JOINT SURGE AND ESCALATION PLAN FOR THE BRISTOL, NORTH SOMERSET AND SOUTH GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUPS 2013/14

Transcription

1 JOINT SURGE AND ESCALATION PLAN FOR THE BRISTOL, NORTH SOMERSET AND SOUTH GLOUCESTERSHIRE CLINICAL COMMISSIONING GROUPS 2013/14 CHANGE CONTROL: Version number Date of change Changed by Description of change /10/13 Tiina Mustonen Updated plan following first review with NHS England BNSSSG Area Team /10/13 Tiina Mustonen Updated plan following second review with CCG Winter Leads and NHS England BNSSSG Area Team /10/13 Tiina Mustonen Updated plan following comments from Bristol and North Somerset CCGs Winter Leads /10/13 Tiina Mustonen Updated plan following comments from NHS England BNSSSG Area Team, South Gloucestershire CCG Winter Lead, NBT and UH Bristol /10/13 Tiina Mustonen Updated plan following further data submission from NBT and SGCHS /10/13 Tiina Mustonen Updated plan following further data submission from Harmoni for NHS 111 and BrisDoc for GP Out of Hours Service /10/13 Tiina Mustonen Final draft following comments from Bristol,CCG Winter Lead, updated BNSSG whole system escalation summary, details of Flu Leads 1

2 Contents 1 INTRODUCTION... 5 Approach to Winter 2013/ Links to other plans... 5 System Priorities... 6 Lessons learnt from winter 2012/ OPERATIONAL READINESS... 7 Urgent Care Boards and Networks... 7 Surge and Escalation and Influenza Planning Leads... 7 Handover of patient care from ambulance to acute trust JOINT ARRANGEMENTS... 9 System wide escalation... 9 Major Incident / Business Continuity / Severe Weather CAPACITY Intermediate care Learning Disabilities Mental Health Management of infectious diseases including norovirus outbreaks Home Oxygen Services NHS AND SOCIAL CARE JOINT ARRANGEMENTS University Hospitals Bristol NHS Foundation Trust Weston Area Health NHS Trust North Bristol NHS Trust Bristol Community Health North Somerset Community Partnership South Gloucestershire Community Health Services Bristol Adult Social Care North Somerset Adult Social Care South Gloucestershire Adult Social Care South West Ambulance Service NHS Foundation Trust GP Out of Hours Service LINKS BETWEEN PRIMARY CARE SERVICES, AMBULANCE TRUSTS AND A&E DEPARTMENTS CRITICAL CARE SERVICES PREVENTATIVE MEASURES, INCLUDING FLU IMMUNISATION CAMPAIGNS AND PNEUMOCOCCAL IMMUNISATION PROGRAMMES

3 Definitions AL AT BNSSG BCH BCP CCGs CMS CICU CLDT CHC CPA CTPLD CMS CMP CSU ECWG ED GPSU HCP HLN HSC ICT IMAS IP&C LDT Air Liquide Area Team Bristol, North Somerset and South Gloucestershire Bristol Community Health Business Continuity Plan Clinical Commissioning Groups Capacity Management System Community Intermediate Care Unit Community Learning Disabilities Team Continuing Health Care Care Programme Approach Community Team for people with Learning Difficulties Clinical Management System Capacity Management Plan Commissioning Support Unit Emergency Care Working Group Emergency Department GP Support Unit Health Care Professional Hospital Liaison Nurse Health and Social Care Infection Control Team Improving Ambulance Handover Practical Approaches Infection Prevention and Control Learning Disabilities Liaison Team 3

4 LDU LHRP LRF NBT NSCP PACU PCL PHE PICU RATT REACT SDAS SOP SPA SWASFT UH Bristol WAHT Local Delivery Units Local Health Resilience Partnership Local Health Forums North Bristol NHS Trust North Somerset Community Partnership Post Anaesthetic Care Unit Primary Care Liaison Public Health England Paediatric Intensive Care Unit Rapid Assessment, Triage and Treatment Rapid Emergency Assessment and Care Team Speciality Drug and Alcohol Service Standard Operating Procedure Single Point of Access South West Ambulance Service Foundation Trust University Hospitals Bristol NHS Foundation Trust Weston Area Health NHS Trust 4

