Improving patient waiting times:

a simulation study of an obesity

care service
Antuela A Tako,
1
Kathy Kotiadis,
2
Christos Vasilakis,
3
Alexander Miras,
4
Carel W le Roux
4,5
1
School of Business and
Economics, Loughborough
University, Loughborough, UK
2
Warwick Business School,
University of Warwick, Coventry,
UK
3
UCL Clinical Operational
Research Unit, University College
London, London, UK
4
Imperial Weight Centre,
Imperial College London,
London, UK
5
Experimental Pathology, UCD
Conway Institute, School of
Medicine and Medical Science,
University College Dublin,
Dublin, Ireland
Correspondence to
Dr Antuela A Tako, School of
Business and Economics,
Loughborough University,
Richard Morris Building,
Ashby Road, Loughborough
LE11 3TU, UK;
a.takou@lboro.ac.uk
Received 28 April 2013
Revised 5 August 2013
Accepted 27 August 2013
To cite: Tako AA, Kotiadis K,
Vasilakis C, et al. BMJ Qual
Saf Published Online First:
[ please include Day Month
Year] doi:10.1136/bmjqs-
2013-002107
ABSTRACT
Background Obesity care services are often
faced with the need to adapt their resources to
rising levels of demand. The main focus of this
study was to help prioritise planned investments
in new capacity allowing the service to improve
patient experience and meet future anticipated
demand.
Methods We developed computer models of
patient flows in an obesity service in an
Academic Health Science Centre that provides
lifestyle, pharmacotherapy and surgery treatment
options for the UKs National Health Service.
Using these models we experiment with different
scenarios to investigate the likely impact of
alternative resource configurations on patient
waiting times.
Results Simulation results show that the timing
and combination of adding extra resources (eg,
surgeons and physicians) to the service are
important. For example, increasing the capacity
of the pharmacotherapy clinics equivalent to
adding one physician reduced the relevant
waiting list size and waiting times, but it then led
to increased waiting times for surgical patients.
Better service levels were achieved when the
service operates with the resource capacity of
two physicians and three surgeons. The results
obtained from this study had an impact on the
planning and organisation of the obesity service.
Conclusions Resource configuration combined
with demand management (reduction in referral
rates) along the care service can help improve
patient waiting time targets for obesity services,
such as the 18 week target of UKs National
Health Service. The use of simulation models can
help stakeholders understand the
interconnectedness of the multiple microsystems
(eg, clinics) comprising a complex clinical service
for the same patient population, therefore,
making stakeholders aware of the likely impact
of resourcing decisions on the different
microsystems.
INTRODUCTION
Obesity is a major concern in a number
of countries worldwide.
1
Thirty per cent
and 24% of adults in the USA and UK,
respectively are currently classified as
obese, and these figures are expected to
double in the future.
2 3
The clinical treat-
ment of obesity has become part of
obesity care services delivered by dedi-
cated care providers.
4
So far, mathematical and computer
modelling efforts with regards to obesity
have concentrated on developing epi-
demiological models that estimate
expected obesity trends and healthcare
expenditure due to related diseases in the
USA and the UK.
4 5
Given that multidis-
ciplinary obesity centres are a relatively
new service, at least to the National
Health Service (NHS) in England, studies
looking at their performance from an
operational perspective have not been
reported in the literature. An obesity care
service typically forms a complex inter-
connected clinical service comprising
multiple microsystems that provide a
range of non-surgical and surgical ser-
vices to the same patient population.
6
Obesity care service performance is typic-
ally judged using targets aimed at ensuring
patients right to accessing services within a
maximum waiting time. In the UK, the
18-week target from when a patient is
referred to when treatment is provided
7 8
has received significant attention in the last
1015 years, and has been used to evaluate
the performance of NHS institutions. This
target is also used to evaluate the perform-
ance of obesity centres, however, for the
purposes of obesity treatment, this target
needs to be measured differently to accom-
modate for the time the patient needs to
prepare to receive some specific treatments
ORIGINAL RESEARCH
Tako AA, et al. BMJ Qual Saf 2013;0:19. doi:10.1136/bmjqs-2013-002107 1
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such as obesity surgery. Further detail about how these
targets are measured is provided in the Methods section.
