www.rcem.ac.uk/WinterFlow

RCEM Winter Flow Project Final Report: July 2019

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Introduction

In 2015, we launched the ‘Winter Flow Project’ in an effort to

highlight the difficulties facing an NHS struggling with

unprecedented financial difficulties and insufficient resources.

The project looked at patient flow within Emergency Departments over

the winter. It was a great success because of the generosity of its

contributors, with over 50 NHS Trusts and Health Boards from across

the UK submitting data over a six-month period. This data helped to

provide a better understanding of system pressures and four-hour

standard performance.

The findings enabled RCEM to broaden the debate around

emergency medicine and meant that providers, commissioners, the

national press and governments in each of the four nations of the UK

were better informed about the challenges faced by staff working on

the NHS frontline.

The project has proven invaluable and is now in its fourth year. As

was the case in previous years, each participating Provider has

submitted weekly data on attendances, four-hour standard

performance, delayed transfers of care and cancelled elective

operations. For the second year we have also asked participating

Providers how many locum and agency staff are working in their

Emergency Departments.

The data is aggregated to ensure the focus of consideration is the

wider health care system rather than the performance of individual

Trusts/Boards. Over 50 Providers have submitted this data on a

weekly basis since the beginning of October.

Published on a Friday of the week following data collection, the

summary data provide a current overview of ‘winter pressures’.

The College is grateful to the participants who represent Trusts/

Boards of all sizes and geographical locations.

Unlike NHS England datasets, there is no suggestion that our project

represents a complete or permanent scrutiny of the healthcare

system. Our data include all four countries of the UK though the

majority of participating sites lie within England. It is just a sample of

Trusts/Boards, albeit a large and representative one.

The data has already been of immense value to the College and

allows informed comment and analysis rather than just speculation.

The project has now reached its end point for 2019 (26 weeks) and it

is therefore timely to present the data and our findings.

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Summary Findings - What Happened This Winter?

There was a continued deterioration of four-hour Emergency Care

system performance in the UK compared to previous years and was

the worst on record overall. 54 sites each contributed 26 consecutive

four-hour performance scores. The range of performance against the

standard was 50.66% to 99.74%, with an overall average of 80.75%.

Hospital systems improved the proportion of patients with Delayed

Transfers of Care (DToC) compared to the previous winter. For the 54

contributing Providers the proportion of bed stock tied up by DToC

cases of 5.2% is almost identical to that of the previous year of 5.3%.

A total of 68,356 elective operations were cancelled over the 26 week

period. The weekly number of cancellations for 2018-19 is higher than

was the case in 2015-16 (1491) and 2016-17 (2398) but lower than

the number declared in 2017-18 (3410).

However, this may not actually be a fair reflection of the facts on the

ground. Even though our data definition has remained the same since

2015-16, a number of project contributors have experienced

sustained difficulties this year in reporting against this metric and full

compliance in many cases was not possible. As a result, the number

of cancellations – while already high by historic standards – may be a

significant underestimate.

The number of locum staff employed on the front-line increased by

around 18.77%. This is the same pattern as was observed last year.

However, it is worth noting that the numbers of such staff started from

a higher point (602 compared with 524 in 2017-18) and continued to

grow. This bears out the vacancy data published by the NHS in

England which has seen a steady increase in the number of

Emergency Medicine vacancies since 2015-16.

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Contributors

54 locations contributed to the project. The nation analysis

of contributors is as follows:

As an indication of size, the bed capacity of the contributing sites

ranged from 160 to 1,595.

The five measures reported on a weekly basis were:

• Four-hour performance

• Acute Bed stock

• DToC instances

• Cancelled elective operations

• Locum numbers (qualified doctors and nurses)

Four-Hour Standard Performance

54 sites each contributed 26 consecutive four-hour performance

scores. The range of performance against the four-hour standard was

50.66% to 99.74%, with an overall average of 80.75%. The overall

weekly trend was as follows:

England Scotland Wales Northern Ireland

45 1 5 3

Winter Flow Project 2018/19 Final Report

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Three sites achieved an average of 95% or more four-hour

performance over the 26-week period and one site achieved 95% or

more every week.

The following chart plots the distribution of performance by ED with

the overall average.

The chart below shows the number of locations achieving the 95%

target compared to a 90% performance level on a weekly basis.

This illustrates that the proportion of providers able to maintain

performance of, at or above 90% is now firmly in the minority, and

these figures are a deterioration on the results of the previous year.

Winter Flow Project 2018/19 Final Report

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Comparing the maximum, the minimum and average four-hour

performance of the total population shows the following results:

The chart given below gives four-hour standard performance over the

three years the project has been running.

Winter Flow Project 2018/19 Final Report

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If the performance for the first and second halves of the Winter Flow

programme years to date are compared, it can be observed from the

following table that the 2018-2019 performance is similar to that of the

previous winter. Once again there has been no recovery in the

January to March period after the pre-Christmas decline.

It is noticeable that for the past two years the January to March

performance has been around 79%. It should also be pointed out that

– if only by the narrowest of margins – performance from January to

March was an improvement on the previous year although this proved

insufficient to prevent a continued year on year decline in four-hour

standard performance.

