval of the Regional Team of Officers (RTO). The RTO is the top management group within the RHA, and they are accountable to the RHA members themselves, who are appointed by the Secretary of State. The RTO is a five-person group that manages by consensus, it contains the Regional Administrator (to whom Management Services is accountable), Regional Medical Officer, Regional Nursing Officer, Regional Treasurer and Regional Works Officer (who controls the Architects, Engineers and Quantity Surveyors). In the West Midlands RHA they meet every Monday, and so on Monday, 2nd December 1976, I met them to gain their support for a trial implementation of BOC.
First Attempt--a Multi-District Area The RTO accepted my proposal and agreed on one of the four multi-district AHAs as the site of the experiment.
Since BOC was still an experimental tool, the OR Service of the DHSS was prepared to provide support to an application in the West Midlands. Accordingly, arrangements were made to meet the Area Administrator and Area Medical Officer, and the Director of Social Services from the local authority. Meetings with the former revealed few problems and enthusiastic support was obtained. However, when we met the Director of Social Services, he expressed serious reservations about a fundamental assumption of BOC, that it was possible to consider the needs of a particular population group, such as the physically handicapped, in terms of a classification of attributes as described above. The Director of Social Services was unable to accept this, and stated his view that each Social Services client had individual characteristics which could not adequately be catered for when clients were grouped together. In addition, he was confident that his strategic plans were well enough developed, and he doubted that BOC could offer any help to him. These views naturally presented us with a difficult problem of differing levels of enthusiasm for BOC from the two authorities. A rather uneasy compromise was offered by the Director of Social Services, who recognised the
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Nicholls--Joint Plannin# in Dudley
potential value of BOC to his Area Health Authority colleagues, and agreed to proceed with the study, whilst reserving the right to dissociate his Department from necessarily accepting the results of the study. This compromise was accepted and negotiations progressed during 1977, until the time came for us to seek the support of the Psychiatric Division (the group of all consultant psychiatrists practising in the Area). We met the Chairman of the Division, who chose to describe BOC personally to the rest of. the Division. They decided that they did not wish to participate in the study, having been adversely influenced in their decision by the particular formulation of the mental illness part of the model that had been described to them. Recognising that an alternative formulation had been developed in Devon, we invited the leader of the OR project team in Devon, Mr R Canvin, to meet the Chairman of the Psychiatric Division and a consultant colleague, together with the Area Administrator and Medical Officer. The results of this meeting were encouraging; the alternative formulation was liked, and a further consideration of the proposal would be made by the Division. Eventually their decision was relayed to the Area Team of Officers: although one psychiatrist was not interested in BOC, the others would co-operate, provided that an additional appointment of a research registrar be made, specifically to be concerned with BOC. This was a precedent that the Area Team of Officers could not afford to set and, very reluctantly, they decided to terminate the proposed BOC study in their Area.
port. This proved to be the most crucial step in what became our successful second attempt to implement BOC. With him we arrived at a short-list of four potential AHAs. We discussed these with the Regional Administrator and Regional Medical Officer and Dudley, a singledistrict Area, was unanimously placed at the top of the list. Following meetings with the Director and Deputy Director of Social Services, and with the Area Medical Officer, it became clear that the support o f two key groups would be necessary before BOC could proceed. On the one hand were the staff of Social Services, and on the other were the consultant medical staff. Our approaches to these two groups were very different. About 15 representatives of the different levels within the staff of Social Services met members of the OR team to hear BOC explained to them. Following this meeting, we wrote up the details of our oral presentation in a paper which the staff could then consider at length. They subsequently asked for two further meetings to clarify various points in what we had said, and we discovered our first potential stumbling block. A major worry was becoming evident amongst the middle managers, in that their staff were already under pressure to cope with the very heavy workload on the Department. BOC represented an additional workload which would place further pressure on Social Services. In debating this quite reasonable concern of the middle managers, the structure of our implementation became clarified. What the OR project team were hoping for was an agreement to move straight into the building of a tailor-made verSecond Attempt--a Sin#le-District Area, Dudley sion of BOC for Dudley. However, this was The DHSS OR Service were still willing to effectively asking the two authorities to invest provide support to an application of BOC in significant amounts of time and effort from the the West Midlands, and I and members of my professional care providers in the development staff agreed that we should have one more try. of a tool of unproven value. As a result of the We discussed the likely AHAs that might worries expressed by the Social Services satisfy the relevant criteria of interest in devel- Department it seemed to us sensible to offer a oping their joint planning, good relationships two-stage implementation process. In the first with their corresponding local authority and stage all we should attempt to do would be to important planning issues to resolve. In these offer a demonstration of the potential value of discussions we included a number of RHA staff BOC to Dudley. We would do this by using and one in particular, the Specialist in Com- the model developed for Devon and insert into munity Medicine with responsibility for health it the data on population numbers and information (SCM), was very interested in our resources for Dudley. This would have the proposals and wished to offer his personal sup- advantages of:
