Illustrating the impact of COVID-19 on clinical service provision
Peter Barwick - 24 November 2021
The Autumn 2021 edition of Rotamap's benchmarking data packs have been sent out to our client departments. These include reports which illustrate trends and variability in rostered activity, the impact of leave, and the use of additional paid shifts over the last year.
Rotamap examined trends in this data for our 2021 Autumn forum, forming the basis of this article. Videos of the event and this talk are available on the event page.
The last 18 months have seen drastic variation to the provision of clinical work due to COVID-19, and in the face of very challenging operational demands, departments have had to frequently re-evaluate and redesign their operational rotas.
During this 18 month period, the weeks with the highest number of active COVID-19 hospitalisations are where the largest disruption to service provision would be expected, given the increase in physical and staffing resource required to treat these additional patients.
Through this uncertain period, a large variety of approaches were taken by different departments to coordinate in the face of differing local conditions. For example, in some cases departments would remove all planned patterns of activity in favour of completely ad-hoc working arrangements, whilst others would adjust existing working plans week to week.
Taking different rostering approaches into account, Rotamap have created the analysis below to illustrate the change to the provision of clinical work over this period.
Where does the data in this article come from?
This article will examine anonymised data on delivered clinical activity, as recorded by departments using Rotamap's CLWRota and Medirota rostering software.
The data on active COVID-19 hospitalisations was taken from official UK government statistics.
The information on delivered activity was taken from summarised, anonymous rostering data of 160 anaesthetic departments, and are presented in a stacked line graph format. The data points are the delivered sessions of work for each calendar week - the weekly throughput of clinical activity of each department.
All of the graphs on this page are interactive. For example, interacting with the legend will show or hide lines, hovering over or touching the lines will show specific data points for that week, and selecting an area of the chart will zoom in to that section.
The weekly delivered sessions of clinical activity can be separated into four categories to show how this activity was resourced.
The categories of work are:
- Normal: Sessions of work delivered by contracted staff through job-planned availability.
- Solo: Sessions of work delivered by trainee staff acting as consultants.
- Extra: Sessions of work delivered by staff in addition to their contracted time, for additional payment.
- Locum: Sessions of work delivered by non-substantive agency staff for additional payment.
Data for both the pre- and post-pandemic period will be used to illustrate changes in service throughput and resourcing through the COVID-19 pandemic.
An additional dashed line has been added to these graphs plotting the delivered clinical sessions for the same calendar week in the year preceding the pandemic.
Comparing these figures is a straightforward means to assess the difference in service throughput in the last 18 months (accounting for normal yearly variation).
The overall change in service provision
Data from all 160 hospitals has been combined to illustrate the collective throughput of service provision, and identifies a clear general trend.
The blue shaded area on this report shows the total number of weekly delivered sessions for these 160 anaesthetic departments together, starting from March 2020.
The dashed line represents the total number of delivered sessions for the same calendar week in 2019.
Comparing the two lines shows the deficit in service throughput in the same calendar weeks before and during the pandemic.
Overlaying the data for the 7 day average of UK-wide COVID-19 hospitalisations illustrates that this change in service throughput does generally correlate with the UK peaks of COVID-19 hospital admissions.
What happened through the last 18 months?
The first major peak in hospitalisations in March 2020 caused an immediate drop in delivered sessions to around one fourth of normal levels.
April to September 2020
The next 6 months saw the weekly delivered sessions gradually climb back towards their pre-pandemic levels as hospitalisations reduce.
October to December 2020
The next three months between October and December saw the total weekly delivered sessions are close to those before the pandemic, despite hospitalisations having started to rise again.
December 2020 to January 2021
The second large peak of COVID-19 hospitalisations arrived at the same time as a general reduction of activity in the Christmas and New Year period. It is notable that the Christmas 2020 reduction in activity is less than that in 2019.
January to May 2021
The first four months of 2021 saw a second drop in UK-wide service delivery as the second major peak in COVID-19 hospital admissions started to decline.
May 2021 onwards
From around May 2021 the total number of delivered sessions was closer to those of the preceeding year, though COVID-19 hospitalisations had started to rise once more in the summer months.
It is interesting to see the general UK-wide trends, however when examining this data on a per-department level, different patterns of response can be seen.
Local changes in service provision
When looking at the change in service throughput on a per-department basis, four general trends can be identified that fit most departments surprisingly well.
The following section is an examination of four anonymous departments that demonstrate these trends, and the possible causes of these changes to service provision are discussed.
