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Variation in end-of-life workload

Article  in  British Journal of Health Care Management · January 2018

DOI: 10.12968/bjhc.2018.24.1.48

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An edited version of this article has been published as Jones R (2018) Variation in end-of-life
workload. British Journal of Healthcare Management 24(1): 48-50. Please use this to cite.

Month-to-month variation in
end-of-life workload and
costs
Dr Rodney P Jones (ACMA, CGMA)
Statistical Advisor, Healthcare Analysis & Forecasting, Worcester, UK
hcaf_rod@yahoo.co.uk

For further articles in this series go to: http://www.hcaf.biz/2010/Publications_Full.pdf

The published version can be obtained via an NHS Athens Login from www.bjhcm.co.uk

Key Points

• The absolute number of deaths serves as a proxy for end-of-life workload

• The last year of life accounts for around half of a person’s entire acute utilization
• Month-to-month volatility in deaths is very high
• January usually shows the highest increase relative to December
• December shows the highest volatility over a 17-year period while March shows the least
• The use of annual average in financial and capacity planning omits the reality of seasonal
profiles and their high associated volatility

Over the past months the ‘Money Matters’ series has been exploring the fundamental issues
surrounding uncertainty in STP workload and costs. Most STPs work on annual averages, and show
little understanding of the fundamental principles behind budgetary and workload risk. As has been
pointed out previously, the last month of life constitutes a period of intense community and acute
workload.

While end-of-life does not drive all demand, it is best to view the situation in this way. There is an
underlying level of elective and non-end-of-life demand, and on top of this sits the marginal changes
in demand which arise from end-of-life care and its sensitivity to the environment. In addition, the
same forces acting to trigger final decease also appear to trigger non-end-of-life emergency
admissions. In both instances death acts as a good proxy for workload and costs.

So, what are the factors regulating variability in deaths? Firstly, is temperature (see review by
Ekamper et al 2009), with fewest deaths occurring around 17 C and 30% more deaths at-4 C and 25
C respectively, i.e. extreme heat is more deleterious than cold. Temperature variation is therefore
important, and, for example, the average monthly temperature in central England in January can
vary between 1 and 7 C, while the day-to-day variation in temperature in January can be extreme
with up to a 10 C difference possible (Jones 2013). The effect of temperature on human mental and
physical condition is also an important factor in attendances at the emergency department for
accidental injury (Ma et al 2016). Next is the presence of common winter infections which mostly
peak around late-December and January (Fleming et al 2005)……. truncated due to copyright
An edited version of this article has been published as Jones R (2018) Variation in end-of-life
workload. British Journal of Healthcare Management 24(1): 48-50. Please use this to cite.

Figure 1: Month to month differences in deaths in England and Wales, 2014 to 2017

26%

21%

16%
Change to previous month

11%

6%

1%

-4%

-9%

-14%

-19%

-24%
Mar-14
May-14

Mar-15

Jan-16
May-15

Mar-16
May-16

Mar-17
May-17
Jan-14

Nov-14
Jan-15

Nov-15

Nov-16
Jan-17
Jul-14
Sep-14

Jul-15
Sep-15

Jul-16
Sep-16

Jul-17
Footnote: Monthly deaths are from the Office for National Statistics,
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/monthl
yfiguresondeathsregisteredbyareaofusualresidence

Figure 2: Change in deaths in England and Wales compared to the previous month over the 17-
year period, 2000 to 2017

37%
Jan Feb Mar Apr
Change relative to previous month

May Jun Jul Aug

27%
Sep Oct Nov Dec
17%

7%

-3%

-13%

-23%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Footnote: Change in February and March has been adjusted to account for only 28/29 days in February.
Monthly deaths are from ONS, as in Fig. 1.
 An edited version of this article has been published as Jones R (2018) Variation in end-of-life
workload. British Journal of Healthcare Management 24(1): 48-50. Please use this to cite.

Figure 3: Range in the month-to-month percentage difference in deaths over a 17-year period,
2000 to 2017

34%
Maximum
Median
24%
Minimum
Range over 17 years

14%

4%

-6%

-16%

-26%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

In conclusion, the volatility associated with deaths is, and always has been high (Jones 2012b), and
implies far greater pragmatism around staffing and costs. The implied flexibility in staffing is high,
which is one of those “too difficult to touch” areas that politicians and government agencies have
shied away from addressing, leave it to purchasers and providers to carry all the risk and all the
blame. Welcome to the real world!

References

Beeknoo N, Jones R (2016) A simple method to forecast next years bed requirements: a pragmatic
alternative to queuing theory. British Journal of Medicine and Medical Research 18(4): 1-20. doi:
10.9734/BJMMR/2016/29518

Ekamper P, van Poppel F, van Duin C, Garssen J (2009) 150 Years of temperature-related excess
mortality in the Netherlands. Demographic Research 21, Article 14, 385-426. DOI:
10.4054/DemRes.2009.21.14

Fleming D, Elliot A, Ngujen-Van-Tam J, et al (2005) A winter’s tale: Coming to terms with winter
respiratory illnesses. Health Protection Agency. https://www.avogel.co.uk/conference2015/Fleming-
D-M-2005.1.pdf

Jones R (2004) Financial risk in healthcare provision and contracts. Proceedings of the 2004 Crystal Ball User
Conference, June 16-18th, 2004. Denver, Colarado, USA. http://www.hcaf.biz/Financial%20Risk/CBUC_FR.pdf

Jones R (2012a) Why is the ‘real world’ financial risk in commissioning so high? BJHCM 18(4): 216-217.

Jones R (2012b) End of life care and volatility in costs. BJHCM 18(7): 374-381.

Jones R (2013a) Environmental volatility and healthcare costs. BJHCM 19(4): 198-199.

Jones R (2013b) What every GP needs to know about financial risk in commissioning. General Practice Online
http://www.priory.com/family_medicine/GP_commissioning_risk.htm

Ma P, Wang S, Fan X, Li T (2016) The impacts of air temperature on accidental casualties in Beijing,
China. Int. J. Environ. Res. Public Health 2016, 13, 1073; doi:10.3390/ijerph13111073

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