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--speed, since the process should last no longer than six months; --simplicity, since the emphasis would be on the potential value of the tool, rather than the intricacies of its construction: --safety, since very little effort would be required from health or local authority staff, and almost all the risk would be carried by the OR project staff. At the end of this first phase, the two authorities would have a much sounder basis on which to assess whether they wished to give a commitment to the development of a tailormade version of BOC for Dudley which would be Phase 2. Our approach to the consultant medical staff was equally important, but, on the advice of the Area Medical Officer, was handled entirely by him. He ensured that the subject of BOC was tabled at all the critical meetings in the Area's medical machinery and he, personally, gained acceptance for it. The process of gaining support for BOC in Dudley lasted from October, 1977 to May, 1978, when we again called our colleague from Devon, Mr Canvin, to describe BOC in Devon to a meeting attended by the Area Team of Officers and the Director and Deputy Director of Social Services. His eloquence won the day and Phase l had begun.
Phase one--demonstrating the potential of BOC To manage this first phase we needed a representative, but small, group of officers from the two authorities. This became known as the Joint Management Team and was composed of the following people:
All meetings were attended by the OR project team, which included staff from the W M R H A OR Unit and from the OR Service of the DHSS. The meetings were chaired by me. A very tight timescale was set for the completion of this first phase of the study, and it was the project team that set it rather than the Joint Management Team (JMT). With the first meeting held in late September of 1978, we had the target of completing the computer runs of the model and commencing the writing up of the results by the following January. In order to achieve our target we needed to accept the model as formulated for Devon, with the Devon care providers' views on acceptable alternative forms of care without any modification, and collect data which represented the numbers of patients/clients in Dudley who fell into the various categories. Obviously, we were unable to undertake any surveys to supplement available local data, and, where there were gaps in what was routinely recorded, it was necessary to use existing surveys. There were two such surveys which were very valuable to us, one was a survey undertaken by the local authority in the early 1970s, and the other was a well-known national survey [6] on the handicapped and impaired. The JMT meetings worked extremely well and both the members of the JMT and the OR project team became very 'task-oriented', with the result that the target was only missed by two weeks. Thus, in mid-January, 1979, we began to write up the results of our efforts. Basically, what we had done was to undertake. three successive runs of the model. Run 1--1978. The aim of this run was to simulate the existing allocation of resources as a basis for comparison, but this had the additional value of indicating existing imbalances
Dudley Metropolitan District Council
Dudley Area Health Authority
Deputy Director of Social Services,
Specialist in Community Medicine (Social Services), Divisional Nursing Officer, (Community), Sector Administrator (Community).
Assistant Director of Social Services, (Fieldwork), Principal Administrative Officer, (Social Services), Assistant Director of Finance. 2
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2 (at some meetings the G r o u p Accountant (Social Services) deputised for this officer).
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Nicholls--Joint Planning in Dudley
in the levels of service provided to different sections of the community (notably the younger physically handicapped and the elderly handicapped) and those resource areas which would be most cost-effective for expansion. Run 2--I 983 'most likely'. In this second run, we modelled Dudley five years into the future when the first phase of the new district general hospital was due to open. We attempted to reflect the most likely pattern of resource provision as indicated by the two authorities' forward plans. The two main results from this run were that the planned increase in meals on wheels appeared to be considerably in excess of what was required, and that for some patient groups, the level of services was likely to decline in comparison with 1978. Run 3--1983 'optimistic'. Following the second run, a number of modifications were made to the pattern of resource provision (for example a residential home for the elderly was deleted and one for the mentally handicapped put in its place). The result was that, although the level of meals on wheels provision had been reduced, it was still too high, but it was now possible to maintain the levels of care achieved in 1978, although not to improve upon them. This last point was particularly important. The effect of an ageing population appeared to be that, even with increased levels of resource, standards of service would only stand still, and they were not particularly high in 1978. Although these results obviously had to be interpreted with great caution, and were really only intended to be illustrative of BOC's capabilities, actions were taken by the two Authorities as a result of their production. Our report [-3] was discussed with members of the AHA's Area Management Team in March, 1979, and with the local authority Chief Officers in April. The joint planning machinery of the two authorities takes place via meetings of the two sets of chief officers, the so-called Joint Care Planning Team (JCPT) and meetings of councillors and health authority members, the Joint Consultative Committee (JCC). We subsequently pre~ented our results to these two bodies. At all these meetings we were seeking support for a move into phase two of the study, where we would build a tailor-made version of BOC for Dudley. This step would involve both authorities investing sig-
nificant amounts of time and effort of various individuals and groups, and would commit them to an 18-month development programme. The results of the first phase study were sufficiently convincing for there to be complete agreement that the second phase should begin straight away.