This paper reports on a simulation study under-
taken to help prioritise planned investments in new
capacity that will allow the service to improve patient
experience and meet future anticipated demand. We
chose to use discrete event simulation (DES) as it is
generally considered appropriate for modelling and
evaluating the allocation of resources in the health
context.
9 10
Its overall aim is to evaluate the likely
effect that the capacity of different resource configura-
tions has on patient waiting times in a UK-based
obesity service situated in an Academic Health Science
Centre. The novelty of the study is that multiple
microsystems have been included in the model rather
than the single microsystem (eg, an outpatient clinic)
usually modelled in simulation studies.
1116
This
in turn has enabled us to explore targets such as the
18 weeks target that involve a longer part of the
patient journey through a number of clinics within
the obesity system. A number of computer models
were used to explore the impact of alternative config-
urations of resources on the emerging waiting lists.
These models explored the following options:
Increasing capacity to meet demand, that is, employing
additional clinical staff (surgeons and physicians).
Managing demand through a reduction in patient refer-
ral rates into the service.
Although the results obtained are specific to the
particular service, the methods and findings could be
useful to other similar centres within and outside the
UK.
METHODS
The care setting
The obesity care service studied was designated as an
International Centre of Excellence for bariatric
surgery by the Surgical Review Corporation and one of
the preferred providers of bariatric surgery services for
London and Northern Ireland. The service providers
wanted to understand how the 18 week target could be
consistently met in the foreseeable future, without adding
unnecessary capacity, by employing new resources such
as surgeons and physicians. The service was experiencing,
at the time of the study (2009), increasing numbers of
referrals and an increased pressure to meet the demand
for consultation and treatment. The pressure was mostly
experienced in the parts of the system treating patients
with pharmacotherapy (medication) and surgery. The
service referrals were increasing each year at an exponen-
tial rate which made planning difficult. In addition stake-
holders found it difficult to consider the effect of adding
resources on the entire system. Avisual interactive simula-
tion tool was considered appropriate in bridging the sta-
keholders views.
The treatment of obesity focuses on the reduction of
body weight using three different options depending on
patient choice: a change in lifestyle, pharmacotherapy
and bariatric surgery (also known as obesity surgery).
The first option involves diet, exercise and behavioural
change. The second option involves the administration
and management of weight loss medications over a
long period. The third and final option is surgery.
17
In
the NHS the three most common types of surgical
interventions are gastric band, sleeve gastrectomy and
gastric bypass.
18
The choice of treatment is made based
on patient preferences and health indicators such as the
body mass index and specific comorbidities.
Patients were referred to the obesity care service
either from primary care services (general practi-
tioners) or from other secondary care services (as a
result of serious comorbidities related to obesity). A
group induction session was organised once a week
for newly referred patients, where members of the
team ( physician, surgeon and nurses) explained treat-
ment options. Patients completed a questionnaire with
details of their health conditions and treatment prefer-
ences. Next, a specialist nurse screened the question-
naires and referred patients to one of the three
medical outpatient clinics which focused on preparing
patients for the lifestyle, pharmacotherapy or surgery
treatment options.
The lifestyle clinic led by dieticians operated twice a
week. Patients attended in total six consultation visits,
on average 1 month apart. After that patients were
discharged and advised to continue the dietary regime
for life, while also having the option of attending spe-
cific lifestyle group support sessions.
