Journal of Enterprise Information Management

Healthcare planning and its potential role increasing operational efficiency in the health
sector: A viewpoint
Anthony Virtue Thierry Chaussalet John Kelly
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Anthony Virtue Thierry Chaussalet John Kelly, (2013),"Healthcare planning and its potential role increasing
operational efficiency in the health sector", Journal of Enterprise Information Management, Vol. 26 Iss 1/2
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JEIM VIEWPOINT
26,1/2
Healthcare planning and
its potential role increasing
8 operational efficiency in the
health sector
A viewpoint
Anthony Virtue
EC Harris LLP, London, UK
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Thierry Chaussalet
Department of Business Information Systems,
University of Westminster, London, UK, and
John Kelly
HealthCare Partnering Ltd, London, UK

Abstract
Purpose – The purpose of this paper is to consider a number of issues around the poor adoption
of healthcare simulation models and reflect whether there has been a broad failure of academic
healthcare simulation modellers to build models that reflect real healthcare problems as acknowledged
by healthcare stakeholders. This paper will also review the role of healthcare planners within the
health sector and propose that they are well suited to act as change agents to improve the adoption
of simulation within the sector.
Design/methodology/approach – This paper reviewed academic evidence around poor adoption of
simulation modelling in healthcare, including differences to other sectors, its size and complexity,
stakeholder issues and current and future challenges to improve operational efficiency. This paper also
reviewed the role of healthcare planning and its valuable links with health stakeholders, suggesting
that these links could be exploited to increase simulation modelling within the healthcare sector to
improve operational efficiency.
Findings – This paper highlights the strong links between healthcare planning and the healthcare
stakeholders and proposes that healthcare planning can play a key role in adoption of healthcare
simulation modelling to achieve operational efficiency improvements.
Originality/value – This paper illustrates the potential link between healthcare planning and
healthcare stakeholders to achieve operational improvements within the health sector.
Keywords Simulation, Modelling, Health care, Healthcare planning
Paper type Viewpoint

Journal of Enterprise Information
Management
Vol. 26 No. 1/2, 2013
pp. 8-20
r Emerald Group Publishing Limited
1741-0398
DOI 10.1108/17410391311289523
1. Introduction
A number of industries have benefited from application of simulation modelling
including healthcare. Despite the documented benefits, a number of academic papers
have suggested that within healthcare, the application of simulation to real problems is
not as wide as in other industries. This paper will consider a number of issues around
the poor adoption of healthcare simulation models and reflect whether there has been a
broad failure of academic healthcare simulation modellers to build models that reflect
real healthcare problems as acknowledged by healthcare stakeholders. This paper will
 also compare the adoption of simulation modelling in healthcare to other industries, Healthcare
including a dialogue as to whether healthcare is fundamentally different to other planning
industries resulting in problems of adoption. Issues related to the size and complexity
of the health sector as well as the range of health stakeholders and their requirements
will also be discussed in context of the adoption of simulation modelling.
In the UK, as demand for health and associated health cost increase against a
backdrop of public spending cuts, there is a huge opportunity for simulation modelling 9
to help achieve productivity (financial) savings. It could well be the case that simulation
modelling occurs more often in the health sector than suggested by academic papers. For
example, in the UK beds and/or patient activity modelled for hospitals constructed under
private finance initiative (PFI) schemes are essentially private commercial agreements
and as such, generally hidden from public view. In this paper, phrases or terms
describing modelled beds or modelled patient activity, will refer to actual modelled beds
or non-bedded patient activity (e.g. outpatients or imaging) at a hospital level. This paper
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will review the impact of PFI and the healthcare planning role within it.
This paper will also review the wider role of healthcare planners, who have
historically modelled beds and activity, whilst developing their skills and relationships
with health stakeholders and designers developing facilities and services in health.
Building on their established relationships with healthcare stakeholders, this paper
will propose that the role of healthcare planners can be an ideal actor to help further
increase the adoption of simulation modelling in the health sector. The healthcare
planners’ relationships could also be used to foster other initiatives within health such
as Lean methodologies. As a practicing healthcare planner in the UK, modelling NHS
hospital activity is the primary focus of this paper; although it is likely that ideas
discussed in this paper can be transferred to many other areas in and around health,
both at home and overseas.