Phase two--delivering the goods For the W M R H A OR project team, we were very much now on our own. The level of support that could be provided by the DHSS OR Service had decreased to a mainly advisory service, and the experience of our colleagues in Devon was only of limited value. The nature of the task that faced us was twofold. Firstly, we had to bring together four groups of advisers, drawn from the caring professions, to develop the parts of the model concerned with the four population groups (elderly, mentally ill, mentally handicapped, younger physically handicapped). Secondly, we had to ensure that BOC became an integral part of Dudley's joint planning machinery: if it was a parallel exercise to the conventional methods of planning then it was almost certainly doomed to fail. It needed acceptance and commitment. In achieving this second aim we were helped greatly by the AHA's General Administrator (Planning) and the Assistant Director of Finance from the local authority who produced a paper for the JCPT, suggesting the creation of a 'Joint Strategy Group' (JSG). Whilst each authority had a second-in-line officer planning group, the J C P T did not, and they proposed that there should be one, called the JSG, with second-in-line officers from the two authorities on it. Its role would be primarily advisory to the JCPT, but it would have one executive responsibility and that would be to run BOC. This proposal was accepted and the JSG came into being in the autumn of 1979. At the same time we were bringing together nominations for membership of the four advisory teams. In November, 1979, these teams had their first meetings, which usually last about an hour, and take place over lunch to minimise the disruption to the members' other work. Membership of a typical group includes a consultant, a hospital nurse, a community nurse and one or two representatives of the local authority, such as a senior social
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worker, an occupational therapist, the home help supervisor or a member of the Housing Department. There have been four tasks facing the teams of advisers: la) Construction of a classification system. This is the basic building block of BOC. Each team took the system developed in Devon, and considered it in the light of their own experience. In all cases significant modifications to the classification have been made. (b) Determination of resources to be included. Inevitably, the resources available in Dudley have differed from those included in the Devon model and an eye has had to be cast to the future to see what new resources might be worth including as possibilities for new patterns of care. (c) Creation of packages of care. For each category of patient within the classification system the advisers have had to consider all the various ways in which the resources might be used to provide alternative patterns (or 'packages') of care. This, without doubt, has been the most difficult task for the advisers, since, not only have they had to consider which resources to group together, but they have also had to determine the amounts of each resource to be included in each package. (d) Acquisition of the relevant data on patient numbers in each category and resource levels. This task has posed a considerable problem for the project team, because of the many sources of data, the large volume of coding onto data collection sheets necessary, and the checking of the data that is required, and the formulation of the model. Of these tasks, the first two are complete, the third is complete all but for one patient group, and we are well advanced into the collection of data. At the time of writing, June 1981 is the predicted date for completion of Phase 2. D u r i n g the last year, the JSG has become increasingly involved in the development of the structure of the Phase 2 model, and in the formulation of the questions which it will be used to investigate. Its members are also giving considerable thought to its impact on the two
507
authorities' information and planning systems and to the maintenance in the future of BOC as an effective tool for policy analysis in Dudley. BOC has acted as a catalyst in throwing into relief the information requirements of an effective planning and policy-analysis tool, and much of the OR project team's work after Phase 2 is complete will be in turn!ng it into a routine tool with the necessary information systems in support. A further development, recently begun, is the extension of the model to cover other groups in the population. The first of these is children, and two groups of advisers have been created to consider local authority services for 'children in care' and health services for 'handicapped children'. W H A T HAS OUR I N V O L V E M E N T W I T H BOC T A U G H T US'? Although the BOC study in Dudley is far from over, it is already possible to see a number of issues which it has brought to the surface about successful (and unsuccessful) OR, and about issues facing the NHS.
