agenda item: 15 paper no: 13 appointment activity

Primary Care Commissioning Committee Part One / 11/09/2020 / Appointment Activity and OPEL Framework

Title of Report: Appointment Activity & Operational Pressures Escalation Levels (OPEL) Framework

Status: TO NOTE

Committee: Primary Care Commissioning Committee Part 1

Date: 11/09/2020

Venue: Virtual Meeting – Microsoft Teams

Presented by: Nikki Mallinder, Associate Director of Primary Care Commissioning and Development

Executive Lead sign off:

Colin Thompson, Surrey Downs Director & Executive Lead Primary Care

Date: 03/09/2020

Author(s): Nikki Mallinder, Associate Director of Primary Care Commissioning and Development

Governance

Conflict of Interest: The Author considers:

None identified

Previous Reporting: (relevant committees/ forums this paper has previously been presented to)

PCOG / Primary Care Restoration & Recovery Group (Regional) / Primary Care Senior Team Meetings

Freedom of Information: The Author considers:

Open – no exemption applies. Part I paper suitable for publication.

Agenda item: 15 Paper no: 13


Executive Summary

NHS Digital has been collecting data from general practice appointment systems and publishing it, collated by CCG area, since 2018. This data has been heavily caveated as General Practice is complex, appointment books are set up differently at each practice and therefore the data has been difficult to do any real comparisons on. It has given us a very high level set of activity data for CCG areas. Over the last 7 months the new technology has supported a more robust way of looking at those appointments that travel through this ‘mode of contact’ and is showing the delivery/demand and pressures that our GP services face. Surrey Heartlands has been working with local providers/regional & national colleagues to support the collection and reporting of GP appointment activity. Having robust data will support us in many ways:

Reporting activity alongside all other providers

Supports the planning of local commissioning arrangements

Escalation status and triggers to support surge Current data shows us that we are delivering about 5 contacts per patient per year and 43-50% of contacts in General Practice is for an ‘urgent’ issue. We have 3 programmes of work outlined in the attached slides: 1. Local appointment data capture 2. National GPAD 3. Development of an OPEL framework Appendix 1- Surrey heartlands OPEL System shows the dominance of other providers in the urgent/same day escalation process.

Implications

What is the health impact/ outcome and is this in line with the CCGs’ strategic objectives?

Better planning of services

Supports periods of surge

Improve patient access

In line with the Long Term Plan

What is the financial/ resource required?

Activity data is required to understand the need/resource

What legislation, policy or other guidance is relevant?

General Medical Services Contract Long Term Plan Primary Care Network DES (ARRS – 50m more appointments) Government Pledge – 50m more appointments in General Practice

Is an Equality Analysis required?

N/A


Any Patient and Public Engagement/ consultation required?

N/A

Potential risk(s)? (including reputational)

N/A

Recommendation(s)

To note the work/

Next Steps

3 programmes of work: 1. Local appointment data capture

Continue to ‘sign-up’ practices

Start to collect and publish data at PCN level 2. National GPAD

8 practices in first wave

Locally driven approach to ‘mapping’ exercise 3. Development of an OPEL framework

2 workshops planned (small group) then socialise with member practices for development & implementation

Nikki Mallinder, Associate Director Primary Care

August 2020

Surrey Heartlands General Practice Appointment Data &

OPEL Reporting

GP Appointment Data

Improving the quality of GP Appointment Data has been identified as a clear priority through the Primary Care Restoration and Recovery Board. Working with system

colleagues in both the SO1 and SO2 working groups and the national GP Appointment Data Programme team, a clear problem statement has been defined and key

initiatives identified to drive this work, both in the short term to support winter/second wave planning and in the longer term to tackle the underlying data quality issues.

National GP Appointment Data Programme Local Activity, Access and Appointment review

• New national appointment categories have been developed to allow for more

accurate and standardised reporting on primary care activity.

• Practices will be expected to map their appointment types to these new

categories – will become a contractual requirement in April 2021.

• Having completed the early beta phase, national programme leads have agreed

to partner with the South East region as early adopters, with the first cohort of

practices identified to pilot the categories in early September.

• SE region will work with national colleagues to shape support offer for practices

to enable full roll out, inc. testing technical and practice level implementation

guidance and identifying additional business change support required

• Timeframe: Kick off with early adopters in Sept. Full deployment by Apr ‘21.

Practice Input: Sign Up & <45 minutes one-off mapping exercise

• Short term tactical data capture being trialled in Surrey Heartlands to record

outcome of appointment/consultation (Face to Face, Telephone Call, SMS, Visit

etc) to allow STP wide standardised reporting.

• Whereas previously there have been challenges reporting at scale due to

inconsistent appointment types between practices and the option to leave the

appointment type on default when entering on to the clinical system, this will

allow for an accurate, STP wide snapshot of activity for the first time.

• Dataset will inform local planning as well as the work at a regional level to

develop a data driven capacity and demand model for general practice (SO1).

• Timeframe: EMIS tool just needs to be switched on in all practices, local primary

care teams will support practices to do this and this will give us data sets NOW

to support an OPEL system in General Practice .

Practice Input: Tick 2 boxes at the end of every consultation

Future Vision: In the future, primary care will be able to access timely and accurate demand data, allowing for effective resource planning and the

safe operational management of any escalating pressures resulting from either a surge in demand or depleted capacity. At a regional level, NHSE/I will

be able to clearly quantify the demand on our primary care systems, highlighting where systems may be under-resourced and supporting the delivery

of effective demand and capacity planning to ensure a safe, sustainable and high-quality primary care service.

Short term tactical solution to support planning Longer term strategy to tackle data quality

Surrey Heartlands General Practice OPEL Reporting

C-19 Outbreaks

• Rise in symptomatic

• Utilising Surrey Heartlands Early Warning Sign

Data to produce map local outbreak areas

• GP Consultation data

• Online Consultation – change from baseline in

footfall request number that may be cause for

concern

• Practice Closures due to outbreaks/workforce/deep clean

• 111 Contacts about COVID

Workforce - Reporting through the National

absence tracker:

• At present, GP/ AHP absences are tracked through the

national reporting tool - https://nwcat.azurewebsites.net/ • Using this data the capacity in general practice can be

modelled for both GP and AHP

• Further considerations need to be taken into account in

the trigger metric

• FTE/ Headcount

• Practices with a sole GP

• Practices with workforce over 65/at risk

Assumption of 90% staffing levels for safe practice – due to

the capacity always being affected by capacity detractors,

for example Staff Annual Leave, Study Leave or Sick

Leave

Utilisation - Appointment capacity / demand

Now:

• Based on a widely accepted formula of 72 appointments

per 1,000 patients each week

• Footfall request

Medium Term:

• Clinical System Protocol

• Weekly data grab

Long-term:

• National data extraction

• Extraction in real time

3

Proposed Opel Triggers Metrics

Unexpected Events

• In the event of Extreme Weather, Fire or Flood

• Can practices still able to function or has it causes practice closures and

diversion of services

4 Infection Control

• GP Reports, Anecdotal Reports, Care Homes

• Local Outbreaks (non COVID) – e.g. Norovirus in multiple community settings

5

https://nwcat.azurewebsites.net/

SH ICS Escalation Plan: Operational Surge Page 1 of 39

Surrey Heartlands

Operational Pressures Escalation Levels System Plan

Version 1 October 2019 In association and in conjunction with our system partners:

Guildford Waverley Integrated Care Partnership (ICP)

North West Surrey ICP

Surrey Downs ICP

East Surrey ICP

South East Coast Ambulance Service NHS Foundation Trust

Surrey and Borders Partnership- NHS Trust

Care UK

NHS England South (South East)

INVOCATION OF THIS PLAN

This plan should be used by system partners in managing OPEL levels and for referring to expectations of requirements when the system, or part of the system changes an OPEL level. The overall system level will be determined by the ICP Partners and this will determine the overall ICS OPEL level.

1. Document Control


Version 5.1

Name of Document

Surrey Heartlands ICS Escalation Plan; Operational Pressures

Version Date October 2019

Owner Karen Thorburn Integrated Care System (ICS) Director of Performance

Author(s) GWCCG Head EPPR and Business Support GWCCG Surrey Heartlands Head of Urgent Care

Next Review September 2020 by document Authors

GPMS OFFICIAL - SENSITIVE

Document Location

TBC

Purpose

Purpose To improve patient experience by documenting the processes, systems and expectations for all constituent ICP system partners within the Surrey Heartlands ICS. It details how the ICS will respond to operational pressures. This includes management escalation levels, and the agreed proportionate response at both as an ICP and as an ICS l with extended stakeholders..

Significant change summary since last version Version 1 Drafted by Ben Hill Mark Twomey Version 2 Review from Karen Thorburn and Jackie Raven Version 3 Review from Ian Thompson, Felicity Govas and Jamie Hogg Version 4 Ben Hill Jackie Raven drafted action cards. Version 5 Ben Hill added Sections 10 and 11 and review by Felix Wright. Version 6 Review; Craig McGowan. Version 7 Review by Katy Neal Beverley Kendrick, Sara McMullen Version 8 Review of ICP and ICS TOR and final read Jackie Raven and Ben Hill Version 9 Update of system call TOR added sections mental health and Paediatric escalation

Distribution and Accessibility This document will be made available to all staff via system e-mail groups and will also be placed on Resilience Direct The document and any revisions will additionally be e-mailed to all on-call staff.