2. Academic evidence of poor simulation modelling adoption in healthcare

2.1 Simulation modelling – what do we mean?
Before our review of academic evidence of poor simulation modelling adoption in
healthcare, this paper will define its definition of simulation modelling. Simulation
modelling can mean different things to different people. For the purpose of this
paper, simulation modelling is defined as follows. Banks et al. (2001) described
simulation as the imitation of the operation of a real-world process or system over time
and that simulation involves the generation of an artificial history of a system and
observations of that system can be used to draw inferences of the system. The
assumptions used to create the generation of the artificial history (the model) could take
the form of mathematical or logical relationship. This definition of simulation is quite
broad and probably captures a range of modelling (simulation) techniques currently used
in health such as discrete-event simulation (DES); probably the most widely used within
healthcare (Naseer et al., 2009). This definition also captures spreadsheet modelling
which is also quite widely used in the UK health sector. DES and spreadsheet modelling
will be the particular focus of this paper.

2.2 Is healthcare simulation modelling any different to other sectors?

The benefits of simulation modelling have been applied to many industries including
healthcare. For example, Bagust et al. (1999) stochastic simulation model paper
highlighting bed shortage risk if average bed occupancy rises above 85 per cent in an
acute hospital setting. The 85 per cent occupancy rate has almost become a de facto
 JEIM occupancy target for many hospitals in the UK. Numerous healthcare-related DES
26,1/2 papers have been written ranging from a hospital wide view (Günal and Pidd,
2010), departments such as emergency departments (Ceglowski et al., 2007), or an
associated service such as blood supply (Katsaliaki and Brailsford, 2007). Some
reviews of academic papers suggested that levels of real problem simulation in
healthcare are not as high as in other industries. Brailsford et al. (2009) reported
10 few studies had evidence of healthcare implementation. On the face of it, over the
years little had changed; Wilson’s (1981) survey of computer simulation application
to health also indicated low levels of implementation. Eldabi (2009) found poor
application of healthcare simulation and modelling to real problems and real
stakeholders. Eldabi reviewed and compared the use of modelling and simulation
across three industries:
(1) healthcare;
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(2) defence/aerospace; and

(3) industry/business.
Eldabi review further classified the outcomes into three classes:
(1) Class A – a real problem and real stakeholders;
(2) Class B – real-life problems, no engagement from real stakeholders; and
(3) Class C – theoretical propositions and enhancements.
A summary of Eldabi’s modelling and simulation use by industry by class is illustrated
in Figure 1. The results in Figure 1 showed that healthcare had lower levels of real
problem and real stakeholder application (8.0 per cent) compared to defence/aerospace
(36.5 per cent) and industry/business (48.9 per cent). In contrast, healthcare had a much
higher level of theoretical propositions and enhancements (52.9 per cent) compared
to defence/aerospace (44.2 per cent) and industry/business (8.1 per cent). The results
of Eldabi’s study shown in Figure 1 tend to suggest that healthcare modelling is
somewhat different to other industries. The Tako and Robinson (2012) study to test if

100
8.1
90
80 43.0
48.9 44.2
70
60
50
%

19.2
40
30 36.5
52.9
20 39.1
10
8.0
0
Figure 1. Class A Class B Class C
Distribution of levels of Healthcare Defence/aerospace Industry/business
stakeholders by domain
Source: Adapted from Eldabi (2009)
 healthcare was empirically different to other industries also suggested that health was Healthcare
different. The study suggested a range of factors which differentiated health from other planning
industries. The differentiating factors were described as:
. the problems perspective: structure of problems, complexity and rate at which
problems change;
. the cost and data perspective: effort and difficulty associated with collecting data 11
and ease of results interpretation; and
. external factor perspective: influence of political events, rate of change and the
appropriateness of simulation software.
Eldabi’s findings also appeared to support the observations by Proudlove et al. (2007)
who suggested that rather than focusing on the environment and needs of health sector
stakeholders, academics publishing work were often rewarded for developing large
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complicated models with detailed analysis. Taylor et al. (2009) similarly noted that
academics and researchers, rewarded for publishing in high-quality journals, could
potentially be disengaged from real-world issues.