Salesmanship and inter-personal relationships Many of OR's potential customers, and not an insignificant number of its practitioners, see OR as essentially a highly-technical, mathematical subject with a repertoire of mathematical tools at its disposal. We have long believed, in my own OR unit, that OR is much more than that narrow view implies. An essential quality in a successful generalist OR practi.tioner must be 'salesmanship'; there is no point in being able to solve a problem if you cannot sell that solution to the client. Salesmanship is also about credibility; the OR practitioner must be able to convince the client that he is competent to work on the problem in the first place. Such skills are difficult to teach, but they are critical in studies like BOC, where you are asking the client to place a lot of faith in your ability to deliver what you promise. Part of the skill of salesmanship, and an important element in establishing and maintaining a good working arrangement with the client, is an understanding of the mechanisms of inter-personal relationships and group dynamics. Group working in the JMT, its successor the JSG, and in the four advisory teams,
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has been a key part of the BOC study. Fortunately, most members of the WMRHA OR Unit have had training in these topics.
Planning the early stages of a study From what has been said earlier in this paper it is evident that our plans to gain the necessary commitment in the multi-district AHA were defective. We did not think through the mechanics of the process properly, nor did we identify the importance of a committed doctor to work alongside with us in the 'selling' phase. BOC as a catalyst There is good evidence that, despite its undoubted imperfections, BOC is the most useful tool yet developed to aid policy-makers in the health and personal social services with their joint planning. It represents such a jump in sophistication in comparison with existing methods, that it inevitably highlights weaknesses in the information systems of authorities. This should be seen as a benefit, rather than as a disadvantage, since BOC provides a sound reason for wishing to improve these systems, because it provides a mechanism to make proper use of information for decision making. BOC is also acting in this catalytic fashion in the effect that it has had on the planning machinery in Dudley. It is providing a vehicle for joint planning to become a worthwhile and effective activity. However, it should be recognised that in one sense BOC is making the decision-maker's task that much harder than previously, because the implications of his possible decisions are made quite explicit, and he is now required to re-consider his value judgements on, for example, the importance of services to one patient group as compared with another. The wider application of BOC Given that BOC has been successfully applied nationally and in Devon, and that ira-
plementations are in progress in, at least, Dudley, Cornwall, East Sussex and Wiltshire, the NHS and local authorities will soon need to consider its wider application. If the decision is taken to apply it widely, this will be great news for those involved in its development, but where do we find the OR practitioners to implement it'? ACKNOWLEDGEMENTS It is the hope of the author that the reader will have found this case history interesting and, to some extent, thought-provoking; however, any views expressed in it are entirely his own, and are not necessarily the policy nor the practice of the bodies listed below, whose support for this piece of work is gratefully acknowledged: West Midlands Regional Health Authority, Dudley Area Health Authority, Dudley Metropolitan District Council, the OR Service of the DHSS.
REFERENCES 1. CANVINRW, HAMSONJ, LYONS J & RUSSELLJC (1978) Balance of Care in Devon: joint strategic planning of health and social services at AHA and County level. Htth soc. Serv. JI 88, C17 C20. 2. CANVINRW & WALKERCL (1976) A model to support the planning of the provision of health and personal social services resources: a case study. Paper Fair, Euro II, Stockholm. 3. CLARK A, NICHOLLS IG, ROYSTON GHD & WEIR M (1979) Balance of Care in Dudley--A Report on the Phase 1 Study. We~t Midlands RHA & Operational Research Service, DHSS. 4. COVERDALEIL & NEGRINE SM (1978) The Balance of Care project: modelling the allocation of health and personal social services. JI Opl Res. Soc. 29(11), 1043-1054. 5. GIBBS RJ (1978) The use of a strategic planning model for health and personal social services. JI Opl Res. Soc. 29(9), 875-883. 6. HARRISAI (1971) Handicapped and Impaired in Great Britain. HMSO. 7. NICHOLLSIG (1981) Strategic planning of health and personal social services in Dudley experiences with the Balance of Care model. Proc. of the Second International Conference on Systems Science in Health Care, Montreal, 1980. Pergamon Press, Toronto. In press.
IG Nicholls. Operational Research Unit, West Midlands Regional Health Authority, 326 High Street, Harborne, Birmingham, B17 9PX.
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