The pharmacotherapy clinic led by a physician oper-
ated weekly. Two types of medication therapies were
typically prescribed, reviewed initially after a 3 months
period and 9 months thereafter. Patients successfully
treated were discharged to the care of the general prac-
titioner to continue on a lifelong treatment. If one type
of drug did not work for the patient, the second type
of drug was prescribed. If none of the drug types
worked, patients were either referred to the lifestyle or
surgical clinic or discharged.
The surgical care component of the obesity service
involves a range of outpatient appointments and a sur-
gical procedure. Patients were first seen in an out-
patient clinic, called the Eligibility clinic, led by a
physician and psychiatrist, who reviewed the patients
history and assessed whether surgery would be appro-
priate. Patients, with psychological comorbidities that
need further optimisation were sent for a 3-month
psychiatric review and if a satisfactory improvement
was achieved, they were then referred on for a surgical
opinion. In the next clinic called the Decision
clinic, a surgeon and dietician assessed the patient to
establish if he/she can safely have an operation.
Following the decision to operate, patients were regis-
tered on the surgery waiting list. Before their sched-
uled operation, they were reviewed and educated in a
Pre-assessment clinic led by an anaesthetist and a
specialist nurse. If the patient passed the necessary
Original research
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health checks he/she was scheduled for one of the
three types of surgical interventions (gastric band,
sleeve gastrectomy or gastric bypass). The number of
operations scheduled on an operating list would vary
depending on the type of surgery. Patients were admit-
ted on the day of surgery. After operation postoperative
care was provided depending on the type of surgery.
Patients were then discharged from hospital and seen
as follow-up cases at the medical or surgical outpatient
clinics under a shared care arrangement.
The simulation model
The obesity care pathway described above was repre-
sented in a simulation model built using Simul8, a
DES software.
19
The main objective was to identify
the impact of capacity changes in resources (namely
surgeons and physicians) and patient referral rates on
patient waiting times. Capacity is modelled as the
available patient appointments (slots). Stakeholders
determine this in practice by translating the available
resources (eg, physicians, surgeons, nurses, dieticians,
beds, rooms, etc) of each microsystem into available
patient capacity. The model runs for one simulated
year with a time unit of 1 day. Patient movement is
best represented in days for two main reasons. First
the overall system in simulation terms is slow moving
as it takes several weeks for a typical patient to move
through the system. Second, the individual microsys-
tems (eg, clinics) are modelled as patient slots (cap-
acity) which do not require a time unit lower than a
day as it would be unlikely to attend two clinics
within a day. Results on patient waiting times are
represented in multiples of days, which are automatic-
ally converted into weeks to fit with the targets of
interest (eg, 18 week target). Patients are shown to
arrive into the model in appropriate intervals and can
follow various routes within the obesity system. These
routes are determined by probability distributions.
Movement of patients to the next process (eg, clinic)
is determined by the available capacity. If there is no
available capacity, patients are held in the model in
queues, which conceptually fit waiting lists. Patients
are assigned a range of attributes such as time stamps
at different points within the model in order for the
calculations of waiting times to be performed.
We chose DES because it can depict the concept of
individual patients competing for different types of
resources (eg, a slot in the operating theatre list or a
postoperative bed) and thus making it possible to
model the impact of different levels of available
resources and referrals on waiting times. Furthermore,
the software can graphically display on screen the
movement of patients, which members of the obesity
team found useful to gain an overall understanding of
the obesity care pathway. Figure 1 shows a flowchart
of the flow of patients within the obesity care
pathway and the simulation model. Table 1 provides a
summary of the objects, model parameters and
distributions used in the model, which further explain
the simulation model developed.
As it is the case in modelling studies, some aspects
of the real life service which were not relevant to the
objectives of the study were not modelled and others
were modified for simplification purposes. The
assumptions and simplifications made are listed
below:
The capacity relevant to the study was mostly related to
the number of physicians and surgeons. This was due to
the difficulties when it comes to increasing these resources
because of costs and limited availability in expertise.