2.3 Healthcare size and complexity

Healthcare is big and complex industry employing a large number of people
delivering a wide range of services. In 2011, in the UK, NHS employees exceeded
1.7 million and they provided a range of health services to a population of
62 million (NHS Choices, 2011). Harper and Pitt (2004) suggested that the size
and complexity of healthcare had brought with it associated conflicting objectives
and data issues. Complexity of services and stakeholders were also issues observed
by Kuljis et al. (2007) who suggested that a multitude of stakeholders constrained
simulation adoption and seven axes set health apart from other industries. The
seven axes were:
(1) patient fear of death;
(2) medical practitioners, for example approach to healing, investigation by
experimentation and finance;
(3) healthcare support staff;
(4) healthcare managers;
(5) political influence and control;
(6) society view; and
(7) utopia.
In describing the seven axes, Kuljis et al. suggested that patient fear of death
introduced irrationality and unpredictable pressure in to the healthcare system.
Other noted factors included a diverse, highly opinionated medical community
with the potential to disagree on many issues; healthcare support staff with yet
another set of views; and healthcare managers trying the best to reconcile complex
and competing issues whilst trying to manage their own, sometimes different,
goals. Kuljis et al. also observed that healthcare is often highly exposed to political
influence and control, whilst the society and utopian view that “no one dies” was
particularly unique to health sector.
 JEIM Eldabi discussed the complexity of healthcare modelling in terms of its “wicked”
26,1/2 (impossible to solve) nature and posed the question whether modeller using linear
modelling methodologies to solve “wicked” problems was part of the problem. Instead,
Eldabi suggested, to model these problems more effectively, modellers needed to first
identify the wickedness of the problem; second, tame the problem using defined tools
and techniques; third, improve modelling skills. A key message from a review of the
12 above papers was that healthcare simulation modellers need to focus on meeting
stakeholder needs and requirement in their timescale.

2.4 Healthcare stakeholders issues

The review of papers above suggests poor engagement of stakeholder issues.
Communication in a wide sense appears to be problematic area and some points for
consideration are outlined here. Selecting a model at an appropriate level of complexity
(clearly communicating the model) were observations noted by Sinreich and Marmor
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(2004), Young et al. (2009), Proudlove et al. (2007) and Chick (2006) to name but a few.
Likewise, developing models to address real business needs were issues highlighted by
Sanchez et al. (2004) and Proudlove et al. (2007).
Another issue related to model complexity was the time taken to develop models.
Model development needs to be on the stakeholders’ timelines. As suggested by
Eldabi, in a fast-moving (wicked) world, healthcare projects rarely have the time
(nor funds) to model to a complete resolution; instead projects need to be resolved
within a specified time and budget. The timeliness of the model was issues highlighted
by Bowers et al.’s (2009) study of an emergency department. Whilst the model
provided a major contribution to the understanding of the process, the model was
delivered after the system had been thoroughly investigated and changes
implemented. Young et al. (2009) suggested the possibility of developing generic
models and working with practitioners developing rules of thumb to provide ready
guides to practice. These suggestions may show potential moving forward. They
may offer pragmatic solutions to wicked problems as described above which
simplify and thus speed up the modelling process, better suiting stakeholders’ needs
and requirements. Sometimes within health, determining relevant stakeholders can be
problematic in itself, as noted by Brailsford et al. (2009) who counted 28 stakeholders
ranging from the public to Parliament.
The evidence provided by the papers above suggests that although healthcare is
perhaps different to other industries, they also implied that often academic researchers
failed to respond to the challenges of health service stakeholders to fix real problems.
Moreover, the papers above alluded that academic-based healthcare simulation models
did not do enough to capture the attention of healthcare stakeholders. Another possible
reason to explain the poor adoption of academic style simulation and adoption could
be related to the issue that the healthcare community currently has a level of bed
and activity modelling capability and health stakeholders might not see a need for
additional modelling or simulation capability. The current bed and activity modelling
capability is discussed below.