Author Contact Details Ben Hill Surrey Heartlands Head of Urgent and integrated Care [email protected]

Mark Twomey Surrey Heartlands Head of EPPR and Business Support [email protected]

Contents

mailto:[email protected]



1. Document Control .................................................................................................. 1

2. Equality Statement ................................................................................................. 3

3. Purpose of this Document ...................................................................................... 4

4. Definitions .............................................................................................................. 5

4.1 Operational Pressures Escalation Levels ........................................................... 5

4.2 Declaration of Major, Business Continuity and Critical Incidents ........................ 7

5. Governance ............................................................................................................ 8

5.1 Expectations ...................................................................................................... 8

5.2 Whole system risks ............................................................................................ 8

6. Roles and Responsibilities...................................................................................... 9

6.1 Local A&E Delivery Board ................................................................................. 9

6.2 Determination of System (ICP) Level ............................................................... 13

6.3 Determining ICS OPEL Position. ..................................................................... 13

6.4 Process for Triggering ICP OPEL 4 status .................................................... 14

6.5 Escalation process ........................................................................................... 15

6.6 Mitigating actions at each level ........................................................................ 16

6.7 Escalation triggers at each level ...................................................................... 19

6.8 Local specific triggers and actions should then be shared and agreed with NHSE/I during assurance in the autumn. ............................................................... 20

7.0 Communications ................................................................................................. 22

7.1 System Calls Conference Call details .............................................................. 22

7.2 ICS System Escalation Calls ........................................................................... 22

7.3 Principles for a successful teleconference: ...................................................... 22

8.0 De Escalation process ........................................................................................ 23

9. Handover / Diverts / A&E closure ......................................................................... 23

9.1 Diverts and ED Closures ................................................................................. 24

10. DOS 111 Escalation ....................................................................................... 26

11. Escalation Beds .............................................................................................. 27

12. Mental Health Escalation (In development) ..................................................... 27

13. Paediatric Escalation (In development) ........................................................... 27

Appendix ................................................................................................................ 28

Appendix 1: The Joint Decision Making Model ..................................................... 28

Appendix 2: Serious Incident (SI) Reporting and Investigation .............................. 29

Appendix 3: SECAmb Divert SOP and Emergency Handover Procedure. ............ 30

Appendix 4: A&E Closure- Governance Flowchart ............................................... 31

Appendix 5 Acute Trust Scoring Matrix .................................................................. 32

Appendix 6: SECAmb Surge Management Plan (SMP) ........................................ 32

Appendix 7: Escalation Status Triggers for Community Services .......................... 32

Appendix 8: System Call TOR and Escalation Report ........................................... 32

Appendix 9 OPEL Framework ............................................................................... 32

Appendix 10 Paediatric Scoring Matrix .................................................................. 32

Surrey Heartlands OPEL Action Card .................................................................... 33

Surrey Heartlands Escalation Call Action Card ..................................................... 38

2. Equality Statement


2.1 Surrey Heartlands Integrated Care System (ICS) aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. We take into account the Human Rights Act 1998 and promote equal opportunities for all. This document has been assessed to ensure that no employee receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. 2.2 Members of staff, volunteers or members of the public may request assistance with this policy if they have particular needs. If the member of staff has language difficulties and difficulty in understanding this policy, the use of an interpreter will be considered. 2.3 We embrace the seven staff pledges in the NHS Constitution. This policy is consistent with these pledges (see link below). https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#staff-your-rights-and-nhs-pledges-to-you

3. Purpose of this Document Emergency care is highly predictable. Demand can be forecast by hour, by day with a high degree of accuracy. Part of this predictability is a degree of normal variation between anticipated limits, both day-to-day and seasonally; organisations can and should plan a response to these changes in demand. Organisations may require some form of surge capacity to deal with highest predictable peaks of demand, as these will only occur periodically. Also, within a year there will be periods where special cause factors create higher than anticipated demand or difficulty m e e t i n g the demand. Examples being heat-wave, snow and sustained cold weather, seasonal and pandemic influenza. All require a coordinated, planned and partnership response to manage and mi t igate the risks these pose, often across organisational boundaries. Both individual organisations and whole systems require surge escalation plans. These specify the actions required at different levels of surge. Surge plans detail how presenting risk is managed to maintain patient safety and experience. An essential element of managing surge and peaks in demand is the ability to communicate effectively and consistently with partner organisations. The expectation being d e c i s i v e action to support and mitigate s u r g e m a n a g e m e n t risk. This document defines clear management escalation activation levels, how these will be communicated to partners, and the thresholds, actions and expectations for escalation and de-escalation at organisational, ICP and ICS levels. In summary, the Plan:

https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#staff-your-rights-and-nhs-pledges-to-you

https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#staff-your-rights-and-nhs-pledges-to-you


Sets out the risks and triggers for escalation

Sets out minimum expectations at each level of escalation

Clarifies roles and responsibilities

Sets consistent terminology / definitions

Defines communication processes e.g. through agreed ICP and ICS System Call Terms of Reference.

This Plan is not a replacement for accurate demand predictions, sound operational processes, or adequate capacity at key stages of individual patient pathways. Individual organisations are expected to use available tools to forecast demand and manage capacity. Normal day-to-day variability must be managed without the need for escalation. With sound prediction and organisational management, escalation should not be required. Should elements of this plan be considered useful in preventing escalation, agreement at ICP level is required. A&E Performance is one measure of a whole health and social care system. It highlights areas experiencing service demand pressures., but it is not the only one. An A&E department could be experiencing isolated difficulties, but the rest of the system is coping well; there are sufficient beds available and there is good flow through the system. Alternatively, an A&E could be managing well whilst the rest of the hospital, and the wider system; community beds, community services and social care are experiencing high pressures due to a lack of capacity. The highest level of alert (OPEL 4) should be reserved for when an ICP system, the whole, system has no identified flow; nor is the system able to identify how flow might be re-established within the following 4 hours.

Due to the above, an ICP system on OPEL 4 will require extra – ordinary responses, this may include an ICS Exe to Exe system call; should another ICP system also be in or at risk of high escalation OPEL 4.

4. Definitions

To enable Local Accident and Emergency Delivery Boards (LAEDB) to align escalation protocols to a standardised national framework. The framework has been built on work completed at regional level. The National Framework escalation levels mirror systems already in use around the UK like the ambulance national Resource Escalation Action Plan (REAP). SECAmb Surge Management Plan (SMP) is based on the national REAP framework. The Operational Pressures Escalation Levels (OPEL) is used by acute and community providers, primary care and adult social care in England. It should be noted that OPEL status is not determined by a single factor, but a combination of risks. These are described below.

4.1 Operational Pressures Escalation Levels

Operational Pressures Escalation Levels


OPEL 1

Four-hour performance is being delivered. The local health and social care system capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. The Local A&E Delivery Board area will take any relevant actions and ensure appropriate levels of commissioned services are provided. Additional support is not anticipated.

OPEL 2

Four-hour performance is at risk of falling below 80%. The local health and social care system is starting to show signs of pressure. The Local A&E Delivery Board will be required to take focused actions in organisations showing pressure to mitigate the need for further escalation. Enhanced co-ordination and communication will alert the whole system to take appropriate and timely actions to reduce the level of pressure as quickly as possible. Local systems will keep NHS E and I colleagues at sub- regional level informed of any pressures, with detail and frequency to be agreed locally. Any additional support requirements should also be agreed locally if needed.

OPEL 3

Four-hour performance is being significantly compromised below 80%. The local health and social care system is experiencing major pressures compromising patient flow, and these continue to increase. Actions taken in OPEL 2 have not succeeded in returning the system to OPEL 1. Further urgent actions are now required across the system by all A&E Delivery Board partners, and increased external support may be required. Regional teams in NHS E and I including the Regional Director will be made aware of rising system pressure, providing additional support as deemed appropriate and agreed locally. Decisions to move to system level OPEL 4 will be discussed between the ICP leadership (ICP Director, CEO/Deputies of ICP members). This should also be agreed with the Regional Director, or their nominated Deputy. The National UEC Operations team will be immediately informed by the Regional UEC Operational Leads through internal reporting mechanisms.

OPEL 4

Four-hour performance is not being delivered and patients are being cared for in overcrowded and congested department(s). Pressure in the local health and social care system continues and there is increased potential for patient care and safety to be compromised. Decisive action must be taken by the Local A&E Delivery Board to recover capacity and ensure patient safety. If pressure continues for more than 3 days an extraordinary AEDB meeting should be considered. All available local escalation actions taken, external extensive support and intervention required. Regional teams in NHS E and I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally, and will be actively involved in conversations with the system. The Regional UEC Operations Leads will have an ongoing dialogue with the National UEC Ops Room providing assurance of whole system action and progress towards recovery. The key question to be answered is how the safety of the patients in corridors is being addressed, and actions are being taken to enable flow to reduce overcrowding. The expectation is that the situation within the hospital will be being managed by the hospital CEO or appropriate Board Director, and they will be on site. Where multiple systems in different parts of the country are declaring OPEL 4 for sustained periods of time and there is an impact across local and regional boundaries, national action may be considered.