5 1 INTRODUCTION Approach to Winter 2013/14 The purpose of this plan is to describe how health and social care organisations in Bristol, North Somerset and South Gloucestershire will maintain services during increased pressures, surges in patient activity and unforeseen circumstances. A co-ordinated proactive and responsive approach is essential to ensure that preparation is robust and that processes are in place that can adapt to the different pressures as and when they arise. Metrics will be used to monitor pressure in the system and identify areas requiring additional support to maintain good access and high quality care for patients. The Plan takes account of: The recommendations: from the national A&E performance improvement plans; Kings Fund Checklist; Review of Urgent Care - Emerging Principles The Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Groups (CCGs) Local Recovery and Improvement Plans 2013/14 Local lessons learnt from winter 2012/13 The NHS England winter planning checklist The Plan will be subject to the review and approval of the BNSSG CCGs Governing Bodies and their associated Urgent & Emergency Care Working Groups, which for the purpose of this plan will be known as that, but locally are: The Bristol Urgent Care Working Group, The North Somerset Urgent Care Network, and The North Bristol System Flow Partnership Group. Delivery against the plan will be managed by the BNSSG CCGs Urgent and Emergency Care Working Groups. Links to other plans The Plan has a direct link to other key plans: BNSSG System Capacity Management and Escalation Plan 2013/14 NHS England Seasonal Flu Plan 2013/14 Individual Organisations Seasonal Flu Plans Individual Organisations Pandemic Flu Plans Individual Organisations Major Incident / Incident Response Plans Individual Organisations Business Continuity Plan Avon and Somerset Local Health Resilience Partnership: Pandemic Flu Plan Incident Response Concept of Operations Severe Weather Plan (including 4 x 4 Transport Support Standard Operating Procedures) BNSSG Winter Communications Strategy North Somerset and South Gloucestershire Systems Additional Winter Funding Plans 5

6 System Priorities The plan focuses on eight key priority areas: Handover of patient care from ambulance to acute trust Operational readiness - review of local health and social care community plans to ensure that high quality urgent and emergency care services, including NHS 111 are maintained during typical winter pressures, and especially over the Christmas and New Year holiday period Out of Hours arrangements NHS/Social Care joint arrangements, including work with Local Authorities to prevent admissions and improve discharge Ambulance Service / Primary Care / A&E links Critical Care Services, including capability to increase capacity to cope with a pandemic Preventative measures, including flu campaigns and pneumococcal immunisation programmes for patients and staff. Infection control measures in local health and social care community plans for joined up and effective management of infections, especially norovirus and other general outbreaks of diarrhea and vomiting Communications - Internal and external communications strategy to be developed for promoting and accessing services Lessons learnt from winter 2012/13 For 2012/13, the BNSSG health and social care community took a partnership approach (under the BNSSG Health Futures Programme Delivery Board) to winter planning. Plans were based on priorities informed by national advice, local learning both from previous winters and from a whole system simulation exercise in September 2012 and analysis of data from past winters. The rationale for the 2012/13 approach was to reduce traditional seasonal pressure, reduce unexpected and additional costs to commissioners and providers, and ensure high quality care for patients at times of increased demand. The key strands to winter 2012/13 approach were: Take action early development of a Web-based Metric Dashboard (WMD) for identifying pressure based on a set of revised sustainability metrics Improve the escalation plan to support early action including: revised escalation plan with pre-defined trigger points robust preventative escalation arrangements with a system approach ambulance service cell to manage escalation Only convey when necessary Health Care Professional (HCP) protocol for ambulance service to ensure patients were conveyed to the right service, first time The approach to winter did not see the pressure on the system reduce dramatically and it proved problematic to take preventative action to reduce pressure as the developed sustainability metrics were not consistently actively completed or monitored. 6