3. Healthcare planning – the current offering

3.1 Estate strategies
Foundation Trust (FT) hospitals (NHS hospitals with a degree of management
autonomy) are advised to have an estate strategy (NHS Estates, 2005a). An
estate strategy is a high-level document that defines the current and future healthcare
 service needs of the local population and the current condition of the healthcare estate. Healthcare
A key element of the estate strategy is the service strategy which should capture: planning
. national policies and priorities;
. specialist services;
. cross-boundary issues;
. wider health economy needs; and 13
. other needs identified from other heath organisations and local government.
Guided by the service strategy, the estate strategy can link together other key
components such as finance, staffing and the physical estate to deliver the service
strategy. The estate strategy is usually a key document, often used by the Trust chief
executive and the Trust board to guide and steer the overall direction of the Trust. As
such, a formulated estate strategy can provide the following benefits:
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. premises developments that support service (including capacity requirements) to

national and strategic-level commitments;
. the provision of appropriate, safe and secure buildings, encouraging commitment
towards sustainable development and environmental targets;
. the provision of high-quality healthcare environments, to enhance patient
clinical outcomes, satisfaction and improved staff retention;
. opportunities to dispose of poorly used or surplus assets – releasing capital for
re-investment; and
. a clear plan for change with measurable goals.
Furthermore, estate strategies are often seen as a precursor to the allocation of capital
and as such often used to inform business cases. Sometimes, estate strategies are
wholly developed within the Trust. Sometimes, small teams of people, known as
healthcare planners, are used by Trusts to assist the development of their estate
strategy. Over time, a range of healthcare planning functions have been developed to
support the development of estate strategies and wider business cases. Often
healthcare planning functions are used as analysis tools in their own right. A range of
healthcare planning functions are described below:
(1) Demand and capacity analyses – analysis of patient numbers and their duration in
a particular area to determine facility requirements. For example, if we can assess
how many patients will require theatre treatment and how long they might stay in
theatre, the number of theatres required can be calculated. This methodology can
be applied to calculate inpatient beds, outpatient rooms, imaging facilities, etc.:
. impact of demographic, technological or service changes over time – these
inputs will have an impact on demand and capacity analyses and are often
integrated into them to show different modelled scenarios; and
. improvement analysis such as admissions avoidance and reduced lengths of
stay – as above, these parameters are sometimes used to enhance demand
and capacity analyses.
(2) Model of care analysis encapsulating room adjacency planning, patient
pathways and process mapping – the positioning of clinical services can be
important. For example, intensive care units should ideally be placed adjacent
 JEIM to theatres. Pathways are an important consideration. For example, sterile and
26,1/2 dirty material flows in hospital should be kept apart where possible.
(3) Schedules of accommodation (SoA) – a detailed listing of room requirements
in a healthcare facility area. Acting like an inventory, an SoA for an area
typically would describe the number and size of clinical and support rooms for
the area including plant and circulation space. SoAs are often used to define
14 the footprint of an area for space requirements.
(4) Equipment data sheets – a detailed list of equipment required in a specific area
(i.e. a room) in a healthcare facility. Examples would include furniture, plugs
and sockets, gases required and other specialist equipment.
(5) Room output specifications – a document often used in PFI schemes to describe
the functional requirements of a room – i.e. the room will need to provide
service X for Y number of patients over a given time.
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(6) Operational policies – specific policies defining a healthcare procedure or

