Editorial

Meeting Health Challenges with OR

For this particular Special Issue, we wanted to attract and publish papers from both academics and practitioners which demonstrate how OR is meeting the challenges of changing health care provision in the 21st century. These challenges may be even greater than ever before. AIDS has become endemic in large parts of the world, particularly Africa. The spread of diseases worldwide is exacerbated by the widespread use of national and international transport networks. In the developed countries, there is a high prevalence of chronic problems arising from lifestyle and old age. New treatments are developed and some, known to be effective, are too expensive for universal provision. Interventions are available that prevent future disease but need to be targeted to those most at risk. The rapid advance in technology makes it feasible to provide information almost instantaneously in different locations and institutions. Such systems must, however, be designed to serve the needs of the organization and will inevitably require changes in behaviour from those who use them. In the UK, the health service structures are subject to constant change. Recent reforms include: the introduction of new facilities (eg see paper in this Issue by Ashton et al), the facilitation of patient choice as to where treatment takes place, the reorganization of funding mechanisms and the reform of systems for commissioning resources.

This Issue has been put together by an academic and a practitioner in order to encourage papers that bridge the gap between practice and theory. We invited people to submit: ‘papers from a spectrum of topics from international to UK based and from strategic policy issues to more tactical problems’ hoping ‘to include papers concerned with:

• appropriate OR methodologies for practical health challenges,

• modelling and analysis of policies for the provision of health care,

• case studies which show the added value of using analytical techniques.’

Our referees were specifically asked to comment on the extent to which a paper demonstrates the practical impact that OR can make on national or international health problems. We were looking, in particular, for lessons that could be drawn from the research. Most papers were refereed by one academic and one practitioner and all were scrutinized by both editors.

Some history

Possibly the first published OR study in health was by Norman Bailey in 1952¹ who used the queuing theory to study appointment systems. One of the earliest simulation papers to be published in the OR press about health care was by Fetter and Thompson;² this paper describes four linked discrete event simulation models of hospital facilities. A useful source of OR applications in health in the United Kingdom was the 1971 book by Luck et al,³ which cited several practical applications of OR in hospitals. OR specialists were also concerned with models of disease processes; for example, Ruth Davies et al's Markov model of end-stage renal failure in 1975⁴ demonstrated the increasing requirement for dialysis resources. Over the past 3 decades, there has been a steady stream of academic OR papers covering a range of health issues from appointment systems to disease processes and strategic planning.

Some recent key review papers in OR include Jun et al⁵ and Dangerfield.⁶ Jun et al reviewed over 100 applications of discrete event simulation health-care clinics. These cover simulations of inpatient, outpatient and emergency facilities. Most of the simulations reviewed describe the allocation of resources at quite a detailed level and aim to identify where resource allocation may be improved in specific facilities. Dangerfield looked at the contribution of system dynamics to health care in Europe, covering a range of applications. A further review⁷ in 2003 covering all types of simulations in the health field was more focused on public health issues. The Centre for Reviews and Dissemination at the University of York⁸ provides a database of economic evaluations of drugs, treatments and procedures, including many papers describing models of disease processes and treatments.

Despite the wealth of contributions, relatively few academic papers on health issues in OR or MS journals address issues of outcome, implementation or the use of the work reported. They do not, in particular, reflect on poor outcomes or lack of implementation. Practitioners, on the other hand, who engage in challenging and useful work often do not publish.

The papers in this Special Issue

We have 11 high-quality papers that are largely or entirely case study based, which cover a range of domains: the staffing of an intensive care unit (ITU), the location of dental services, residential and nursing care for the elderly, planning walk-in centres, the provision of muscular–skeletal services, organization of hospice care, information technology (IT) provision for emergency services, the provision of services for the mentally ill, the transmission of variant Creutzfeldt–Jakob disease (vCJD), the comparative cost-effectiveness of drugs for osteoporosis and the vertical transmission of HIV. The techniques include soft OR, knowledge management, discrete event simulation, system dynamics, spreadsheet simulation, survival and statistical analysis, the most common of these being discrete event simulation (five papers).