Other staff specialties (ie, nurses, dietician, etc.) are indir-
ectly modelled as capacity in some parts of the system
(eg, lifestyle clinics) but in this system their availability
exceeded demand. Infrastructure components (eg, equip-
ment and operating theatres) were a secondary concern
when determining the capacity.
Repeat outpatient appointments for patients returning for
regular check-ups after treatment were not included. In
fact, follow-up clinics were being established in primary
care which followed the agenda of the NHS plan, but also
allowed an almost unlimited capacity in principle as GPs
would take up the follow-up care for uncomplicated
patients.
While placement of patients on the surgery waiting list is
in reality more complex, taking into consideration
patient preferences and fulfilment of requirements for
surgery, in the model they are allocated an operation
using a simplified first in first out rule.
It is standard practice in DES to improve the accur-
acy of the results by removing the initial transient
effects (due to the simulated service starting empty)
and by running the simulation several times to
account for the variability in the input parameters.
20 21
Statistical estimations informed our choice of using a
warm-up period of 1 year and execute 30 simulation
runs for each model configuration.
22
The computer
model then continues to run for a further year
whereby the results show the level of the different
performance measures calculated at that point in
time.
A number of models were developed, including the
baseline model, representing the obesity service
running a year into the future as it was resourced at
the time of the study, with the equivalent capacity
resulting from operating with one surgeon and one
physician. The remaining models represented other
future scenarios of different options, which were pre-
viously agreed with the obesity care team. These
models forecast the future performance of the service
under variations of the following parameters:
Number of surgeons: additional surgeons are repre-
sented as multiples of the capacity of services requiring a
surgeon in Decision clinic and Operation theatre slots
Number of physicians: additional physicians are repre-
sented as multiples of the capacity of services requiring a
Original research
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physician in Group Induction, Pharmacotherapy clinic
and Eligibility clinic
Managing demand (referrals): reducing patient referrals
to half of the baseline figures
Six scenarios (models) representing the feasible solu-
tion space were selected by the stakeholders. These
scenarios look 1 year into the future (table 2).
Data collection
In order to populate the models input parameters we
obtained real life data from members of the obesity
care service. The data used are detailed in table 1,
where the data sources are also explained. The obesity
service was regularly audited which meant that some
data such as number of patients in the different
waiting lists, number of patients discharged, etc, was
available in reasonable quantity. These are detailed in
table 1 as existing data. In most cases, data referring
to the proportion of patients that choose a specific
treatment were collected based on a randomly chosen
sample of 60 patients from a database containing 600
patients (every 1 patient in 10 was chosen from the
existing patient database). Some of the data, such as
the waiting time between clinics, were not known
with accuracy and it was not possible to estimate
empirically, hence informed guesses were made and
approximate distributions were used in the model such
as the triangular distribution (see table 1). Data on
patient referrals were also estimated based on existing
numbers accounting for the increased future demand
for obesity services, hence slightly higher than the exist-
ing numbers. The source is detailed as expert opinion.
Performance indicators
We were mainly interested in patient waiting list size
and times as these indicators are used by senior man-
agement to assess the performance of the obesity care
service.
Waiting list size for Group Induction: the number of first
time patients on the waiting list for group induction
session.
Waiting list size for Pharmacotherapy clinic: the number
of patients waiting to be seen in the Pharmacotherapy
clinic.
Waiting list size for Operations: the total number of sur-
gical patients (who opted for surgical intervention at
group induction), waiting for surgery at any point in the
surgical pathway. This includes the waiting list for the
Figure 1 Flow chart showing the process flow within the obesity service. WL, waiting list.
Original research
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Eligibility clinic, Decision clinic, surgery ( patients who
are allocated a date) and the weekly operating list (ie,
patients scheduled for operation).
Waiting time to operation: the total time (in weeks)
patients spent in the system from first referral to the day
of operation.