service.
(7) Business cases (strategic, outline and financial) for PFI requirement.
(8) Strategic reviews – other ad hoc studies/analyses or reviews of healthcare-
related services.
Estate strategies tend to be a long-term activity (five to ten years), whereas other
healthcare planning functions typically take place over different time horizons as
illustrated in Table I. For example, healthcare planners help the health sector to create
strategic-level plans over a long-term horizon; tactical plans over medium-time
horizons; and operational decisions over a short term. These strategic-level plans
include estate strategies, strategic planning and business cases. Tactical decisions
might include improvement analysis, model of care analysis and operational policies.
Short-term operational functions tend to be similar to medium-term tactical function
except they are focused to localised activities, for example a ward or a particular unit.

Healthcare planning
Horizons Decision levels function examples

Long term Strategic Estate strategy

Strategic planning
Business cases
Demand and capacity planning
Medium term Tactical Demand and capacity planning
Improvement analysis
Model of care analysis
Schedules of accommodation
Equipment data sheets
Room output specifications
Table I. Operational policies
Healthcare planning Short term Operational Demand and capacity planning
function examples Improvement analysis
by horizons and Model of care analysis
decision levels Operational policies
 The key function of demand and capacity planning often spans the range of horizons Healthcare
and usually includes bed modelling and activity projections (Table I). planning
3.2 The role of healthcare planners in PFI schemes
Historically within the UK health sector, healthcare planning was a centralised
function at the Department of Health. However, the period of Thatcherisation (the
1979-1997 Thatcher and major governments) as described by Gorsky (2008), saw the 15
contraction of centralised services and the rise of internal markets within the NHS.
This resulted in many healthcare planning roles moving from a centralised function
within the NHS to the private sector or to NHS Trusts. Following the Thatcherisation
era was the era of New Labour (Gorsky, 2008). The New Labour period (the 1997-2008
Blair and Brown governments) saw a huge increase in public spending to rebuild
the health infrastructure, with spending rates to match the European-level average.
The primary funding vehicle used at the time was the PFI. Prior to PFI, hospitals
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owned and managed the physical structure that delivered healthcare. Under PFI, a
hospital Trust would enter into a contractual agreement with a private sector
consortium that would build and then provide a fully serviced building over an agreed
period. During the agreed period, typically 25-30 years, the trust would pay the PFI
consortium annual service charges. The PFI process had a number of formulised steps
including development of a number of business cases as shown in Table II.
Therefore, as illustrated in Table II, business case development (the strategic outline
case (SOC), outline business case (OBC) and full business case (FBC)) was a key step in
the PFI process. A number of PFI schemes started up in a relatively short period of
time creating PFI (and related business cases) skills and knowledge gaps in the health
sector. Healthcare planners were often used to help fill the skills gap to develop PFI
SOCs, OBCs and FBCs (Department of Health, 2007). Healthcare planners, employing
skills such as estate strategy development, demand and capacity planning (with its
associated bed and activity modelling) and business case development often played a
key role in the PFI approval process. With their knowledge of the PFI process,
frequently healthcare planning teams separately represented both the consortium and
the Trust as advisors. By April 2009, there were 76 PFI hospital contracts worth
a capital value of £6 billion (House of Commons Committee of Public Accounts, 2011).
As highlighted by Pollock and Dunnigan (1998), due to the private nature of PFIs
commercial agreements, FBCs in particular are rarely made public. Pollock et al. (1997)