These figures can also be expressed by adjusting the previous years’

figures to a common start point. In this way the relative performance

may be compared over the four years. This is shown below:

Average Score Oct-Dec Jan-March Overall

2015/16 88.15% 83.50% 85.83%

2016/17 81.95% 82.01% 81.98%

2017/18 83.41% 79.02% 81.21%

2018/19 82.41% 79.09% 80.75%

Winter Flow Project 2018/19 Final Report

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This gives us an indication of the volatility of four-hour standard

performance for 2018-2019 being much lower than in previous years.

This can be shown mathematically by calculating the standard

deviation, that is, the amount by which the members of the group

differ from the mean value for the group.

When considered in these terms we can see that four-hour standard

performance has remained closer to the overall mean performance

than in each of the previous years. On one level this is a helpful

conclusion because it shows that it is possible to achieve consistent

performance at this or other levels of four-hour standard compliance.

However, it also shows that the system has little or no capacity to

respond to changes in demand in ways that also result in a recovery

of performance.

Year Mean % Standard

Deviation

2015/16 85.83% 13.41

2016/17 81.98% 14.10

2017/18 81.21% 18.52

2018/19 80.75% 12.59

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Acute Bed Capacity

The overall profile of bed stock over the period was as follows.

The y axis of the graph has been selected to carefully illustrate the

weekly movement. However, this masks the fact that the maximum

(week 19) is only 3.9% higher than the lowest point (week 12).

Acute Bed Stock Flexing

The extent to which the individual participating sites flexed their bed

stock (minimum to maximum) to meet demand is shown below.

In order to compare the changes in acute bed stock over the four

Winter Flow projects the results may be presented calculated from a

common starting point as below.

It may be observed that in 2018-19 capacity was reduced to a greater

extent in weeks 1 to 13 than in previous years and that less capacity

was returned in weeks 14 to 26. This again helps to illustrate that

while four-hour standard performance may have been remarkably

stable in the second half of this year’s project (at around 80%) this is

in part because the resources made available to hospitals to

accommodate their patients had in reality little capacity to respond to

demand, and less than we have seen in previous years. No flexing 0 - 5% 5 - 10% 10 - 15% 15%+

Number

of sites 2 17 16 11 8

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Delayed Transfer of Care – DToC

The overall picture was as follows:

The chart below demonstrates that the proportion of bed stock tied up

by DToC cases of 5.2% is almost identical to that of the previous year

of 5.3%.

Winter Flow Project 2018/19 Final Report

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Cancelled Elective Operations

The overall picture was as follows:

This represents a total of 68,356 cancelled elective operations over

the 26 week period.

The definition of an elective cancellation has remained the same for

the four years of the Winter Flow Project’s operation. This is:

‘The number of cancelled elective operations should

include both those that are cancelled in advance and those

that are cancelled on the day they are due to take place – in

patients and day cases – all irrespective of reason. It must

only exclude those which are cancelled by patients.’

In this way we endeavour to provide a patient facing indicator as well

as a measure of cancellations in response to demand pressures on

bed capacity. If we compare the average of declared elective

cancellations as part of the Winter Flow Project in each of the last four

years the results are as follows:

On this basis you can see that the number of elective cancellations for

2018-19 is higher than was the case in 2015-16 and 2016-17 but

lower than the number declared in 2017-18.

However, this may not actually be a fair reflection of the facts on the

ground. Even though our data definition has remained the same since

2015-16, a number of project contributors have experienced sustained

difficulties this year in reporting against this metric and full compliance

in many cases was not possible. As a result, the number of

cancellations – while already high by historic standards – may be a

significant underestimate.

Year Average Weekly Cancellations

2015-16 1491

2016-17 2398

2017-18 3410

2018-19 2627

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Locums Engaged – Qualified Doctors and Nurses

The overall picture was as follows:

What this shows is that, beyond the expected dip in locum numbers

around the Christmas period, the number of locum and agency staff

employed within the Winter Flow group increased steadily over the

duration of the project.

This is the same pattern as was observed last year. However, it is

worth noting that the numbers of such staff started from a higher point

(602 compared with 524 in 2017-18) and continued to grow. This

bears out the vacancy data published by the NHS in England which

has seen a steady increase in the number of Emergency Medicine

vacancies since 2015-16.1

1 NHS Vacancy Statistics England - February 2015 to September 2018

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However, as you would expect, the number of locum doctors and

nurses has varied from provider to provider. This is illustrated by the

following chart.

Similarly, the overall increase in locum resource was not seen

uniformly across each location. In fact, over the duration of the project

we have seen a mixture of reductions, no movement and increases.

Rather like data available from bodies like NHS Benchmarking, this

illustrates the considerable variation in resources and staff shortages

across the NHS.

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In many ways the four-hour standard performance data recorded

by the Winter Flow Project this year is nothing short of

remarkable.

