7 day working: can you tame a wicked problem? Dr John Lowes, Dr Mike Williams, Dr Oliver Dyar South Devon and Torbay Presentation from seven day services event held on 20 August 2013

1. 7 day working:
can you tame a wicked
problem?
Dr John Lowes, Dr Mike Williams, Dr Oliver Dyar
Learning from South Devon & Torbay

2. THREE TYPES OF PROBLEM

3. Simple
Build a rowing boat - change a rota

4. Complicated but tame
Design and build a hospital

5. Wicked –
running healthcare delivery services
Solutions are difficult to recognise because of the complex
interdependencies that surround the problem

6. Wicked
problem
1. ‘Problem’ is ill
structured – solutions
expose new problems
2. There is no
definitive
‘solution’
3. Solutions are assesses
in a social context –
many views of what is
good as consequences
ripple out
5. Every attempt to solve
has consequences –
spawn new problems
6. Matter of creativity to devise
potential solutions; judgement
to decide which are valid
Rittel, H. & Webber, M. (1973) Dilemmas in a General Theory of Planning. Policy Sciences, 4, 155-169.
Conklin, J. (2006) Dialogue mapping – building shared understanding of wicked problems, Chichester, John Wiley & Sons.
4. Problems are
unique due to
dynamic social
context
7. Is a symptom of
another problem

7. Taming
Wicked
problems
Lock down the
problem – solvable
sub-problem
Assert that
the problem
is solved
Specify objective
parameters to
measure success
Give up trying to find
good solution – just
follow orders
Declare there are just a
few solution; frame
problem as either - or
Conklin, J. (2006) Dialogue mapping – building shared understanding of wicked problems, Chichester, John Wiley & Sons.
Cast problem as
‘just like’ a solved
problem
Ignore social
complexity

8. A wicked problem tamed?

9. 7 day
emergency
only service
Full 7 day for
all services
7 day urgent
care
7 day urgent
plus partial
elective

10. How to respond
Simple Complicated
(Tame)
Wicked
Command
Manage
Lead
Just do it
Project
manage
process
Engage in dialogue
& social change

11. 7 day force field
Currentstate
Weekend
mortality
Perceived costs
Senior staff preferences
Lack of whole system
approach (primary and
community services)
Recruitment &
retention of staff
Public & political
opinion
Media interest
Supervision of
junior staff
Push harder creates
stronger push back therefore...
enter into dialogue to engage in
social process to address
emotional values and concerns

12. Torbay & South Devon Journey
South Devon
Healthcare NHS
Foundation trust
2007
Torbay & South
Devon Health &
Care Trust
2005
Integrated
H & Care
Zones
2007
Intermediate
care services
2009
Radiology
services
2000+
Hospital
@Night
2004
T & O
service/
#NOF
Acute
physician
model
Enhanced
recovery
in surgery
Extended
ward
round
Combined ICO
2014?
Joinedup
Health &
Care Cabinet
2011
System
modelling,
mapping &
understanding
Enhanced
recovery
in
medicine
Sunday
test of
change -
discharge
Weekend
working -
Trainee
Doctors
Hospice@
Home
Joinedup
Leadership
Norman
Lamb
Pioneer Bid
Redesigning
the front
door
South Devon &
Torbay CCG

13. Modelling & understanding our system –
plan for reality not rhetoric
Acute emergency admissions have been rising at
~1.6% per annum

14. Modelling & understanding our system – 8 mins or 8 hrs to
treatment
• GPs visit sickest patients 1 - 3pm – then
phone for ambulance (HCP calls)
• Ambulance prioritise 999 response <
8mins therefore GP call as ‘urgent’ <4
hrs
• Patient arrives at hospital late afternoon
/ evening
• Patient’s need subordinated to local
optimisation of parts of system
Calls per hour by time of day by GPs 2009 - 2011
“Visits are a very inefficient use of GP time.”
“Achieving the 999 target is our priority.”

15. Modelling & understanding our system – junior doctor capacity
Junior Doctors estimated clerking capacity (1 hr per pt) cf expected admissions
WeekendWeekday

16. Modelling & understanding our system – primary care
0
5
10
15
20
25
30
35
40
A B C D E
GP Survey (July 12 - March 13) (Q12)
Failure demand (%)
No
Call Back
“March is always busy but I think
that’s because of doctors on
holidays. We seem to take our
holidays around this time for
some reason, I don’t know. “ GP

17. Problem
• Sustained increase in emergency admissions (Highest % unplanned medical)
• Low levels of discharge at weekend, particularly on Sundays.
• Requirement for additional escalation beds to cope with demand
• System has continued to be under significant pressure
• Variation in the quality of care inc. safety, patient experience & outcomes
Aim
• To reduce the variation in care 7 days a week
• Sunday test of change – multidisciplinary consultant led ward round
• Weekend test of change – timely discharge summaries (ongoing)
Sunday test of change: consultant led multi-disciplinary ward round

18. Sunday test of change: what happened
“Flow been much better into the
hospital. No significant delays in
getting beds”
EAU Consultant
“ Much calmer on ward area.
Patients seen by team over
weekend reassurred that they
were not forgotten over the
weekend” Staff nurse
“Greatly reduced number of 2nd
calls chasing patient jobs” H@D
Findings inc:
•Improved team work
•Calmer
•Empty beds on Mon.
•Improved flow
•Better organised
•Better patient care

19. Actual discharge rates and forecast savings by increasing
discharge rates
Note: Discharge rates increase throughout week. It is possible that 7 day working would maintain
discharge rates at the higher end of the observed values.

20. How can we better match the resource of foundation doctors
to out of hours demand?
0900
1100
1300
1500
1700
1900
2100
2300
Medical Surgical
SURGICAL JOBS
Acute reviews
PR bleed – EWS 7
Routine reviews
Prescribe fluids
Take bloods
Put in cannula
Analgesia
MEDICAL JOBS
Acute reviews
Chest pain – EWS 8
Routine reviews
Prescribe fluids
Prescribe warfarin
Take bloods
Examine ear
Put in cannula
Elevated BM
Medical
Surgical

21. F1 ward cover: weekend test of change

22. F1 ward cover: what actually happened
Medical F1 Surgical F1
H@D/H@N
Ward staff
Patients
“Actually managed to finish
on time” F1 doctor
“I felt like I was on a team with the other F1s, there
was more opportunity to ask for help on certain
wards, and workload felt more manageable.
F1 doctor
“No 2nd calls, jobs completed earlier… I felt like I was
actually coordinating” H@D
“When doctors arrived .. they did all
the jobs [medical and surgical]
meaning patients were not left for
hours in pain or without fluids”
Nurse, Allerton ward

23. Taming a wicked problem – solutions are context
specific; methodology is generalisable
In Torbay & South Devon
during the next 5 years
those aged 70-75 will
increase by 35%, those over
90 by 20%.
Engage in
dialogue & social
change
Project
manage
process
Just do it
Lead
Manage
Command
WickedComplicated
(Tame)
Simple