The PFI process

1. Strategic outline case (SOC)
2. Outline business case (OBC)
3. Preparation for procurement
4. Procurement process
5. Full business case (FBC)
6. Contracts award
Prepare outline sketch of project and obtain approval to proceed
from capital advisory group
Define service requirements, appraise the options and make the
case for change in an OBC, obtain approval to process
Translate approved option into a detailed specification of
outputs, outcomes and desired allocation of risks
Already suitable providers and the best obtainable privately
financed solution through a procurement process Table II.
Complete the definitive investment appraisal and FBC and Summary of the private
obtain approval finance initiative
Finalise, award and implement the contract (PFI) process
 JEIM had fears that as PFI bed modelling or activity assumptions were rarely testing it
26,1/2 would lead to a shrunken NHS unable to provide a range of services to all sections of
the community. Whilst the value for money of PFIs is outside the scope of this paper,
there is little evidence to support the notion of a shrunken NHS unable to support a full
range of services, 15 years post Pollock et al.’s paper.
In many ways perhaps these contractual arrangements brought some clarity to the
16 stakeholder/healthcare planner relationship. Services to provide healthcare planning
advice (including bed and activity modelling) generally were clearly defined and
budgeted. Contractual arrangements also tended to reduce the physical number of
stakeholders in relation to healthcare planning assignment. In these instances, a key
stakeholder (or stakeholders) often acted on behalf of other stakeholders. As such, a
key stakeholder (or stakeholders) acted as the link to other “absent” stakeholders as
described by Young et al. (2009).
To perform the space planning functions, healthcare planners often worked
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closely with healthcare building designers. The Department of Health and

Social Security (DHSS) had over the years developed and issued guidance notes
with the aim to help standardise space requirements reflecting user and component
requirements in a variety of health settings (Hignett and Lu, 2009). These guidance
notes have been issued in a number of different forms over the years including NHS
Estates (2005b) and Department of Health (2011). A number of guidance notes use
calculations or use rules of thumb to calculate clinical space (including required
beds), for example emergency department rooms (NHS Estates, 2005b), outpatient
rooms (Department of Health, 2011) and theatres (NHS Estates, 2004). As a
consequence, these guidance notes were often used in conjunction with relatively
simple spreadsheet models to develop modelled scenarios for clinical space.
This short review of the healthcare planning role demonstrated strong historical
links within the healthcare sector and experience working with a wide range of health
stakeholders delivering high-value projects to the general satisfaction of those
stakeholders. Also, contractual arrangements helped to keep the focus of delivering
health planning services on time and within their budget. As such, health stakeholders
could be of the mindset that the healthcare planners could cater for the majority of their
modelling and simulation needs.

4. Current and future challenges

Arguably the need of simulation modelling in healthcare has never been greater. For
example, within the UK, public spending constraints have resulted in huge demands
for cost savings in health spending. These constraints have led to unprecedented levels
of efficiency savings for the health sector. The NHS chief executive in his 2008-2009
annual report called for efficiency savings between £11 billion and £20 billion between
2011 and 2014. Some reports have suggested that billions of pounds could be saved by
productivity savings. McKinsey (2009) suggested that between £5.6 billion and £7.9
billion could be saved by improving productivity and optimising spending within care
pathways. Similarly, a King’s Fund report suggested productivity savings in the order
of £4.6 billion (Appleby et al., 2010).
By their nature, the thrust of many of healthcare planning functions described
above (e.g. demand and capacity analysis and process mapping) is to challenge and
reduce waste and efficiency. Simulation modelling is ideally suited to process mapping
and arguably other waste reduction methodologies such as Lean. Arguably, there is an
 opportunity for healthcare planning to act as a link to bring together simulation and Healthcare
Lean and some common threads are discussed below. planning
4.1 Lean healthcare
In many industries, Lean methodology has been viewed as an ideal tool to reduce
waste and optimise processes. Arguably, these techniques can be applied to healthcare
(Young et al., 2004). The NHS Institute for Innovation and Improvement (2008) went 17
further and translated Lean’s seven wastes into healthcare context. The seven wastes
translated into health were defined as:
(1) overproduction – just in case and/or batch activity (examples include requesting
unnecessary referrals or tests);
(2) inventory – holding high levels of inventory which could include patients
(examples includes using beds to hold patients that could be discharged or
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over ordering material to compensate for erratic supply);