18 week targets: the proportion of patients waiting more
than 18 weeks from referral to receiving treatment. Two
separate 18-week targets were calculated, specific to the
obesity pathway as opposed to an overall 18 week target
used in other clinical areas,
7
where patients require
shorter timescales to first treatment. The first target
counts the combined waiting time from first time referral
until a first treatment is provided (in Eligibility or
Pharmacotherapy clinic). The second target is counted
only for surgical patients, where the clock starts counting
from Eligibility clinic until surgery. Effectively the clock
stopped when the patient was seen for the first time and
Table 1 Input parameters to simulation model in baseline scenario
Parameter Resources
Value in baseline
scenario
Distribution
type
Data
sources
Referral rate 100 patients/month Poisson Expert opinion
Group induction (one group session per week) Nurse
Physician Surgeon
Up to 20 patients/week Existing data
Following group induction
Patient assessment 93% Bernoulli Existing
Do not continue 7% Bernoulli Data
Patient assessment (once a week) Nurse Up to 20 patients/week
Following patient assessment
Lifestyle clinic 5% Bernoulli Existing
Pharmacotherapy clinic 16% Bernoulli Data
Eligibility for surgery clinic 79% Bernoulli
Lifestyle clinic (two group sessions per week) Dietician Up to 8 patients/week Existing data
Six separate appointments/patient
Time period between appointments 20 working days (1 month) Triangular Expert opinion
Pharmacotherapy clinic (once a week) Physician Up to 14 patients/ week Existing data
Following Pharmacotherapy Expert
Receive drugs (drug A) 84% success rate Bernoulli opinion
Receive drug B (if drug A fails) 80% success rate Bernoulli
Time period for second appointment 90 days (3 months) Triangular
Time period for third appointment 120 days (6 months) Triangular
If drugs A and B fail, Expert
Referral to surgery 15% Bernoulli Opinion
Referral to lifestyle clinic 10% Bernoulli
Discharged 75% Bernoulli
Eligibility clinic (outpatients) Physician
Psychiatrist
Up to 10 patients/week Existing data
Following Eligibility clinic Existing
Decision clinic (surgery) 60% Data
Psychiatric review 30%
DNA surgery 10%
Decision (for surgery) clinic Surgeon Dietician 8 patients/week Existing data
Preassessment clinic (2 weeks before the scheduled
operation)
Anaesthetist Nurse 8 patients/week Existing data
Operations (three types of surgical procedures) Surgeon
Anaesthetist
3 half day theatre
lists/week
Existing data
Gastric band (1 h procedure) 19% Bernoulli
Sleeve gastrectomy (1.5 h) 22% Bernoulli
Gastric bypass (2 h) 59% Bernoulli
Postoperative length of stay following Beds Depending on type of
surgery
Expert opinion
Gastric band 1 day
Sleeve gastrectomy 2 days
Gastric bypass 2 days
Original research
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then it restarted at zero when the decision/referral to
proceed to surgery was made. At the time of the study
these divisions were of interest to the members of the
obesity centre. However, other centres may view the
interpretation of the18 week target differently. A differ-
ent calculation would require a change in the model
coding for such calculations but would not invalidate the
model itself. The lifestyle clinic was not included in our
findings as it was underused and the computer model
and centre data supported that finding.
For each performance indicator, we used the output
from the 30 runs per scenario to calculate the point
estimates (mean) and 95% CI values.
Model validation
The aim of validation in simulation modelling is to
enable the modelling team and stakeholders to gain
sufficient confidence in the model.
21
The simulation
model was validated throughout the life cycle of the
study to ensure that it adequately represented the
behaviour of the real life service. Specific validation
activities included presenting the model in detail to a
group of key stakeholders where modellers and stake-
holders had the opportunity to ask questions and
suggest alterations. Following minor changes stake-
holders found the simulation model and its results to
be representative of their experience of the system.