LAEDB areas will operate Operational Pressures Escalation Level (OPEL) one when operating within normal parameters. At OPEL 1 and 2, operations and escalation wil l continue to managed at organisation and ICP leve l . At OPEL 3 organisation and ICP Executive level involvement is implemented, as agreed locally. ICS leads to be informed. At Pre black (risk of OPEL 4) or OPEL 4 ICS urgent care exec or lead and or strategic on call must be involved.


4.2 Declaration of Major, Business Continuity and Critical Incidents

The NHS England Emergency Preparedness Resilience and Response Framework 2015 defines three types of emergency response: Business Continuity; Critical and Major Incident. Each will impact upon service delivery within the NHS and partners, may undermine public confidence, and require contingency plans to be implemented. NHS organisations should be confident of the severity of any incident that may warrant a major incident declaration, particularly where this may be due to internal capacity pressures, if a critical incident has not been raised previously through the appropriate local escalation procedure

Business Continuity Incident A business continuity incident is an event or occurrence that disrupts, or might disrupt, an organisation’s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed)

Critical Incident A critical incident is any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions.

Major Incident A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented. For the NHS this will include any event defined as an emergency. Surrey Heartlands ICS through its constituent Clinical Commissioning Groups (CCG) is listed as a Category Two Responders (Civil Contingencies Act 2004) and is member of the Surrey Local Resilience Forum (SLRF). The SLRF Major Incident Protocol explains how category one and two responders across the forum partnership will respond and recover from incidents. It details this at a local level and how arrangements link into the National Concept of Operations. This incorporates the relationship, should it be activated, with the Cabinet Office Briefing Room (COBR) and national response mechanisms. It is expected that NHS providers and ICP partners that declare a pre-black OPEL 3 or black OPEL 4 escalation response level, must have exhausted all internal organisational critical and/or business continuity incident actions. When an ICP is declares an OPEL 4 black escalation status, then all ICP partners would be expected to declare an internal critical and/or business continuity incident. Should service demand continue to be challenging, despite having an internal critical and/or

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http://new.surreycc.gov.uk/__data/assets/pdf_file/0017/31805/Surrey-Major-Incident-Protocol-V10.0-Dec-2014.pdf


business continuity incident mitigations in place, then the ICP will give due consideration to escalating the incident to an ICP system-wide Critical Incident. If two or more ICPs communicate a potential or actual OPEL 4 status, this triggers the Surrey Heartlands ICS Strategic ICS System Call. This is Executive-level ICS-wide response and should be prompted to consider whether the situation warrants the declaration of a major incident as defined in the Surrey Local Resilience Forum Major Incident Protocol. The ICS Strategic Call should be assured that if the situation relates to a place based incident that the relevant plans have been activated by the appropriate provider organisations.

5. Governance

5.1 Expectations

Each ICP member organisation of the LAEDB will have arrangements in place to align local procedures to the nationally recognised Operational Pressures Escalation Levels (OPEL). As described in the OPEL Framework see Appendix 9.

Each organisation has responsibility to ensure partner organisations plans dovetail with their own and provide the necessary response at each level of escalation

The LAEDB using outcomes from the annual EPRR Assurance Process ensures individual plans are both fit-for-purpose and support the relevant assurance process. As part of this assurance process, there must be confidence that:-

Plans define how ICP members will notify partners levels of activat ion and escalation in real t ime. This must include context, remedial activities completed and planned, key contacts and timescales for de-escalation.

This is understood by partners.

The level of response required is defined.

5.2 Whole system risks

The highest whole system risks are associated with: Ambulance Trusts. For Surrey Heartlands ICS, SECAmb (not being able to

respond to acutely unwell / injured patients within safe/critical timeframes). Acute Hospital with Emergency Departments. For Surrey Heartlands ICS, not

being able to assess / stabilise acutely unwell patients, especially. in Accident & Emergency and across Critical Care and cancellation of urgent elective care, leading to poorer outcomes, particularly patients on a cancer 62-day or RTT 18-week pathway

The Primary Care sector’s ability to manage workload. In particular, urgent same day activity.

Community and mental health providers bed capacity and resource in community services to meet demand.


The Plan therefore assumes that wider whole-system escalation will be triggered from the escalation status of these organisations as illustrated in Appendix 4 Acute Escalation scoring Matrix. Appendix 5 SECAmb Surge Management Plan Appendix 6 Community Provider Scoring Matrix All organisations can be expected to be under pressure at the highest level of escalation, but action must be focused to mitigate the highest mutual risks. It is therefore assumed that every organisation will undertake the necessary actions required, regardless of their individual “business as usual” processes or priorities, supported by ICP partners.

6. Roles and Responsibilities

6.1 Local A&E Delivery Board Patient experience improves when efficient and safe surge management across health and social care partners is cohesive. This is particularly relevant when partners come together to resolve service demand pressures, taking a system-wide perspective. Health and social care organisations have been working with increasing collaboration to solve short-term surge demands. This has been to the benefit of whole populations and communities. This exemplar of system partnership is valued and should continue. This document fosters and further encourages collaboration across health and social care. This plan places a responsibility on LAEDBs to determine and document activation to OPEL 4 status only when ICP constituent members have enacted all elements of critical incident and business continuity plans.


Local A&E Delivery Boards

Organisation Role/ Responsibility

Local A&E Delivery Board

All providers should:

o Maintain timely updating of local information systems that monitor pressures in their patch o Ensure all trust level pressures are communicated regularly to all local partner organisations,

and communicate all trust level escalation actions taken (e.g. opening escalation beds)

Acute providers should:

o Investigate at a senior (executive or nominated deputy) level the reasons for diverts (last resorts) and identify and apply the lessons to prevent reoccurrence.

o Liaise with local ambulance services over pressure levels affecting EDs and address issues including increased ambulance handover times etc.

ICPs should:

o Keep in touch with the day to day situation across the patch and be aware of any developing

issues. This includes information on community services, mental health etc.

o Maintain oversight of the A&E Delivery Board area (including social care system) and monitor receipt of hot weather / cold weather / flooding alerts and ensure appropriate actions are taken in response.

o Agree the measures taken by partners to address increased demand for NHS services. o Broker agreements across the patch and ensure mutual aid is available if required to re-

balance pressures (e.g. acute and community services). If there is protracted failure to reach a conclusion favourable to patient care, NHSE/I may intervene to help reach a resolution.

o Liaise with bordering ICPs/ CSUs on any issues which may impact upon their own pressures, and advise ALBs if there are any actions that cannot be taken locally in partnership.


o Commission additional resources (beds, staff etc.) and ensure local ICP demand management initiatives are working during times of surge.

o Ensure the NHS 111 Directory of Services (DoS) is kept up to date in respect of any changes to community capacity.

o Ensure a full investigation and debrief takes place following a system-wide escalation to level 4, share findings with all A&E Delivery Board partners, and ensure actions are implemented to prevent reoccurrence.

ICS Performance and Urgent Care Team

Maintain arrangements to review daily pressure across the ICS.

Put a process in place to inform partners of relevant alerts.

Provide advice and guidance to ICP’s on the handling of escalating situations.

Where applicable locally, NHSE/I to be informed of any agreed diverts.

Agree reporting requirements at a local level.

Ensure that communication protocols in reporting to NHSE/I are followed if pressures affecting Trusts outside of the local area are likely to impact across boundaries.

Implement coordination arrangements across Surrey Heartlands as pressure levels increase across

agreed thresholds.

Ensure that ‘lessons learned’ events are held locally and updated plans reflect the actions identified and agreed.

Inform NHSE/I regional operations and communications colleagues of system pressures.

Inform NHSE/I regional teams regarding system-wide escalation to OPEL 3 or 4 and actions being taken.

When the decision to move to OPEL 4 as a system is being considered then the ICP / ICS should escalate and agree with the NHSE/I Regional Director, their nominated Deputy or the Regional On-Call Director and the National Operations Team should be immediately notified of the outcome.


ICS Performance and Urgent Care Team working in conjunction with Joint NHS England/NHS Improvement teams (Regional A&E Delivery Boards)

Provide oversight and coordination to local ICP / ALB teams where system-wide level 4 applies across a number of areas in the region.

Proactively brief and liaise other NHSE/I regions the National Operations Room.

Support local NHSE/I team as required.

ICS to Ensure a full investigation and debrief takes place following a system-wide escalation to level 4,

share findings with all A&E Delivery Board partners, and ensure actions are implemented to prevent

reoccurrence. Overview of OPEL system and actions can be found in appendix 8.


6.2 Determination of System (ICP) Level

The overall ICP system level will be determined and agreed by ICP Partners using the daily ICP System Calls. The expectation is for all providers to determine and agree their system OPEL escalation status jointly. Before its reported to the ICS and NHS England / NHS Improvement.

Level Minimum requirements

One All providers reporting Level One

Two Acute Provider and at least one other provider reporting level two or

More than two Community Providers reporting level two

Three Acute Provider and at least one other provider reporting level three or

More than two Community Providers reporting level three or

One provider reporting a business continuity or critical incident

Four At least one provider has declared level 4 and at least one or more providers have declared Level 3. Or

More than one provider reporting a Business Continuity or Critical Incident

This is not an exhaustive list and other circumstances may also require a level to be declared for levels three and four this will be determined by an Executive Director

6.3 Determining ICS OPEL Position. To determine the OPEL level for the ICS this will be determined by the OPEL level of the four ICPs.