The first three papers address the issue of capacity within the health-care system. Most models of ITU services have concentrated on bed capacity. Griffiths et al use simulation to analyse and cost the requirements for nurses per shift and, in particular, agency nurses. They use visual interactive discrete event simulation to convey results to a non-mathematical audience. The study by Harper et al is exciting in that it applies discrete event simulation to location problems, which, as far as we are aware, has not been performed before. The study evaluates configurations for services in terms of travel time and clinic distance. Pelletier et al use survival distributions in residential and nursing homes in order to provide information about future capacity and costs.

The next two papers are also concerned with capacity but in this case in the context of changing the wider health-care system. Ashton et al use discrete event simulation to design and plan the operation of an NHS walk-in centre. The stakeholders were able to interact with the simulation model to evaluate their own scenarios. Van de Meer et al develop a sequence of discrete event simulation models as student projects. The paper focuses on the reduction in waiting time to be seen for the first appointment at clinics and the reduction of the load on consultant surgeons.

The subsequent two papers are concerned with innovative IT provision. Leonard et al develop new metrics to evaluate a decision support system in palliative care and justify the expenditure of the resources. Edwards et al use the Journey Making methodology, a cognitive mapping approach. Knowledge management provides understanding of the potential benefits of an electronic patient record system in the provision of emergency care both in hospital and by the ambulance services. The next paper is by Walsh et al and uses Ulrich's critical heuristics and other soft OR techniques, with patient involvement, to improve the provision of mental health services.

The final three papers are concerned with disease processes, their control and treatment. Bennett et al use spreadsheet models, risk analysis and system dynamics in the evaluation of the vCJD infection and the potential transmission risk via surgical instruments. The results of this study influenced national policy in providing a £200 m programme to improve instrument decontamination. Stevenson et al use a patient-based spreadsheet simulation approach together with a metamodel for probabilistic sensitivity analysis. This is an evaluation of three drugs for the treatment of osteoporosis in order to provide cost–benefit information for the National Institute for Clinical Excellence (NICE). Rauner et al's work is the only paper to address international disease problems. They use discrete event simulation to describe the vertical transmission of HIV disease and to assess the relative benefits of breast feeding and bottle feeding, and of providing anti-retroviral drugs.

We have brought together a set of interesting papers, which use a range of techniques and which focus on various topics. The health-care systems of the future will continue to consume substantial resources, technology will improve and management systems will continue to change.

The challenge to the OR community is to develop methodologies that are interactive, aid decision making and provide robust solutions in the wider systems context. We hope to see many more academic papers reporting applications that have an impact on local, national and international policies and activities.

Ruth Davies is a Professor of Operational Research and Systems in Warwick Business School, University of Warwick. Her research interests include the methodology of simulation modelling and its application to health policy planning. She has been engaged in research concerned with the allocation of resources to patients with end-stage renal failure, screening for diabetic retinopathy and with policies for the prevention and treatment of coronary heart disease. Her most recent publication in the OR press⁹ is concerned with the use of simulation to evaluate cost-effectiveness in the evaluation of interventions and treatments. She may be contacted at Warwick Business School, University of Warwick, Coventry CV4 7AL (e-mail: [email protected]).

David Bensley is currently Operational Research Programme Manager in the Department of Health in Leeds responsible for managing a team of Senior Analysts undertaking a programme of evidence-based analyses of policies across the broad area of Elective Care, Modernization and Waiting Times. He previously worked for over 20 years as Regional Statistician in Yorkshire Regional Health Authority and latterly as manager of a Regional Analysis Unit supporting the development of a health strategy for the population of Yorkshire. Projects he has undertaken in his current role include the initial feasibility study, and supporting the subsequent implementation plan, for introducing the policy of Booked Appointment Systems in the NHS. He has supported successive National Spending Reviews on Waiting and Booking and he has developed simulation models for waiting times, coronary heart disease and capacity planning.¹⁰ He may be contacted at Department of Health, Room IN31, Quarry House, Quarry Hill, Leeds LS2 7UE (e-mail: [email protected]).