Furthermore, the results of the baseline model, which
represented the care service as was resourced at the
time of the study, were compared with past obesity
service data. The simulation results, such as the number
of patients discharged from the lifestyle, pharmacother-
apy and surgical treatments and the average waiting
time to surgery, compared favourably with the actual
service statistics as at the end of December 2009. For
example, the total number of patients discharged from
the service over a year was 152, 95% CI (100 to 171)
vs 152 actual patients discharged, the total number of
surgeries completed was 92, 95% CI (60 to 123) vs 85
actual surgeries carried out, the average waiting time to
surgery was 11 weeks, 95% CI (10 to 13) vs 10 weeks
achieved by the end of 2009). The service data
provided were based on the past year (2009) at the
time of the validation so it was important to also con-
sider the percentage increase in referrals as the baseline
simulation model simulates a year into the future. This
figure is considered acceptable given that approximately
higher patient referrals were used in the model to
account for the increased demand for services in the
1 year into the future (1187 instead of 952 actual refer-
rals by the end of 2009). The model behaved as
expected. We could not compare the model retrospect-
ively with data of the year simulated as capacity
changes were introduced to the actual system as a result
of the study partway through the year (2010).
Sensitivity analysis was also undertaken in order to
check the impact of referral rate changes on model
results. A 5% change in this parameter incurred a
proportional change in the results. A similar model
behaviour was obtained by changing the time period
between appointments. The stakeholders were made
aware of these findings.
RESULTS
The results of the baseline scenario (table 3) showed
that a high backlog of patients would accumulate in
the different waiting lists, if the same level of
resources were kept in a simulated year (at the time of
the study a year into the future). The rising figures are
not due to any transient effects or an insufficient
warm-up period but are due to the rising referrals.
This result was in line with the expectations of the
obesity care service team members. On an annual
basis, an average 64% (95% CI 63% to 65%) of
patients waited for more than 18 weeks until being
seen at the eligibility visit or pharmacotherapy clinic
from first referral and 47% (95% CI 46% to 47%) of
surgical pathway patients would wait for more than
18 weeks for an operation from the Eligibility visit.
These figures continued to rise, reaching to 100% in
the last month (December of a simulated year).
Comparing the simulation results of all six scen-
arios, scenarios 3 and 5 were the best performing ones
in terms of patient waiting times in the service. The
Table 2 Parameters defining the six simple future scenarios (all values represent patient slots per week unless otherwise stated)
Scenario Resources
Monthly patient
referrals (average)
Group
induction
Pharma-cotherapy
clinic
Eligibility clinic
(surgery)
Decision clinic
(surgery) Operations
Baseline 1 surgeon,
1 physician
100 20 14 10 8 6
1 2 surgeons,
1 physician
100 20 14 10 16 12
2 2 surgeons
2 physicians
100 40 28 10 16 12
3 3 surgeons,
2 physicians
100 40 28 20 24 18
4 2 surgeons,
2 physicians
55 40 28 20 16 12
5 3 surgeons,
2 physicians
55 40 28 30 24 18
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proportion of patients waiting for longer than 18 weeks
was reduced to 9% (95% CI 9% to 12%) with the add-
ition of one surgeon (scenario 1), whereas the addition
of two surgeons (scenarios 3 and 5) provided a further
slight improvement, reducing this proportion to 8%
(95% CI 7% to 10%).
The introduction of an additional physician resulted
in significantly lower waiting lists for group induction,
Pharmacotherapy and Eligibility clinic (scenario 2).
However, more patients progressed to the surgical
part of the system, creating a high backlog of referrals
waiting for surgery. This is obvious when comparing
scenarios 1 (1 physician) and 2 (2 physicians), where a
higher proportion of patients waited for more than
18 weeks (9% compared with 38%). The best per-
forming scenarios were those with more surgeons
than physicians. This demonstrates the dynamic
behaviour of resources and the bottlenecks created in
the system.