7 However, the introduction of the escalation cell fostered an increased level of system acknowledgment and action and continues to be in place. It is recommended that the focus in 2013/14 continues to be on preventative measures and flow to avoid the safety and quality implications of severe pressure on acute trusts. The acute trusts will also review internal procedures for emergency ambulatory care/short stay and direct admission and system wide escalation processes will be prioritised. It is essential that out of hospital care provides real opportunities for admission avoidance and the facilitation of acute hospital discharge. 2 OPERATIONAL READINESS Urgent Care Boards and Networks In light of the changes to commissioning functions during 2012/13, the former BNSSG Emergency Care Network recognised that there was a need to understand the role, purpose and the function of the Network, which led to the development of Urgent and Emergency Care Working Groups. The BNSSG CCGs Urgent and Emergency Care Working Groups will: Oversee and implement their agreed work programmes as outlined in their individual Urgent Care Strategies and local Recovery Plans Monitor activity and pressures using the urgent care dashboards Interpret national and regional policy on urgent and emergency care Identify clinical priorities and decide on clinical pathways that need review or redesign and monitor patient outcomes Actively engage patients, staff, carers and the wider public in the planning and implementation processes of urgent and emergency care in BNSSG Oversee subgroups of the Urgent and Emergency Care Working Groups Oversee the development of the Plan and Escalation Framework understanding issues which may have an impact on urgent and emergency care e.g. Surge and Escalation, Seasonal Flu Planning, Pandemic Flu Planning, Mass Casualty Planning, Major Incident Planning Each CCG s Urgent and Emergency Care Working Group meets monthly and has detailed terms of reference in place. Membership for the individual groups can be found in Appendix 8. Surge and Escalation and Influenza Planning Leads The Chief Officer of each partner organisation is the accountable officer for service delivery. Each respective organisation has lead staff with responsibility for surge and escalation and flu co-ordination planning. Details of these leads can be found in Appendix 2. 7

8 Handover of patient care from ambulance to acute trust Delays in the handover of care between the ambulance and the hospital services represent a risk to patient safety, poor patient experience and a waste of valuable national health resources. To ensure whole system working the BNSSG CCGs and Urgent and Emergency Care Working Groups are focused on reducing handover delays and delivering improvements based on national guidance such as Emergency Care, New Service Standards, Reflecting the True Patient Experience and the NHS IMAS paper Improving Ambulance Handover Practical Approaches 1. Acute Trusts across the BNSSG area are working with South Western Ambulance NHS Foundation Trust and primary care providers to reduce ambulance handover delays. In April 2013, South Western Ambulance Service NHS Foundation Trust (SWASFT) revised the Standard Operating Procedure (SOP) to manage handover delays and circulated it to all Trusts. The SOP takes into account the fact that those patients once in a hospital environment, having been given an initial assessment and treatment by ambulance staff, are safer than those who have contacted the ambulance service for help, are waiting for a 999 emergency response and have yet to receive a definitive clinical assessment. Throughout the year, delays on handover can be experienced by both patients and ambulance crews but historically, these delays increase during the winter months as pressure builds in acute settings. Work has been focussed during 2013/14 to improve handovers so that they are timelier and thereby reduce unnecessary waits across the system. This supports the Department of Health zero tolerance approach to ambulance handover delay. Local measures that have been implemented include: Ambulance Handovers - University Hospital Bristol NHS Foundation Trust Rapid Assessment, Triage and Treatment (RATT) policy in place to address ambulance queues. In addition a trust wide review of escalation triggers is being undertaken to ensure that actions are taken proactively to prevent ambulance queues. Ambulance Handovers - Weston Area Health NHS Trust The Trust has an Emergency Department (ED) action plan in place to assist with Ambulance Handovers. Thus plan includes senior ED staff placed at the triage/receiving desk to help expedite ambulance handovers. The Trust will continue to work with SWASFT and North Somerset CCG, and will meet on a fortnightly basis to further improve ambulance handover. As a result of this joint approach, a clear pathway has been implemented the validation process is done daily and the number of ambulance handover delays has reduced