Level Minimum requirements

One All ICP reporting Level One.

Or one ICP on OPEL 2 rest on OPEL 1

Two At least Two or more of the four ICP are declaring OPEL 2.

Or one ICP declaring OPEL 3 with the remaining ICP on OPEL 2 or less.

Three At least Two ICP Are reporting OPEL 3

Or one ICP declaring OPEL 4 but the remainder are on OPEL 2 or less

Four At least two or more ICP declaring OPEL 4.

Or at least one on OPEL 4 with one or more of the remaining three ICP at high risk of escalating to OPEL 4.


6.4 Process for Triggering ICP OPEL 4 status

Should an ICP need to escalate to OPEL 4, the ICS Urgent Care Exec/lead and/or ICS Strategic On Call must be engaged. It must be demonstrated that OPEL 4 escalation is appropriate and that all preventative actions have been taken by exploring all mitigation at an ICP level by holding an ICP system call. Once agreed by the ICS strategic on call/or ICS urgent care exec/lead, the regulator is then informed by the ICS so that further assurance and support can be provided or requested. At ICS level, should two or more ICPs be at or potentially declaring OPEL 4, the ICS will conduct the ICS System Call. Executive representation (or suitably senior deputy) is required for an ICS System Call. Suggested participants include the ICS Director of Performance, ICS Lead/ICS JAO, LAEDB Chair and ICP CCG Executive On Call and CEO, COO or Executive On Call from across ICP memberships. Out of hours this will be decided by the relevant Executives On Call from across ICP and ICS memberships. As WhatsApp is not GDPR complaint. it will only be used to alert partners to an ICS System Call. The focus of an ICS System Call is to ascertain the immediate and foreseeable OPEL status from across Surrey Heartlands stakeholders. It ensures requesting ICPs are at OPEL 4 and acts to assure ICS partners that the ICP has exhausted ALL local critical and business continuity activities and mitigated associated risks in line with agreed parameters. The ICS System Call core group (ICS Lead Director / Executive On Call, ICP CCG Lead Director or Executive On Call, Acute Trust Chief Executive / Chief Operating Officer or Executive On Call) will then decide how support from across the ICS membership can be mobilised to manage increases in service demand and de-escalation of OPEL level. Standardised Agenda and ICS System Call Action Point templates are being formed to serve as a ‘menu of opportunity’ to support ICS System Call decision making. Should an ICP OPEL 4 status be agreed, the ICS Urgent Care Lead will inform regulators, supplemented by direct ICP reporting. The ICP declaring OPEL 4 will, through the LAEDB, complete an ICP System Root Cause Analysis (RCA). The RCA aims to understand how and why mitigations failed to counter increased service demands and what action is required to prevent future OPEL 4 escalations. An important aspect of the RCA will be to describe each ICP’s escalation, pressures and responses during the same period - this will help ensure parity across the ICS and highlight any shared learning. This will be presented to the UECN and then to SOAG. NB: No system can declare OPEL 4 until this process has been completed.

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6.5 Escalation process

Escalation level

Acute Trust (s)

Community Care

Social care

Primary care

Other issues

OPEL One

Demand for services within normal parameters

There is capacity available for the expected emergency and elective demand. No staffing issues identified

No technological difficulties impacting on patient care

Use of specialist units/beds/wards have capacity

Good patient flow through ED and other access points. Pressure on maintaining ED 4- hour target

Infection control issues monitored and deemed within normal parameters

• Community capacity available across system. Patterns of service and acceptable levels of capacity are for local determination

• Social services able to facilitate placements, care packages and discharges from acute care and other hospital and community based settings

• Out of Hours (OOH) service demand within expected levels • GP attendances within expected levels with appointment availability sufficient to meet demand

•NHS 111 call volume within expected levels

OPEL Two

Four-hour performance is at risk

Anticipated pressure in facilitating ambulance handovers

Insufficient discharges to create capacity for the expected elective and emergency activity

Opening of escalation beds likely (in addition to those already in use)

Infection control issues emerging

Lower levels of staff available, but are sufficient to maintain services

Lack of beds across the Trust

ED patients with DTAs and no action plan Capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

• Patients in community and / or acute settings waiting for community care capacity • Lack of medical cover for community beds • Infection control issues emerging • Lower levels of staff available, but are sufficient to maintain services

• Patients in community and / or acute settings waiting for social services capacity • Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) • Lower levels of staff available, but are sufficient to maintain services

• GP attendances higher than expected levels • OOH service demand is above expected levels • Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) • Lower levels of staff available, but are sufficient to maintain services

• Rising NHS 111 call volume above normal levels • Surveillance information suggests an increase in demand • Weather warnings suggest a significant increase in demand

OPEL Three

Actions at OPEL 2 failed to deliver capacity

Four-hour performance is significantly compromised below 80%

Significant number of handover delays

Patient flow significantly compromised

Unable to meet transfer from Acute Hospitals within 48-hour timeframe

Awaiting equipment causing delays for a number of other patients

Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

Serious capacity pressures escalation beds and on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

Problems reported with Support Services (IT, Transport, Facilities Pathology etc) that can’t be rectified within 2 hours

• Community capacity full, however opportunity to create capacity / flow • Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

• Social services unable to facilitate care packages, discharges etc. • Significant unexpected reduced staffing numbers to under 50% (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

• Pressure on OOH/GP services resulting in pressure on acute sector • Significant, unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

• Surveillance information suggests a significant increase in demand • NHS111 call volume significantly raised with normal or increased acuity of referrals • Weather conditions resulting in significant pressure on services • Infection control issues resulting in significant pressure on services

OPEL Four


No capacity across the Trust

Severe ambulance handover delays

Emergency care pathway significantly compromised

Unable to offload ambulances / Exceptional increase in ambulance attendances

Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety

Severe capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

• No capacity in community services nor immediate ( within 4 hrs) ability to create flow • Unexpected s i g n i f i c a n t l y reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that

• Social services unable to facilitate care packages, discharges etc. • No immediate ability to create capacity ( within 4 hrs) • Significantly unexpected reduced staffing numbers to under 50% (due to e.g. sickness, weather conditions) in areas where this causes

• Acute trust and community trust unable to admit GP referrals • Inability to see all OOH/GP urgent patients • Unexpected significantly reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises

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Infectious illness, Norovirus, Severe weather, and other pressures in Acute Trusts (including A&E handover breaches)


Four-hour performance is no longer being delivered, and patients are being cared for in overcrowded and congested emergency departments

compromises service provision / patient safety

increased pressure on patient flow

service provision / patient safety

6.6 Mitigating actions at each level

The following lists of actions for each level of escalation are not exhaustive, and should be added to at the local level as needed. When the decision is being taken to move to a higher level of escalation, the following actions (and any additional locally determined actions), should be implemented or considered.

Escalation Level

Whole System Acute Trust Commissioner Community Care Social Care Primary Care Mental health

OPEL One Named individuals across Local A&E Delivery Board to maintain whole system coordination with actions determined locally in response to operational pressures, which should be in line with business as usual expectations at this level – this will be undertaken via the ICP System call

Maintain whole system staffing capacity assessment Maintain routine demand and capacity planning processes, including review of non-urgent elective inpatient cases Active monitoring of infection control issues Maintain timely updating of local information systems Ensure all pressures are communicated regularly to all local partner organisations, and communicate all escalation actions taken Proactive public communication strategy eg. Stay Well messages, Cold Weather alerts Maintain routine active monitoring of external risk factors including Flu, Weather.

OPEL Two All actions above done or considered Undertake information gathering and whole system monitoring as necessary to enable timely de-escalation or further escalation as appropriate

Undertake additional ward rounds to maximise rapid discharge of patients

Clinicians to prioritise discharges and accept outliers from any ward as appropriate

Implement measures in line with trust Ambulance Service Handover Plan

Ensure patient navigation in ED is underway if not already in place

Notify ICP tactical on-

Expedite additional available capacity in primary care, out of hours, independent sector and community capacity

Co-ordinate the redirection of patients towards alternative care pathways as appropriate

Co-ordinate communication of escalation across

Escalation information to be cascaded to all community providers with the intention of avoiding pressure wherever possible.

Maximise use of reablement/intermediate care beds

Task community hospitals to bring forward discharges to allow transfers in as appropriate.

Community

Expedite care packages and nursing / Elderly Mentally Infirm (EMI) / care home placements

Ensure all patients waiting within another service are provided with appropriate service

Where possible, increase support and/or communication to patients at home

Community matrons to support district nurses/hospital at home in supporting higher acuity patients in the community

In reach activity to ED departments to be maximised

Alert GPs to escalation and consider alternatives to ED referral be made where feasible

Expedite rapid assessment for patients waiting within another service

Where possible, increase support and/or communication to patients at home to prevent admission

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call Director to ensure that appropriate operational actions are taken

Maximise use of nurse led wards and nurse led discharges

Consideration given to elective programme including clinical prioritisation and cancellation of non- urgent elective inpatient cases

the local health economy (including independent sector, social care and mental health providers

hospitals to liaise with Social and Healthcare providers to expedite discharge from community hospitals.

to prevent admission. Maximise use of reablement/ intermediate care beds

OPEL Three

All actions above done or considered

Utilise all actions from local escalation plans

CEOs / Lead Directors have been involved in discussion and agree with escalation to OPEL 4 if needed.