Type 1: Two drops in service delivery
The first of the categories had two clear drops in service delivery, a large one in March 2020, and a second smaller dip in January 2021.
In hospitals where this pattern appeared, often there were policies in place that would deliberately reduce planned elective work to ensure that, for example:
- COVID-19 safety protocols such as distancing or self isolation were better followed
- More resources were made available to accommodate COVID-19 hospitalisations; such as beds, equipment and staff
- By reducing clinician contact with non-emergency cases, there was less interruption to emergency service provision; for example through reduced contact and reduced isolation
This matched the overall trend identified from looking at all departments together - that of reduced throughput in line with the rise and falls of COVID-19 cases generally. For these departments it seems that the throughput of work has largely returned to somewhere close to that before the pandemic.
Type 2: Continuing reduced service delivery
The second trend was that many departments had, again, a significant drop of over 75% of delivered sessions for at least one week; followed by a stable return to a far lower total amount of weekly delivered sessions compared to that of 2019. These departments sometimes showed a very gradual trend upwards in delivering more work week to week as 2020 progressed, but still continued to deliver a lower amount of clinical work than before.
Type 3: Low change to service delivery throughput
The third trend was that for some departments, the total weekly delivered clinical activity seemed unchanged. This may be unexpected, especially considering most departments exhibited at least one large drop in clinical activity at some point over the last 18 months. However, this specific department previously had a low throughput of weekly delivered clinical activity of only 60 to 70 sessions per week. Departments that exhibited this behaviour were often quite small, being either specialised services that were not able to reduce their activity(for example Paediatric or other specialist anaesthetic services) or were in smaller or more remote hospitals where the impact of COVID-19 was perhaps not as acute.
Type 4: Two drops, but now overdelivering
The final type of response to COVID-19 pressures was quite similar to our first identified category, where there are two clear drops in service provision - however an important difference is that during 2021 the weekly service throughput starts clearly exceeding that of 2019. In this example throughput was over 35% higher at times. This increase is likely aimed at reducing the overall patient waiting lists that have built up during the pandemic. This trend is unlikely to be sustainable in the long term, if financial support for increasing activity ends, or at the end of the 21-22 leave year if if the supply of annualised sessions runs out.
Comparing these departments
By setting the amount of pre-pandemic delivered work as an expected 100% baseline for each calendar week, the amount of delivered sessions after the start of the pandemic can be compared with this to show the percentage change. This allows us to easily compare these anonymised departments to one another despite their differing sizes.
To compare different example departments, click the legend to show or hide lines.
How was this work resourced?
Looking at the changes to the amount of delivered work and identifying trends in that change is interesting, but it is only part of the story where each individual department is concerned.
Whilst there are four general trends in change to the amount of delivered sessions - the resourcing information can reveal other very different situations.
Type 4: Two drops, now overdelivering
When reviewing the resourcing information for the 'Type 4' department above, it becomes clear that through the turbulent 2020-21 period the department primarily covered all the work through standard consultant job planned sessions – even doing so after the throughput of work exceeded pre-pandemic levels.
This could mean or more of the following:
- The clinicians are delivering more contracted sessions per week to help clear the backlog; perhaps because they have an annualised working agreement, and they did less clinical work in the prior months.
- The department has hired more staff to meet the higher service demand.
The next department may have experienced a very similar change to their throughput of work as the last 'Type 4' department, but they resourced this change in service throughput in a completely different way.
Type 4: Another department - Covering with locum staff
In contrast to the previous example, this department seems to have a much greater difficulty in finding the cover required to deliver work. Up to the end of 2020, a large proportion of the delivered work has been delivered by locum staff and that the proportion of work delivered by contracted consultants was much lower than that of the previous department.
This could mean that:
- The consultant staff in the department were unable to work, increasing the reliance on locum staff, and/or
- The department was understaffed, regardless of the impact of COVID-19.
In 2021, however, a much greater amount of work was delivered by contracted consultant staff; in some weeks reaching 100% of the pre-pandemic throughput. There is a lot of variance to this on a weekly basis, so self isolation or other unpredictable leave may still have been making an impact. On top of this, there has been an increased reliance on Extra sessions, where the contracted staff contributed additional paid sessions to meet this additional demand.
Type 3: Low change to service delivery throughput
This next department had a largely unchanged service provision though the last 18 months. This department is a smaller department providing more specialised care, and as such needed to maintain a consistent throughput of activity.