9 Ambulance Handovers - North Bristol NHS Trust Ambulance off load area is in blue bay, which is staffed with a registered nurse. The Trust has got escalation plans in place to support ED by pulling patients through the system as trolley spaces are filled. ED and Ambulance staff will escalate to the operational team when thresholds are reached. At this stage the capacity plan is instigated and admission wards focus on patient transfer to enable capacity to support ED. There are plans to appoint a Corridor Nurse in ED to support and improve ambulance handover performance during the winter 2013/14 period. The recruitment for this post commenced 25 th September The Fracture Clinic can be used as an additional escalation place as a contingency. 3 JOINT ARRANGEMENTS System wide escalation The Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Groups (CCGs) utilise a BNSSG escalation model. The term escalation is generally used to describe pressure building in the system, often focused on acute trusts. The BNSSG model compliments local plans to manage rising activity pressure in the healthcare system. The approach for 2013/14 builds on learning from previous winter experiences with the key outcome of continuing to develop a mechanism to identify when pressure is building in the system so action can be taken early to prevent the higher states of escalation. This approach to 'take action early' will continue for 2013/14 with the further development of a set of system metrics (primary care, community, 111, out of hours, local authority, mental health, ambulance service etc) which will be collected on a daily basis and uploaded to a web based tool for viewing by the system and for use at the regular escalation conference calls. At this stage it is envisaged that escalation conference calls will continue to be chaired by the ambulance service and under pinned by the Capacity Management System (CMS). This will be confirmed during October 2013 and is likely to require investment from the BNSSG CCGs. Once agreed, the ambulance service will conduct conference calls every Monday, Wednesday and Friday at a revised time of Each conference call is attended by representatives of the health and social care system with a remit to ensure rising pressure in the system is identified and action taken. A key development for 2013/14 is that the conference calls will be informed by the system metrics which will provide a more complete picture of pressure in the system. If on-going pressure means additional conference calls are required these will be arranged at the standard calls. Afternoon calls may also be established if warranted by system pressure identified at the call. The overall BNSSG escalation model is being revised and will be available for the winter period. It will include the conference call arrangements including standard agenda items in addition to a set of BNSSG action cards. The BNSSG escalation plan will also reference the provider escalation plans allowing a more accurate system view of actions required at each escalation. 9

10 There will be a Commissioning Support Unit (CSU) manager on call during the week from 9am to 5pm, and during out of hours and at weekends there will be a CCG Director on call. Major Incident/Business Continuity/Severe Weather The Avon and Somerset Local Health Resilience Partnership (LHRP) has developed joint health economy plans for Incident Response, Pandemic Flu and Severe Weather. These plans are underpinned at a local level by individual organisational plans. The LHRP Severe Weather Plan incorporates individual action plans from commissioners and providers and is aligned directly to the winter weather warning system managed by the Met Office. The plan works through a system of cold weather alerts, which will trigger appropriate actions up to a major incident. All commissioners and providers across the BNSSG area have signed up and receive cold weather alerts direct from the Met Office and have 24/7 responsibility to ensure their organisations are able to respond appropriately. The LHRP Incident Response Concept of Operations document articulates the command and control arrangements that have been agreed and are in place for managing both escalation, significant, and major incidents across the Avon and Somerset Geographical area. All commissioners and providers have local organisational level plans for Major Incidents and Severe Weather Plans or plans contained within their Business Continuity Plans for managing the consequences of cold weather and snow. An overview of the content of these plans can be found below: University Hospital Bristol NHS Foundation Trust The UH Bristol Adverse Weather Policy supports business continuity. Plans are in place for all non-invasive ventilated (NIV) patients both at normal demand level and at escalation. The severe weather plan is part of the Trust s Business Continuity Plan and provides guidance when normal business activities are affected by severe weather which prevents staff, patients and visitors from attending the Trust or its periphery clinics. The plan is to be used in conjunction with the Trust s Winter Plan. The plan is in place to maintain safe staffing levels, safely manage a potential increase of trauma patients presenting through the ED and to rebalance the emergency and elective activity. The trust will be holding an Emergo exercise on 9 th October This is a Public Health England (PHE) exercise and is designed to test their major incident plan and other elements of their command and control structure. North Bristol NHS Trust The Trusts has got a comprehensive and up-to-date Major Incident Plan in place that covers response, command and control, communications, training and recovery arrangements for the different types of recognised major incidents. This plan is designed to be sufficiently flexible to enable the Trust to respond to any type of incident however it might progress. 10