ED senior clinical decision maker to be present in ED department 24/7, where possible

Contact on-take and ED on-call

Senior clinical decision makers to offer support to staff and to ensure emergency patients are assessed rapidly

Enact process of cancelling day cases and staffing day beds overnight if appropriate.

Open additional beds on specific wards, where staffing allows.

ED to open an overflow area for emergency referrals, where staffing allows,

Notify ICP tactical on-call director so that appropriate

Local regional office notified of alert status and involved in discussions

CCG to co-ordinate communication and coordinate escalation response across the whole system including chairing the daily teleconferences

Notify CCG Tactical on-call who will inform the strategic on call Director who ensures appropriate operational actions are taken to relieve the pressure.

Notify local DoS Lead

Cascade current system wide status to GPs and Ooh Providers and to recommend alternative care pathways.

Alert ICS Comms team and tailor

Community providers to continue to undertake additional ward rounds and review admission and treatment thresholds to create capacity where possible

Community providers to expand capacity wherever possible through additional staffing and services, including primary care.

Acceptance criteria to be broadened in support of flow from the Acute

Cancel all non-urgent meetings

Ensure decision makers are available to ensure very prompt response to referrals

Social Services on-call managers to expedite care packages

Increase domiciliary support to service users at home in order to prevent admission.

Ensure close communication with Acute Trust, including on site presence where possible

Cancel all non-urgent meetings to ‘free up’ capacity to support de-escalation

Ensure decision makers are available to ensure very prompt response to referrals

OOH services to recommend alternative care pathways

Engage GP services and inform them of rising operational pressures and to plan for recommending alternative care pathways where feasible.

Review staffing level of GP OOH service.

To review all discharges currently referred and assist within whole systems agreed actions to accelerate discharges from acute and non- acute facilities wherever possible.

Increase support to service users home in order to prevent admission.

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operational actions can be taken to relieve the pressure.

Alert social services on-call managers to expedite care packages

Active management of elective programme including clinical prioritisation and cancellation of non- urgent elective inpatient cases

messages out to Escalation status

OPEL Four All actions above done or considered

Contribute to system-wide communications to update regularly on status of organisations (as per local communications plans)

Provide mutual aid of staff and services across the local health economy

Stand-down of level 4 once review suggests pressure is alleviating

Post escalation:

Contribute to the Root Cause Analysis and lessons learnt process through the SI investigation

All actions from previous levels stood up

ED senior clinical decision maker to be present in ED department 24/7, where possible

Contact on-take and ED on-call Senior clinical decision makers to offer support to staff and to ensure emergency patients are assessed rapidly

Surgical senior clinical decision makers to be present on wards in theatre and in ED department 24/7, where possible

Executive director to provide support to site 24/7, where possible

An Acute Trust

Local regional office notified of alert status and involved in decisions around support from beyond local boundaries

The CCGs will act as the hub of communication for all parties involved

Post escalation: Complete Root Cause Analysis and lessons learnt process in accordance with SI process

Ensure all actions from previous stages enacted and all other options explored and utilised

Ensure all possible capacity has been freed and redeployed to ease systems pressures

Director of Operations and teams to prioritise quick wins to achieve maximum flow and turn around

Identification via board rounds and links with discharge team & therapists

Director of Operations to monitor escalation status, taking part in teleconferences as required.

Senior Management team and cabinet member involved in decision making regarding use of additional resources from out of county if necessary

Hospital service manager, linking closely with Deputy Director Adult Social Care, & teams will prioritise quick wins to achieve maximum flow, including supporting ED re prevention of admission & turn around.

Identification via board rounds and links with discharge team & therapists.

Hospital Service Manager/Deputy Director to monitor


Ensure all possible actions are being taken on-going to alleviate system pressures


Continue to expedite discharges, increase capacity and lower access thresholds to prevent admission where possible

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wishing to divert patients from ED must have exhausted all internal support options before contacting the CCG and neighbouring trusts to agree a divert.

escalation status, taking part in teleconferences as required

6.7 Escalation triggers at each level LAEDB and nominated on call representatives should align existing systems to the escalation triggers and terminology used here

within, supplementing appropriate. The escalation criteria below are not an exhaustive list of triggers, nor does it constitute a rigid system, where thresholds must be exceeded sequentially for escalation to take place. Not all parts of the system need to meet all triggers in order to escalate – escalation can be service specific when agreed locally.

LAEDB or nominated on call representatives should demonstrate appropriate triggers have been met to warrant escalation. NHS England and NHS Improvement sub-regional and regional teams will also use this arrangement to moderate and challenge in discussions with local systems.

National terminology (OPEL) and the NHSE OPEL Framework should be adopted wholly by all systems, if not already.

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6.8 Local specific triggers and actions should then be shared and agreed with NHSE/I during assurance in the autumn.

Escalation Level

Acute Trust Community care- Social Care SCC Primary care Other issues

OPEL One Demand for services within normal parameters

There is capacity available for the expected emergency and elective demand. No staffing issues identified

No technological difficulties impacting on patient care

Use of specialist units/beds/wards have capacity

Good patient flow through ED and other access points. Pressure on maintaining ED 4-hour target

Infection control issues monitored and deemed within normal parameters

Community capacity available across system. Patterns of service and acceptable levels of capacity are for local determination

Social services able to facilitate placements, care packages and discharges from acute care and other hospital and community

Out of Hours (OOH) service demand within expected levels

GP attendances within expected levels with appointment availability sufficient to meet demand

NHS 111 call volume within expected levels

CHC delays

OPEL Two Anticipated pressure in facilitating ambulance handovers within 60 minutes

Insufficient discharges to create capacity for the expected elective and emergency activity

Opening of escalation beds likely (in addition to those already in use)



Lack of beds across the Trust

ED patients with DTAs and no action plan

Capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

Patients in community and / or

acute settings waiting for community care capacity

Lack of medical cover for community beds



Patients in community and / or acute settings waiting for social services capacity

Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions)


GP attendances higher than expected levels

OOH service demand is above expected levels

Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions)


Rising NHS 111 call volume above normal levels

Surveillance information suggests an increase in demand

Weather warnings suggest a significant increase in demand

CHC delays

OPEL Three


Significant deterioration in performance against the ED 4-hour target (e.g. a drop of 10% or more in the space of 24 hours)

Patients awaiting handover from ambulance service within 60 minutes significantly compromised

Patient flow significantly compromised

Unable to meet transfer from Acute Hospitals within 48-hour timeframe

Awaiting equipment causing delays for a number of other patients

Significant unexpected reduced staffing numbers (due to e.g.

Community capacity full

Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on

Social services unable to facilitate care packages, discharges etc.

Significant unexpected reduced staffing numbers to under 50% (due to e.g. sickness, weather conditions) in areas where this

Pressure on OOH/GP services resulting in pressure on acute sector

Significant, unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure

Surveillance information suggests an significant increase in demand

NHS111 call volume significantly raised with normal or increased acuity

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sickness, weather conditions) in areas where this causes increased pressure on patient flow

Serious capacity pressures escalation beds and on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)


patient flow causes increased pressure on patient flow

on patient flow

of referrals

Weather conditions resulting in significant pressure on services

Infection control issues resulting in significant pressure on services

OPEL Four Actions at OPEL 3 failed to deliver capacity

No capacity across the Trust

Severe ambulance handover delays

Emergency care pathway significantly compromised

Unable to offload ambulances within 120 minutes


Severe capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

Infectious illness, Norovirus, Severe weather, and other pressures in Acute Trusts (including A&E handover breaches)


No capacity in community services (nor any ability to create capacity within next 4 hours)


Social services unable to facilitate care packages, discharges etc. (nor any ability to create capacity within next 4 hours)

Significant unexpected reduced staffing numbers to under 50% (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

Acute trust unable to admit GP referrals

Inability to see all OH/GP urgent patients


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7.0 Communications ICP System Calls will act as the primary conduit for determining and communicating current ICP and ICS system status. Using the ICP system calls, service demand r isk mitigation actions and OPEL agreed act ions are enacted. Actions/escalated. ICP daily calls and BAU and Winter reporting structures and tools will be utilised, supported by Alamac and SHREWD where applicable during Transformation. When referring to an ICP status, we will refer to the OPEL system in terms of status and escalation.

7.1 System Calls Conference Call details The ICP System Resilience Call will be set up daily, Monday to Friday (including Bank Holidays, but generally excluding weekends except in the winter period). Any additional call will be set up as required by the system during period of escalation across the 7 days. TOR for the system calls see appendix 8.

Extra-ordinary calls at the weekend to be arranged by the on-call CCG tactical or the

agreed partner e.g. the Acute as required. If the system is on a protracted OPEL 3 or

an actual or potential OPEL 4, Executive representation is required. Should an ICP

agree OPEL 4 is applicable, the ICP CCG must notify the ICS Executive On Call.

7.2 ICS System Escalation Calls

Should two or more ICPs declare an actual or potential OPEL 4 status, a Surrey Heartlands ICS Escalation System Call must be undertaken. This will be activated by the Urgent and Integrated Care team and or the strategic on call. See appendix 8 Surrey Heartlands escalation call TOR.

7.3 Principles for a successful teleconference: Terms of Reference, including participants required will be determined by the

LAEDB or their out of hours’ representatives.