This was achieved by filling any capacity shortfall with clinicians providing extra paid-for sessions.
Type 3: Another department - Variable delivery, consistent extra spend
This second department, whilst maintaining a level of service delivery close to that of before the pandemic like the previous department, contrastingly has a much more stable proportional use of staff working additional sessions. This suggests that the department manages their service in a different way, such as budgeting a maximum amount of weekly extra expenditure and adjusting the department work plan based on available staff.
Type 2: Sustained lower service delivery throughput
The next two departments did not return their throughput of clinical activity to that before the pandemic.
This first department has used some extra paid sessions over the last 18 months to help increase the throughput of clinical activity, but not to the extent of other departments.
Type 2: Another department - No extra spend
This second department has not used any locum or additional shifts in the post-pandemic period. This may indicate that either the organisation policy does not allow it, or that clinical demand is lower since April 2020. As noted previously, some organisations have closed theatre or clinic spaces in response to the pandemic, so the reduction in throughput clinical work may not be unexpected.
Type 1: Two drops in service throughput
Finally, when returning to the departments with a reduction of overall service throughput that aligns with UK-wide changes to COVID-19 cases, it is again clear that each department's data illustrates unique and interesting characteristics when the details of resourcing are considered.
Type 1: Example 1 - A managed service reduction
This first department is larger than most and has delivered more sessions per week than the others in this artcile. Whilst in the last 18 months service throughput declined, the week-to-week variability was managed quite smoothly. During 2020 a stable amount of additional paid work was delivered proportionally to job planned assignments, with most of the service provision coming from these contracted sessions.
During 2021 almost all of the service was covered without the need for additional paid staffing. This indicates that whilst perhaps the department has the clinicians available to cover a comparible amount of work closer to that pre-pandemic, there is likely less clinical activity to do. This could be due to the trust closing down theatre areas or reducing elective clinics.
Alternatively, this could indicate that there is no appetite or ability within the clinician to work additional sessions, for example due to burnout or illness.
Type 1: Example 2 - Understaffed
This second department, whilst showing a similar general trend of throughput to the last department, resourced itself very differently.
There was a significant staffing shortfall in the latter half of 2020 with the department using a lot of locum cover to meet demand. This seems to have improved in 2021, where there is a higher amount of clinical work being done by contracted staff, and more staff working for additional pay. This is likely more affordable than using agency locums, but it may be unsustainable and it would also be advisable to check if this is an historic pattern due to the department being understaffed.
Type 1: Examples 3 & 4
This department managed to provide a relatively stable amount of sessions through the use of job-planned staff, with the capacity shortfall being made up by extra, paid-for, sessions.
This final department, however, had a far more variable proportion of work delivered by their contracted clinicians which suggests considerable and unpredictable absence through the period. This could be examined further by examining reports on leave and absence.
Data and benchmarking packs
Departments in anaesthetics, surgical and medical specialties which use CLWRota or Medirota will be sent a personalised pack shortly after the publication of this article.
These packs include department-level data and identify each department within its anonymised cohort so that it is easy to compare and benchmark similar departments.
The benchmarking packs include a version of the reports above, as well as a number of other charts which illustrate different aspects of service provision.
These packs help depertments compare their activity to their peers to enable better planning, resourcing, and improvements to operational strategies.
Benchmarking data for October 2021 can be seen here.
The data that is available in our CLWRota and Medirota services reveals four general trends of how departments have coped over the last year and a half.
However, it is clear that every department has their own individual set of challenges that become more discernible once the the details of each department's resourcing is analysed.
It is important to remember that this data and graphs serve as a means of illustrating a department's experiences and do not tell the whole story.
It is likely that departments that show stable performance are better to work in and collaborate with, providing better work/life balance for clinicians and better patient care.
Hopefully this article has gone some way to explaining what these charts represent and how to interpret them, and will empower clinical teams to use the data from their benchmarking packs to effect positive change within their department or organisation.
Further reading: COVID-19 impact across the UK
Rotamap has previously reported on the impact of COVID-19 on our UK client hospital departments, and updated that analysis in April 2021. These articles examined trends in the amount of sick leave, the amount of cancelled sessions or the relative increase in work that is done out of hours, to further examine the impact of the pandemic.
-  GOV.UK - Daily and cumulative numbers of COVID-19 patients admitted to hospital. Data retrieved November 2021.
If you have any questions about your department's benchmarking pack or about the data above, please contact the Rotamap support team at firstname.lastname@example.org or +44 (0) 20 7631 1555.