11 NBT Business Continuity Management Plan describes the Trust s over-arching arrangements in respect of a significant or widespread disruptive event (i.e. a number of Directorates/Departments affected). It details the command and control that will be instigated within the Trust to deliver a co-ordinated response to the situation. Linked to this over-arching response will be each Directorate s own contingency plans to ensure that, locally, wards and departments are able to maintain a level of service, wherever possible. Clinical Directors and General Managers are responsible for ensuring that business continuity contingency plans are in place for their respective departments and wards and that these are reviewed at least annually and updated whenever necessary. The NBT Full Capacity Protocol details specific Winter Weather Fracture Plan that covers those occasions when the number of patients in ED with limb fractures prevents the normal functioning of the department or they cannot be treated quickly enough to prevent complications. On these occasions additional staff will be requested and an additional area will be set up to accommodate these patients. The staff to include: one anaesthetist to administer to sedation one Orthopaedic Registrar or above to manipulate one senior A&E nurse to plaster and co-ordinate one Physiotherapist In the event that both capacity in the hospital and ED are on black escalation, a serious safety risk is present. It will be the decision of the Chief Operating Officer, Chief Nurse or on call Executive to implement the Full Capacity Protocol. The following actions will be implemented: When a patient requires admission to hospital and no suitable specialty bed is available, the CSM will admit the patient to the next most appropriate bed. Patients who are declared for discharge will vacate their bed and will either be seated in the ward day room or transferred to the discharge lounge. Exceptions to this will be patients who are immobile and those assessed as being unable to leave their bed. When a patient requires admission to hospital and no bed is available, the patient will be admitted to the most appropriate ward as an additional patient. North Somerset Community Partnership Major incident, service recovery and severe weather plans and actions are covered within the North Somerset Community Partnership s Business Continuity Plan. Bristol City Council Adult Social Care Bristol City Council Civil Contingencies Unit is responsible for Council s response to adverse weather events. Council gritters are on standby 24/7 from 1 st November to 31 st March, and there are over 750 grit bins placed around the city on minor routes and hills. This period can be extended if necessary. The council is negotiating with First buses to reroute buses rather than cancel routes during adverse weather. 11