Scenarios 4 and 5 operate under a reduced patient
referrals mechanism, where patients who did not have
sleep apnoea, high cardiovascular risk, diabetes or
infertility would be seen by general practitioners in
primary care centres. The reduced referral rate appears
to allow physicians to clear the backlog of patients
waiting for group induction. As a result the proportion
of patients waiting for more than 18 weeks to be seen
at the Eligibility clinic is reduced from 63% (95% CI
62% to 65%) in scenario 2 to 59% (95% CI 58% to
60%) in scenarios 4 and 5. In the last month
(December year 1) this proportion reaches 0% (scen-
arios 4 and 5). Scenario 5 however provided a better
performance because beyond December of year 1, all
patients wait less than 18 weeks to be seen at the
Eligibility clinic or to receive an operation.
DISCUSSION
Members of the obesity care team were involved
throughout the study and took a keen interest in its
results. The simulation models built provided a visual
representation of the obesity care service, which in
turn helped those involved in gaining a wider under-
standing of the service. The study confirmed the
initial concerns of the team that the pre-existing cap-
acity in place in 2009 (at the start of study), would
not be sufficient to cope with the increases in patient
referrals to the service. In real life this would result
into continuously rising numbers of patients on the
waiting lists with considerably longer waits. Hence
changes needed to be considered. As expected, simu-
lation results showed that the addition of surgical
resources and their associate capacity bring about
improvements in patient waiting times in the surgical
part of the service. However, the results also showed
that adding at the same time the capacity of one phys-
ician, may lead to deterioration in the waiting times
associated with the surgical part of the service. This
occurs because a bottleneck is developed between T
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Original research
Tako AA, et al. BMJ Qual Saf 2013;0:19. doi:10.1136/bmjqs-2013-002107 7
group.bmj.com on July 21, 2014 - Published by qualitysafety.bmj.com Downloaded from
the physician-led clinics and the surgical part of the
service, with the latter not having the available cap-
acity to accommodate the number of additional
patients placed on the surgical waiting lists. Better
service levels were achieved when the modelled
service operated with the concurrent capacity of two
physicians and three surgeons. This finding served as
evidence for the obesity team and its management
that staffing decisions in relation to one part of the
service should not be taken in isolation to other parts
of the service.
Furthermore, the results showed that reasonable
and realistic expansions in capacity alone cannot
improve service performance levels. Introducing the
concept of demand management for treatment
whereby controlling the number of patients referred
to the service and focusing on those that would
benefit would result in a reduction of referral rates to
the obesity care service. Study results confirmed that a
reduction by almost 50% in referral rates would
ensure that the service be in a better position to meet
demand. This finding calls for a more integrated
approach to planning for obesity care services, involv-
ing care providers at primary, secondary and tertiary
levels, as suggested also by Gortmaker et al.
5
As an immediate outcome of this study the Trust
decided to add more surgeons to the service instead
of adding physicians alone. Furthermore, the
Academic Health Science Centre and the Primary
Care Trust engaged into discussions about changing
the local eligibility criteria for bariatric surgery,
23
which eventually led to a reduction in the number of
referrals to the centre. A decision to build a new oper-
ating theatre was also made as the management team
realised that additional capacity was needed in order
to achieve aspired service levels and operation
volumes.
CONCLUSIONS
The simulation study reported here is to the best of
our knowledge, the first computer simulation study of
an obesity service reported in the literature. The simu-
lation model demonstrated the dynamic nature and
impact between different parts of the service, highlight-
ing the need to introduce changes in capacity after
careful consideration of their impact on the overall per-
formance of the service. Unlike many healthcare simula-
tion models built of an individual microsystem,
1116
this
model represents a complex clinical service comprising
of many microsystems serving the same patient popula-
tion. This is a novel conceptual view.