(3) waiting – unnecessary queues;
(4) transportation – wasteful patient movement;
(5) defects;
(6) staff movement – unnecessary movement; and
(7) unnecessary processing.
Virtue et al. (2012) suggested that the healthcare planning role by its very nature would
aim to address many of the Lean waste issues highlighted above. For example, demand
and capacity models could be useful to help provide insights with regards to
overproduction and inventory (Lean items 1-2). Whereas, process mapping could be a
useful tool to investigate transportation, staff movements and unnecessary processing
(Lean items 4, 6 and 7). Adjacency planning could provide useful insights into both
transportation and staff movements (Lean items 4 and 6). Arguably, simulation
modelling could be deployed across the full range of the seven Lean components
providing analysis for stakeholders. The NHS and its Institute for Innovation and
Improvement has also recognised the potential of modelling and simulation as a
vehicle for testing and experimenting potential improvements in a safe environment.

5. Healthcare planning as an agent for change

As the NHS moves to find unprecedented levels of savings, simulation modelling could
be deployed to help achieve those savings targets, possibly working in conjunction
with methodologies such as Lean. To help achieve some of these demanding targets,
moving forward, the NHS will have to learn, adapt and apply useful tools and
methodologies to help itself. Over the years, healthcare planners have developed sound
working relationships with its health stakeholders and as such are ideally placed to act
as change agents within the healthcare sector to help fill any skills gaps. In order to
assist this transition, healthcare planners also need to upgrade their tools and
techniques. For example, many healthcare planning tools and guidance notes use
average data to model. Sometimes, a greater level of modelling sophistication is
required. An emergency department is one example where due to variance in arrival
patterns, average data can produce misleading outputs. In contrast, modelling
emergency department using DES can potentially provide greater insights with regard
 JEIM to arrival variance, area loading and queues. As noted by Eldabi, healthcare planners
26,1/2 need to develop their simulation modelling skills to give their health stakeholder
partners every opportunity to take advantage of current and developing simulation
modelling methodologies, tools and techniques. Healthcare planners also need
to develop and enhance a range of other skills as suggested by Virtue et al. (2012).
The skills include communications with stakeholders, user friendly inputs and
18 outputs matched to the needs of stakeholders, opening black box models as required
by informed stakeholders and models developed in accordance with stakeholders’
timeframes and budgets.
The academic community can also play a valuable role by developing real-world
solutions for the health sector in conjunction with both healthcare planners and health
stakeholders. Jahangirian et al. (2012) observed that compared to other industries, the
health sector tended to use a smaller variety of simulation methods. Every effort should
be made to implement appropriate tools to assist the constant, ever changing demands
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of the health sector. The health sector already uses rules of thumb widely to model
beds and activity (e.g. Bagust et al., 1999) 85 per cent bed occupancy, and a range of
guidance notes to define clinical spaces and beds for emergency departments, theatres
and outpatient rooms. Arguably, the challenge now and in the future, will be to develop
more sophisticated modelling and simulation tools, in shorter timescales, to better
address real stakeholder issues and challenges in the health sector.

6. Conclusions
The health sector already uses methods to model beds and activity. In many respect,
the current rules of thumb were pragmatic approaches to support the NHS capital
build programme under New Labour. Now the upgraded NHS estate is largely in place,
the focus in this current climate is how to make it more operationally efficient.
The academic community needs to be more in tune with the real-world
requirements of health stakeholders, developing a larger percentage of Class A papers
as defined by Eldabi (2009). The academic community also need to be more open to the
challenge of condensing wicked problems into pragmatic solutions. Bagust et al.’s
(1999) 85 per cent bed occupancy rule of thumb serves as a splendid example; sound
academic modelling, shrinking a wicked concept into a rule of thumb widely used by
both the health sector and the healthcare planning community. The health sector is
unique in some elements, but perhaps, the sector itself needs to be more open to ideas
from other sectors, for example simulation modelling and Lean. Finally, health
planners need to build their capability to take advantage of its relationships with
health stakeholders and develop a stronger role acting as a link between the simulation
modelling, the academic world and the health sector.

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Corresponding author
Anthony Virtue can be contacted at: anthony.virtue@echarris.com

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