The conference will start promptly at the stated time. To avoid interrupting the call,

attendees should dial in 5 minutes prior to the start time

The call will focus on gathering information from partners of their key risks

mitigation already in place and targeting problems/issues that require a system

response.

Participants should describe the required outcome, not the solution

Problems that require an immediate solution will be prioritised

Participants will reference plans and confirm agreed actions that are in progress

Risks will be identified, with actions clearly allocated and reviewed at the

beginning of each call (if required)

Actions will be circulated within 30 minutes of the teleconference supported by

Alamac/SHREWD report.

Wicked problems will be acknowledged and taken off line

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The Right People, identified in the terms of reference, will be on the

teleconference

Teleconferences will be held at the correct time to allow internal actions to be

taken and for system escalation to have an impact

Participants will adhere to good teleconference etiquette: introducing speaker,

phone on mute, avoid using speaker phone unless using a phone that is designed

for conference calling etc.; respectful behaviour.

Please don`t use patient identifiable data on the call !

8.0 De Escalation process

Following an escalation report submitted to NHS England, outlining the mitigation actions taken to reduce the OPEL escalation level, Surrey Heartlands CCGs LAEDBs are required to submit a de-escalation report to inform NHS England of the reduced OPEL status and the mitigation actions in undertaken to achieve de-escalation. Mitigating actions required out of hours will be completed through BAU processes by Executives On Call or a suitable nominated deputy. This is particularly relevant during protracted periods of OPEL 3 and OPEL 4. Should the an ICP escalate to OPEL 4, a Serious Untoward Incident report must be completed incorporating a root cause analysis. The aim being to identify and understand the reasons why and how an ICP failed to prevent escalation to OPEL 4.

9. Handover / Diverts / A&E closure Ambulance handover delays are a whole system issue. National policy direction on ambulance handover delays is clear; long delays in handing patients over from the care of ambulance crews to that of accident and emergency department (A&E) staff are detrimental to clinical quality and patient experience, costly to the NHS, and should no longer be accepted. Handover delays not only have an impact on ambulance patients, but also cause delays to patients awaiting an ambulance response in the community. National quality requirements for the timely clinical handover of a patient by an emergency ambulance crew to hospital staff is 15 minutes from ambulance arrival at the receiving hospital. Under best practice a patient will remain under the responsibility of the ambulance service until handover is completed or for a period of up to 15 minutes after arrival. In times of high demand handover times may be extended due to increasing pressures across the system. In these situations, clinicians should work collaboratively with staff from the acute trust, in order that:

Whilst awaiting transfer of care, patients must be continually monitored by Trust staff using the NEWS2 approach which supports the requirement for rapid handover. Documentation will be updated to reflect care during this period to capture clinical deterioration as necessary.

Any deterioration in the patient’s condition during this time will be notified to

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the Nurse in charge immediately. The ambulance Clinician should be authorised to highlight their concerns and seek a timely solution to the matter.

Most handover situations including delayed handover times must be managed in accordance with the Conveyance, Handover & Transfer of Care Procedure (see Appendix 3). This procedure sets out the circumstances in which the majority of patients should be safely left in the department within 45 minutes and provides guidance in escalating hospital delays swiftly and effectively. Acute Trusts are expected to maintain documented internal escalation procedures for managing ambulance handover delays. The escalation procedure must include provision of patient trollies / chairs / wheelchairs as appropriate and a designated Queue Nurse dedicated to the safe and timely transfer of patient from ambulance to A&E to ensure oversight and appropriate management for waiting patients. Where a patient is still in the care of ambulance clinicians at 15 minutes after arrival, a “Delayed Handover Record” (DHR) will be started in order to records trends in patient observations and identify any clinical deterioration The DHR uses serial NEWS scores to record the patient’s clinical status from +15 minutes after patient arrival. This is repeated every 15 minutes until handover is completed. At each 15-minute period, the ambulance clinician must attempt to achieve handover with the hospital. Where the patient has an elevated or worsening NEWS score, ambulance clinicians must inform the Senior A&E Nurse. Should an ambulance to A&E patient handover exceed 45 minutes and/or two or more ambulances are unable to complete handover, the ECHO arrangement must be implemented. Once activated ECHO applies to all handovers exceeding 15 minutes until de-escalation. ECHO will be activated once an ambulance service Bronze Commander is on site at the A&E. The Bronze Commander acts as the ambulance service liaison within A&E, determining the need to activate ECHO, which requires Ambulance Service Gold Commander agreement. ECHO enables ambulance service crews to leave patients in the department with the SECAmb Bronze Commander who will continue to facilitate speedy and safe transfer of duty of care to the Acute Trust, allowing crew to return to their vehicle and respond to patients requiring a face to face ambulance response in the community. The ECHO arrangement once enacted will remain in place until at least 2 ambulance crew handover to the receiving Department within 15 minutes and SECAmb tactical (Silver Commander) and Emergency Operations Control management is satisfied normal operations have been returned.

9.1 Diverts and ED Closures Decisions around the redirection of ambulances or the closure of a hospital (see

Appendix 4) A&E department cannot be made in isolation and should be made in

consultation with ICP partners, ICS and NHSE/I. Diverts should only be considered in

extremis (OPEL 4) and must reflect the following principles and form the basis for all

capacity considerations and actions taken.

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NHS Managers must ensure a consistent and evidence based approach to decision

making. The Joint Decision Making Model (JDM) (see Appendix One) has been

adopted by the NHS as an exemplar of good practice and should therefore be

utilised. It is expected that all providers of NHS care including on call staff, must

receive Joint Emergency Services Interoperability Principles (JESIP) training. Each LAEDB must have health economy escalation procedures in place to ensure

early action is taken to prevent a crisis, rather than reacting once it has occurred. Patient safety, dignity and experience is the priority, all actions must focus on

providing patient access to definitive medical care.

Definitions

Full Divert: In agreement with relevant stakeholders, a full Divert is defined as

movement of all ambulance borne activity (with the exclusion of ASHICE patients)

away from a site under pressure to the next nearest and appropriate healthcare

facility. It aims to utilise available NHS system-wide capacity. This includes alternate

healthcare sites within the same organisation. –N.B. ASHICE are a group of patients

that require immediate specialist care demanding A&E staff are on standby and ready

to receive. Ambulance services must provide advanced notice of age, sex, history,

care requirement context and estimated time of arrival (ETA).

Border Divert: In agreement with relevant stakeholders, a border divert is a request

for all ambulance borne activity (with the exclusion of ASHICE patients) within a

specified geographical area to be taken to an NHS care location with sufficient

capacity. This includes alternate healthcare sites within the same organisation. Border

diverts are used to ease acute demand peaks, should be short term with a defined

number of ambulances over a short, specified time and should be considered a

temporary solution to preventing a Full Divert.

Specialist Divert: In agreement with relevant stakeholders, a specialist divert can be

implemented when actual or potential service failures to specific groups of high care

need patients may or has occurred. This applies to patient groups such as Maternity

and Stroke or may be due infrastructure failure, such as CT scanner issues.

Principles

The decision to request a full or a border divert must only be taken when hospital

trusts have exhausted all internal escalation action plans. The hospital is in ‘black’

status and a Business Continuity (BCI) or Critical incident (CI) has been declared.

Under no circumstances should diverts be used to protect elective beds, or to avoid

excessive waits in A&E or to routinely manage patient flow between sites belonging to

the same Trust.

A request for any divert should only be considered in exceptional circumstances only

and as a last resort. When considering a request for a full or border divert, a total view

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of system capacity should be taken in agreement with commissioners and ICP and

ICS stakeholders. The hosting ICP must have declared OPEL4 before a request for a

divert can be considered. (See Appendix 3)

10. DOS 111 Escalation

Amber: To make the 111 Directory of Services (DoS) amber, activation must be made by ICP Heads of Urgent Care or suitable nominated deputy in response to OPEL 3. Amber can only be agreed for 6 or 12 hours. Amber status must be reviewed throughout its duration. Particular attention should be made when switching to out of hours, weekends and bank holiday coverage. A return to 111 DoS steady state is a priority and will automatically return at the end of the agreed duration. Further extensions must then be negotiated following an identical process. Consideration must be given to the impact on other services which may receive higher numbers of patients. Red: To make 111 Directory of Services (DoS) red, activation must be made the duty ICS Executive. The activation can only be made following an ICS system escalation call (>>Appendix 3ii; ICS system call agenda and participant list by role/org<<). This process has intentionally been agreed to incentivise not making 111 DoS red. It has far reaching implications and should only be considered in extremis. It is closing a service. Should this course of action be required, then existing service closure protocols must be followed (Appendix 4). Should 111 DoS Red be implemented, the service closure will be for 2 hours only (6 hours’ maximum weekends only). Further extensions must then be negotiated following an identical process. It is also important to be aware that when the 111 DoS red status has been applied the service may still return (‘ED catch all’) where no other services are available.

To request a status change in hours email the Surrey DoS team: [email protected] Telephone: Beverley Kendrick: 07833 348280 Debbie Fleming: 07342 063573 During out of hours contact 111 Care UK Telephone: 0300 130 3007 During hours the DoS team will email [email protected] with suggested text below for Care UK internal circulation when a service status has been changed. During OOH this will be the responsibility of the ICP Heads of Urgent Care or duty ICS Executive. FYI capacity status has changed on DoS to Amber. Please can you circulate the message below to colleagues: Emergency Department – (put in name of Acute Hospital e.g. Surrey Royal Surrey Hospital – Guildford)



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Service is open but experiencing pressures. Pressure impacting on disposition timeframes. This means that patients should be made aware of the possibility of an extended wait and directed to consider an alternative service where appropriate.