The model reported here represents what was con-
sidered to be a complex multidisciplinary obesity care
service, to an acceptable level of accuracy. In the spe-
cific obesity care services, complexity exists because at
different stages of the pathway a wide range of investi-
gations and treatment options are available to the
patients. Furthermore, the clinical treatment of
obesity often requires intentional delays in treatment,
while the patient undergoes preparation or an initial
weight loss programme.
7
Such delays are clinically
beneficial for the patient as it may improve the
outcome of their treatment,
7
but it adds to the com-
plexity that needs to be accounted for in planning and
consequently in the model. In addition the variability
found in the real system (eg, referral rates and delays)
is captured through the use of empirical and statistical
distributions. To a certain extent, only through a
simulation model can this level of complexity due to
interconnectedness and variability be captured
adequately.
2426
The main objective of the study was to understand
the performance of targets relating to system through-
put times such as the 18 week target.
9 24 26
The
model does not include a detailed representation of
the microsystems. For example resources in each
microsystem were translated into capacity and more
specifically patient slots. However one can infer from
this capacity and associated resources the correspond-
ing costs as well as the need for new investment. In
this study hospital planners were able to translate
patient slots to the resources required and the asso-
ciated costs. The cost-benefit trade-offs of new invest-
ments in high cost staff such as consultant physicians
and surgeons remain an important determinant of any
decision within a health system. This simplification
was necessary to enable us to focus on the key aim of
the study and to keep the complexity of the model to
a minimum. Future simulation studies, for example,
could consider extending the existing model to
include follow-up (repeat) appointments.
Computer simulation provides a visual representa-
tion of the system in a model that enables modellers
and stakeholders to interact with it while it is running.
The models showed patients flowing through the dif-
ferent clinics, with queues building and statistical
results displayed on demand. This can be useful to
many healthcare providers who are often not aware of
the impact of a decision on other parts of the system.
Running these models with stakeholders present
helped communication between the healthcare stake-
holders and the modelling team. During the experi-
mentation stage the stakeholders were able to visually
experience the model running and suggest scenarios to
be explored, for example adding capacity in different
parts of the model. Many of these scenarios were run
at the stakeholders request. In addition, during this
experimentation with scenarios, stakeholders could
request changes to the models capacity that in real life
may be considered unaffordable. The outcome of such
changes was known in a few minutes. This level of
experimentation could not have been undertaken in
real life as most systems cannot afford to add expensive
structures without being sure it will alleviate the
problem. Therefore, computer simulation modelling,
as this study has shown, can support experimentation
Original research
8 Tako AA, et al. BMJ Qual Saf 2013;0:19. doi:10.1136/bmjqs-2013-002107
group.bmj.com on July 21, 2014 - Published by qualitysafety.bmj.com Downloaded from
in a safe environment and the results can be made
quickly available to those concerned.
Contributors AAT built the models and analysed the results.
AATand KK drafted the paper. CV helped with the editing of
the paper. AM and CWR helped in organising the study,
contributed data for the development of the models and editing
of the paper. All authors have reviewed the paper and have
approved the final version.
Funding This study was supported by the UK Engineering and
Physical Sciences Research Council (EPSRC) grant EP/E045871/1.
Competing interests None.
Provenance and peer review Not commissioned; externally
peer reviewed.
Open Access This is an Open Access article distributed in
accordance with the Creative Commons Attribution Non
Commercial (CC BY-NC 3.0) license, which permits others to
distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided
the original work is properly cited and the use is non-
commercial. See: http://creativecommons.org/licenses/by-nc/3.0/
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Original research
Tako AA, et al. BMJ Qual Saf 2013;0:19. doi:10.1136/bmjqs-2013-002107 9
group.bmj.com on July 21, 2014 - Published by qualitysafety.bmj.com Downloaded from
doi: 10.1136/bmjqs-2013-002107
published online September 19, 2013 BMJ Qual Saf
Antuela A Tako, Kathy Kotiadis, Christos Vasilakis, et al.
simulation study of an obesity care service
Improving patient waiting times: a
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