While there is no getting away from the fact that routinely recording

performance of around 80% speaks of staff working in challenging

environments with patients and staff placed at the ‘highest level of

risk’2, given that NHS England have recorded an increase in Type 1

ED attendances of 6.42% compared with quarter 4 of the previous

year3 and a 6.95% increase in the number of admissions on the same

basis4, this speaks volumes for the grit and determination of NHS

staff.

But beyond the undoubted application of those working on the front

line, it is worth taking a moment to consider why this happened. In our

Interim report for the Winter Flow Project this year we pointed out that

with consistently poor levels of performance against patient flow come

consistent consequences for patients; most notably, from the

available NHS data, the number of patients delayed for more than four

hours from decision to admit to admission.5 Here it is possible to make

the opposite point; with consistent levels of available resources come

consistent levels of performance.

What is notable from this year’s figures both from NHS England6 and

the Winter Flow Project is how consistent they are. The number of

overnight beds in England has seen its smallest like for like quarterly

decrease since 2010 (202 - a 0.16% change).7 This is set against a

backdrop where the proportion of patients subject to Delayed

Transfers of Care has continued to decline. Winter Flow reported

DToC as a proportion of bed stock as 5.10% from January to March

compared with 5.45% in the same quarter of the previous year. The

same figures for NHS England show 4.23% for quarter 4 2017-18 and

3.43% for quarter 4 2018-19.8

This alongside the welcome effects of a mild winter have meant that

the incidence of flu has been significantly lower than last year,9 and

we have seen the lowest number of average weekly bed closures due

to norovirus since 2014-15.10 These things taken together have meant

that for the first time since 2013-14 the percentage of acute bed

occupancy was lower than had been the case at the same point the

previous year (91.70% in quarter 4 2018-19 compared with 92.60%

the previous year).

From this combination of factors has come performance that has

been remarkably stable (five scores of between 80% and 81% in the

latter thirteen weeks of Winter Flow) and virtually unchanged from the

previous year. From January to March Winter Flow recorded Type 1

four-hour standard performance of 79.09% compared with 79.00% the

previous year. NHS England in the same period recorded scores of

77.20% compared with 76.80% the previous year.11

What this shows is something that we have argued consistently since

the Winter Flow Project began in 2015-16. That far from being

impossible, as was the case between 2004-5 and 2012-13, it is

perfectly possible to achieve full compliance with the four-hour

standard, given the correct level of physical resources that those

working on the front line need to do their jobs.

If it is possible to achieve stable performance at or below 80% – with

all the patients languishing in corridors that that entails – then it is

equally possible to achieve the same stability around 95% and

Further Analysis

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eradicate the spectre of corridor medicine. These are practical realities

and it is a political choice not to do so.

What this suggests is that our expectations of the NHS England

Clinical review of NHS access standards12 should be limited. However

well intentioned, while a change in ED flow metric may or may not

succeed in changing behaviour, it will not improve the practical realities

of waiting or working in an Emergency Department for the vast majority

of patients or staff.

For example, the chart given below shows the actual number of

patients in England who spent more than 12 hours in an Emergency

Department from arrival to departure. The data has been calculated as

the ‘duration to departure’ and NHS Digital count all unplanned ED

attendances where the duration to departure is greater than 720

minutes.13

What this shows is that between 2011-12 and 2017-18 there was a

477% increase in the number of patients stranded in an Emergency

Department for more than 12 hours. It is also worth stating that a

similar picture can be observed in each of the nations of the UK.14

While some of this might be explained by flow metrics – and remember

that in this time the four-hour standard has not changed – it is just not

plausible to suggest that problems with the standard explain

deterioration of this magnitude.

What has changed since 2011-12 is that the number of elderly and

otherwise vulnerable patients has increased while the number of beds

to put them in has decreased by just over 7000.15 To improve

Emergency Medicine in the NHS we need to address this reality, not

just change the way that reality is measured.

Recommendation

The College is aware that the NHS clinical review of NHS access

standards may lead to a refocusing of the way that 12 hour waits are

measured in England. The College takes the view that this should be

consistent with the way this is measured in the rest of the UK; that

being from the moment of arrival to the moment of departure.

Further Analysis

2 Improving safety in the Emergency Department this winter 3 NHS England Quarterly time series 2004-05 onwards with Annual March 2019 4 NHS England Quarterly time series 2004-05 onwards with Annual March 2019 5 Winter Flow Interim Report - October 2018 to December 2018 6 NHS England Quarterly time series 2004-05 onwards with Annual March 2019 7 NHS England Bed Availability and Occupancy Data – Overnight 8 NHS England Delayed Transfers of Care Data 2018-19 9 Public Health England Annual Flu Report: Winter 2018-19 10 NHS England Winter Daily Sitrep Reports 11 NHS England Quarterly time series 2004-05 onwards with Annual March 2019 12 NHS England Clinical review of NHS access standards 13 NHS Digital Hospital Accident and Emergency Activity, 2017-18 14 https://www.health-ni.gov.uk/articles/emergency-care-waiting-times & https://www.isdscotland.org/Health-Topics/Emergency-Care/Publications/index.asp & Stats Wales 12 hour waiting times 15 NHS England Bed Availability and Occupancy Data – Overnight

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© The Royal College of Emergency Medicine 2019