11. Escalation Beds

The definition of an escalation bed within the Surrey Heartlands ICS needs to be clearly understood as part of surge and escalation management plans. This is to ensure we clearly record the level of escalation across the Surrey Heartlands ICS. For the purposes of this document, an escalation bed is one that is located in a non-24hrs hospital area and/or requires additional staffing consideration and capacity. Additional areas that are opened and staffed 24/7 over a period of time like a “winter ward” are not considered as escalation beds. These beds are additional winter capacity and are part of the General and Acute (G&A) submission and have been considered a requirement as part of winter planning.

The number of General & Acute beds should be calculated as follows:

Funded and staffed additional G&A beds that will be used every day (not open and closed ad hoc)

Should not include use of areas like cath lab, endoscopy suites, assessment areas etc.

Should not include existing bed that are being swung from surgery to medicine etc. as these are already counted in the G&A bed stock.

12. Mental Health Escalation (In development)

A process for escalation for mental health admission is being finalised along with a MH scoring matrix. Expected Jan 2020.

13. Paediatric Escalation (In development)

As an ICS we are in the process of developing a paediatric escalation plan. The first part of this is the development of the Surrey Heartlands draft Paediatric scoring matrix for acute hospitals. This will be used to assess the acutes paediatric escalation level and is currently being tested across the ICS.

Should significant pressure arise in any of the acutes this winter there may be a request to hold an extra ordinary Paediatric ICS call. Each acute before joining this call should use the scoring matrix to determine their level of escalation as this will aid decision making around mutual aid across Surrey Heartlands. (see appendix 10)

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Appendix

Appendix 1: The Joint Decision Making Model

The tool is taken from the Joint Emergency Services Interoperability Principles

(JESIP). Emergency services already use the model. Training should be delivered

to ensure all participants in the whole system surge plan use the same approach.

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Appendix 2: Serious Incident (SI) Reporting and Investigation Serious Incidents should be reported in accordance with the ‘Serious Incident Framework; Supporting Learning to Prevent Re-occurrence’ (NHS England, March 2015). This framework describes how a serious incident should be reported, timelines for reporting and investigation, methodologies of investigation and mechanisms for prevention of harm in the future. It also provides important information on reporting and investigating responsibilities where there are multiple commissioners or providers involved in the incident, and what is legally required in terms of notification of the incident to patients and their carer’s. The framework does not describe explicitly what a serious incident is, however it stipulates that a serious incident is; ‘…. acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm’ (p7). In relation to the contents of this plan, a serious incident is considered as:

An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:

Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues

Property damage; Security breach/concern; Incidents in population-wide healthcare activities like screening and immunisation

programmes where the potential for harm may extend to a large population; Systematic failure to provide an acceptable standard of safe care (this may include

incidents, or series of incidents, which necessitate ward/ unit closure or suspension of services); or

Activation of Major Incident Plan (by provider, commissioner or relevant agency) Major loss of confidence in the service, including prolonged adverse media coverage

or public concern about the quality of healthcare or an organisation. It is important to note that It may be appropriate for a ‘near miss (i.e. a serious incident that did not cause harm) to be a reported as a serious incident because the outcome of an incident does not always reflect the potential severity of harm that could be caused should the incident (or a similar incident) occur again. Deciding whether or not a near miss should be classified as a serious incident should therefore be based on an assessment of risk that considers:

The likelihood of the incident occurring again if current systems/process remain unchanged; and

The potential for harm to staff, patients, and the organisation should the incident occur again. This does not mean that every near miss should be reported as a serious incident but, where there is a significant existing risk of system failure and serious

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harm, the serious incident process should be used to understand and mitigate that risk. Further details and clarification about the framework and process can be obtained via the following web link:

https://www.england.nhs.uk/ourwork/patientsafety/serious-incident

Appendix 3: SECAmb Divert SOP and Emergency Handover Procedure.

SECAmb Divert SOP

2019.pdf

Emergency

Handover Procedure V0 05.pdf

https://www.england.nhs.uk/ourwork/patientsafety/serious-incident

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Appendix 4: A&E Closure- Governance Flowchart

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Appendix 5 Acute Trust Scoring Matrix

SH Acute Trust

ESCALATION STATUS V3.docx

OPEL Epsom

General V0.4.docx

ASPH Operational

Pressures Escalation Plan - OPEL Sept19 V3. Draft.doc

RSCH SH Trust

ESCALATION STATUS FINAL .docx

Appendix 6: SECAmb Surge Management Plan (SMP)

Appendix 7: Escalation Status Triggers for Community Services

SH Community

Services ESCALATION STATUS V2.docx

SD H&C Community

Services ESCALATION STATUS V2.docx

Appendix 8: System Call TOR and Escalation Report

ICP System Call ToR

refreshed DRAFT v3 06 12 2019.docx

ICS System Call ToR

refreshed DRAFT 06 12 2019.docx

ICP OOH System

Call and Escalation Report.docx

Appendix 9 OPEL Framework

4.

OperationalPressuresEscalationLevelsFramework- v2.0-RELEASED.pdf

Appendix 10 Paediatric Scoring Matrix

OPEL Paeds Scoring

Matrix .docx

SECAmb Surge

Management Plan V4.01.pdf

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Surrey Heartlands OPEL Action Card System OPEL LEVEL 2 System OPEL LEVEL 3 System OPEL LEVEL 4

Organisations Actions Actions Actions

ICS Urgent Integrated Care Team

Seek assurance from ICP leads all mitigation are in place

Out of hours these action will be carried out by the strategic on call.

Seek assurance and support ICP leads in ensuring a system response

Coordinate a ICS response if more than one ICP is at Pre black OPEL3

Ensure the Surrey Heartlands strategic directors and strategic on call aware of the risks and actions.

Coordinate assurance returns to the regulators.

Out of hours these action will be carried out by the strategic on call

Actively coordinate a ICS response to support the ICP’s in OPEL 4 or pre OPEL 4.

Activate the SH ICS system escalation call as required - see action card below.

Ensure all execs are informed and aware.

Following the SH ICS escalation call inform regional director for NHSE/I of the OPEL 4 position.

Support the utilisation of all available resource across Surrey Heartlands as agreed by the individual ICP systems

ICP Urgent Integrated Care Team

Coordinate the ICP response through system calls

Expedite and consider with system partners any additional capacity that can be created to support patient flow.

Coordinate the communication of the raised escalation level across the system

Ensure you ICP director is kept briefed and informed.

Inform the tactical on call.

Ensure all OPEL 2 actions from providers completed.

Ensure ICP director and tactical on call informed.

Keep ICS urgent care leads briefed so they can inform the strategic on call.

Liaise with ICS lead regarding marking provider services under pressure as Amber on the DOS (via Care UK for OOH).

Ensure system communication plan is activated.

Consider targeted comms to primary care.

Coordinate system calls and log agreed actions and follow up on subsequent calls.

Consider setting up weekend system calls and informing the Tactical on call.

Ensure all OPEL 3 actions are completed.

ICP need to escalate to the ICS UIC team who will activate an ICS call to agree escalation to OPEL 4, should one or more areas declare OPEL 4 , or be at risk of OPEL 4, and contact the regional team. Out of hours this will be the strategic on call via the tactical on call for the ICP.

Provide an assurance report for the ICS to then consider before sending to regulators.

ICP to coordinate the ICP system response and provide assurances to the ICS leads.

Consider ambulance divert.

ICP to ensure system calls are in place over weekends and inform both the tactical and strategic on call are aware.

Ensure all additional capacity has

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been considered and commissioned where possible.

Coordinate the RCA and debrief following de-escalation from OPEL 4.

Acute Trust Ensure all Staff within organisation are aware of the OPEL Position.

Ensure all on call managers and clinicians are aware of the escalation status.

Ensure Senior decision makers are supporting rapid assessments in both ED and assessment units.

Pharmacy services to prioritise TTO’s for appropriate areas

Housekeeping to prioritise any deep cleans

Porters to prioritise the transfer of patients

Contact SECAmb to highlight capacity issues and confirm patients are directed to alternative pathways

Clinicians to prioritise discharges and accept outliers from any ward as appropriate

Undertake additional ward rounds to maximise rapid discharge

Medical teams to ensure TTO’s and discharge summaries written

Arrange alternative forms of transport to discharge patients (if necessary to facilitate any discharge which may be at risk due to transport issues)

Ensure PTS prioritise discharges and have sufficient capacity in place

ED consultant /senior clinical decision maker to be present in ED department 24/7, where possible

Contact on-call and ED Consultants to communicate hospital status and bed capacity and offer support to staff to ensure emergency patients are rapidly assessed.

Senior clinical decision makers to offer support to staff and to ensure emergency patients are assessed rapidly

Additional ward rounds to be undertaken by senior clinicians as necessary

Notify CCG on-call Director so that appropriate operational actions can be taken to relieve the pressure.

Alert Social Services on-call managers to expedite care packages

Active management of elective programme including clinical prioritisation of non-urgent elective inpatient cases

Review all delays within the hospital and minimise with a view to building numbers of discharges throughout

Review all meetings and training and cancel all key staff commitments.

Open additional escalation areas.

Consider cancelling out- patient clinics to re-direct medical / surgical teams to wards to facilitate discharges.

Ensure all of Action for OPEL 3 are completed

Consultant Physicians to be present on wards and in ED

Surgical Consultants to be present on wards and in ED

Re-review all delays within the hospital and minimise with a view to building numbers of discharges throughout the day and the next 48 hours.

Ensure all areas have decision makers on site or are immediately available by phone to make any funding decisions

Ensure all partners are promoting all possible discharges

Trust to declare BCI and establish a control room.

Consider ambulance divert

Update Communications and messages to the Public.

Open all possible escalation areas to accommodate gap in bed demand

Consider cancelling cancer electives when safe to do so.

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Additional resource to manage ambulance handovers.

Consider additional PTS to aid discharges.

Ensure Communication plan is activated to general public.

Ensure all staff aware and review each shift for gaps and consider calling in additional staffs as required.

Ensure staff on wards and departments are aware of the escalation status

Consultant only or registrar decision to admit in hours, registrar out of hours (inc surgery where registrar may not be on site)

Liaise with SECAMB to assess risks and agree clinical plan for any patients awaiting handover

Senior clinicians to actively scrutinise all GP requests for admission consider alternative pathways.

Consider additional diagnostic imaging

Ensure Communication plan is activated.

SECAmb Ensure take part in system calls.

Alert acute trusts if there is to be an influx of patients.

Ensure all crews are aware and using alternative pathways where possible.

Operational Commander (OTL) to visit site and determine concerns and support improvement in flow.

SECAmb to continue with Delayed Handover procedure.

SECAmb Operational Commander to escalate to Tactical Commander.

Operational Commander (OTL) to base themselves at Hospital to maximise flow and early clearing of crews from site.

EOC to provide regular broadcasts to crews to consider alternative care pathways wherever possible.

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Community Provider Escalation information to be cascaded to all community providers with the intention of avoiding pressure wherever possible.

Maximise use of re-ablement/intermediate care beds

Provider decision maker to Communicate with Acute Bed Coordinator re bed availability and planning discharge

Community hospitals to liaise with Social and Healthcare providers to expedite discharge from community hospitals.

All CH wards update next 72 hour planned discharges to establish future capacity.

CH Matrons to ensure that every patient has been reviewed, board round completed.

All teams review staffing for next 72 hours including non-critical training

Establish patient reviews with external agencies

Ensure all OPEL 2 actions are complete.

Community hospital matron to be made aware of escalation and contact wider teams e.g. RR to ascertain capacity and also contact Head of Service for locality to make aware of possible challenges

Review all patients either with planned discharge date or without and re-evaluate discharge possibilities in line with MDT – escalate to Matron for support- if unable to improve flow or identify possible discharges escalate to Head of Service

Matrons to escalate unresolved patient flow issues to partners

Lower threshold of escalation and admission criteria in accordance with safe staffing.

Review staffing – consider additional staffing and review all training and meetings with a view to cancelling

Ensure all OPEL 3 actions are complete.

Ensure exec are aware of system status and make them aware of ICS call.

Consider pulling in staff from proactive care teams to complete assessments in acute hospital

streamline assessment processes for community hospitals to help speed up discharge processes

Ensure all additional capacity is open, creating further capacity as able

Community Matrons - Review diary commitments for staff and cancel any non- urgent training and meetings

Consider redeployment of staff into critical areas

Review non critical patient care AD/DAD Notify DOO of escalation status

ASC Expedite care packages and nursing / Elderly Mentally Infirm (EMI) / care home placements

Ensure all patients waiting within another service are provided with appropriate service

Where possible, increase support and/or communication to patients at home to prevent admission. Maximise use of Reablement /intermediate care beds

Social Services on-call managers to expedite care packages

Increase domiciliary support to service users at home in order to prevent admission.

Create additional capacity to improve flow across the system, focusing on delays within the Acute, Community Hospital and Home First / Rapid and Reablement teams.

Ensure close communication with Acute Trust, including on

Senior Management team involved in decision making regarding use of additional resources from out of county if necessary Hospital service manager, linking closely with Deputy Director Adult Social Care, & teams will prioritise quick wins to achieve maximum flow, including supporting ED re prevention of admission & turn around. Identification via board rounds and links with discharge team & therapists.

Manager/Deputy Director to

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site presence where possible

Ensure no delays in decision making and that senior decision makers are available.

Alert wider community partners e.g. Residential and Nursing homes and request support in relation to facilitating discharges.

Ensure all POC are reviewed and frequency of visits reduced where possible.

monitor escalation status, taking part in ICS teleconferences as required.

Ensure all POC are re- reviewed and frequency of visits reduced where possible. Seek family support and consider additional funding for POC.

CHC Team Manager to review all patients known to CHC to see if discharges can be facilitated to ease flow

Escalation of concerns/blocks to Acute trust and CHC senior management

CHC Acute Practitioner to make eligibility decisions on checklist as opposed to panel

Consider redeploying staff from other hospital sites or roles if appropriate to help facilitate the discharge of as many customers as possible.

Identify all customers where ‘Discharge to assess’ is appropriate.

Seek to fund and enact ‘Discharge to Assess’ for all identified patients.

Ensure no delays in decision making and that senior decision makers are available.

Working with ASC – ensure that funding disputes do not hold up discharge.

Locality Lead to review all patients in order to identify alternative pathways/ funding and is empowered to make funding placement decisions.

Consider streamlining assessment processes for CHC to help speed up discharge processes

Outcome decisions to be made out of panel on individual basis, daily

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Surrey Heartlands Escalation Call Action Card System OPEL Four (in two areas or one area on OPEL 4 and another system at risk of OPEL e.g. acute on internal Black alert)

Please note: These actions can only be enacted by agreement of ICS partner via an ICS system call.

Surrey Heartlands ACTION Related Protocol / SOP / Agreement / considerations ICS System Call between all areas Exe / CCO’s

ICS System Call ToR

Check back that all internal Acute / ICP opportunities to de-escalate have been completed

EG – Strong delivery of ‘Red to Green’; limited delay on TTO’s; availability of senior decision makers and focus on EDD – forward planning of discharges (all areas of acute and short term community service delivery inc. ASC)

Identification of areas which a neighbouring ICP could assist with focused interventions.

EG – Access to diagnostics - support to facilitate additional diagnostics across SH to aid decision making in higher escalated area; offer of support with TTO’s; workforce - requests for workforce to cross over to increase resilience in higher escalated system - for example increase senior decision makers in ED/UTC or extended access hubs or general health nurses supporting Mental Health across areas (? Cross boundary agreements required / governance)

Maximum take up of all available ICS resource ?Cross boundary agreements required (one ICP to another ICP)

Re-focus on repatriation internally within ICS and in neighbouring ICPs – seek NHSE/I support if out of area

Acute to Acute Transfer Protocol

Community services and ASC work across boundaries providing all / or elements of required POC’s to release capacity to higher escalated area

Reduce PTS transport delays across SH. Purchase additional PTS capabilities from private providers to support early discharge. Also consider use of local taxi companies.

Arrangements in place via previous Winter plans

Comms messaging – consider national messaging Surrey Heartlands Seasonal and Escalation Urgent Care Communication Plan

111/ DoS - Change dispositions away from higher escalated area to other parts of SH.

Please note – a service placed on the DOS as RED – effectively closes that service; which will have

an impact on other services/ areas

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Agree additional funds from ASC and NHS to allow funding without prejudice to provide interim funding.

Additional monies to agree process of on the day decision to facilitate flow.

Ambulance Divert

SECAmb Ambulance Divert Protocol

Divert Stroke / paediatrics / cardiac trauma pathway patients

? Cross ICS’ agreement required via available Networks

PTS / local community buses’ full divert of resource to area in extreme escalation

Direct impact on slowing down discharges from neighbouring Trusts. ? Cross boundary agreements required

Opening of additional escalation beds in lower escalated Acute / Community Hospital to accommodate neighbouring ICP patients

?Cross boundary agreements required (one ICP to another ICP), along with immediate repatriation (when safe to do so)

Purchase of additional Private Hospital beds.

?need for Transfer agreements to be in place

Cancellation of elective in neighbouring Acute in lower escalation status (if not already done so) Cancellation of OPD in neighbouring Acutes in lower escalation status (if not already done so)

Neighbouring Trust to then be able to receive more ‘diverted’ patients, with staff diverted from OPD to assist

Purchase of immediate additional resource e.g. Nursing home beds; Homecare hours; nursing agency hours on block to work across the ICS; Additional GP’s in WiCs / UTC / OOH’s / ED.

Impact on Budget and Financial re-imbursement arrangements

Seek assistance from neighbouring ICS’

Request to NHSE/I to support this

Consider purchasing capacity for neighbouring NHS acute and community providers outside of SH

? Transfer protocols required

Open an ICS Control Room with senior representation from all areas

Director level oversight

Cancellation of Respite Care in community to accommodate discharges from Acute

Direct impact on Carer Welfare

Cancellation of regular homecare visits diverting staff to short terms services and flow

Direct impact on Carer Welfare

Declare a CRITICAL INCIDENT

EPRR Critical Incident Protocols to be followed

agenda item: 15 paper no: 13 appointment activity

Documents