12 South Gloucestershire Adult Social Care The South Gloucestershire Council Strategic Business Continuity Plan will be implemented when an event is likely to impact on the Council as a whole. The Adult Care Business Continuity Plan details the adult social care departmental response to disruptions to their services including those attributable to adverse weather conditions. Individual Service Business Continuity Plans detail arrangements for services that support vulnerable people in the community including any closures that are as a direct result of adverse weather conditions. The Local Authority receives regular weather warning updates and organise proportionate responses accordingly. All organisations that the LA contract with to provide services are required to have a Business Continuity Plan to ensure the continued delivery of services through adverse conditions. South West Ambulance Service NHS Foundation Trust There is an adverse weather preparedness section, including communications and media requirements, in the SWASFT winter plan. SWASFT are working closely with partners to ensure readiness at the onset of severe weather. SWASFT have a holding statement prepared in readiness for any extreme weather conditions or situations where changes to their usual service provision have to be made. The media relations activity will complement the existing trust capacity and escalation plans. Ambulance stations and locations which have been identified as vulnerable to flooding or severe weather have local arrangements in place for business continuity involving stakeholders and partners. SWASFT has a number of options which are identified in the Responding to Severe Weather Incidents document. The ability to respond under blue light conditions using a 4x4 is limited to SWASFT and those acquired from St John and British Red Cross. Hired-in vehicles from either, Wessex 4x4 or St John Ambulance can be used to take a SWASFT clinician to a 999 response but only under normal driving conditions. This response is supported by clinical advice from the Clinical Support Desk s and escalated to the Silver if this action results in a delayed response to any RED call. The rationale for this type of response is logged using the appropriate Trust procedures. SWASFT has planned and prepared for winter and is continuing to reach every patient dialling 999. The arrangements detailed in the SWASFT Major Incident plan form the basis of the Trust s generic response to a major incident and offers detailed guidance and direction on appropriate action. The plan is supported by individual Action Cards and specific, linked contingency plans. Ambulance staff will be trained and exercised in the plan to ensure an effective response. It is reviewed regularly to keep it up-to-date and relevant. It presents the Service with the very best opportunity of continually improving the care provided to the patients of major incidents. The Trust develops its strategic, tactical and operational responses in cooperation with partner agencies in the Local Health Resilience Partnerships and Local Resilience Forums. 12

13 GP Out of Hours Service Business Continuity Plan is in place for the sustainability of the service during severe weather conditions. This plan cover access to service base and staff action during adverse weather; access to four wheel drive vehicles to support home visits and transporting staff; remote working arrangements scoped to allow clinical advice telephone calls to be made without travel to base and special arrangements to be made to cope with increased patient demand due to cold weather, e.g. respiratory infections. NHS 111 In adverse weather conditions the Bristol 111 centre has business continuity arrangements in place to accommodate staff locally and access available 4x4 vehicles from BrisDoc and St John s Ambulance to pick up staff in outlying areas for work and return home in severe weather conditions where normal road vehicles are not suitable. The Bristol 111 call centre will also network with other Harmoni call centres that are less affected by weather conditions, and the call centre manager will continue to work with the national team to ensure there is sufficient staffing for the service at exceptional demand peaks. The Bristol 111 centre is over-recruiting locally-based flexible low to mid hours staff who can work additional hours where needed in times of adverse weather conditions. There are additional training dates planned to cope with any potential extra demand. Harmoni have a major incident plan into which escalation seamlessly dovetails. If pressure within the system increases and is unmanageable through the normal escalation procedure the major incident plan will then be implemented. Avon and Wiltshire Mental Health Partnership Trust Meteorological Office Cold Weather Alert levels and AWP specific actions in response to these levels including, communications and escalation, are included in the AWP winter plan. Where temperatures are forecast to drop significantly, community teams are to ensure they cascade that information to the Service Users within their care. This is to ensure that the Service User and or carer is suitably warned and prepared for the low temperatures. For periods of extended low or sub-zero temperatures, community teams may be required, if necessary, to make more frequent checks on the wellbeing of the Service Users within their care. In relation to ensuring that FP10 prescriptions reach community pharmacies for drug and alcohol users, prescriptions are sent in advance through the post or delivered directly. Individuals will cover each other to staff the inpatient unit and community dispensing clinics in the event of being unable to get to their usual place of work. The majority of Specialist Drug and Alcohol Services (SDAS) are 'routine'. Priority will be to keep the in-patient unit open, and to continue to run out-patient clinics, if possible. If it is not possible to provide clinical delivery safely, alternative arrangements would be implemented e.g. use of other residential facilities, GP's, community pharmacies etc. All major suppliers have contingency plans in place to cover their services in case of major incident. 13

14 4 CAPACITY 4.1 Capacity to meet demand for elective and emergency services University Hospitals Bristol NHS Foundation Trust University Hospitals Bristol NHS Foundation Trust (UH Bristol) has provided assurance that they have completed capacity planning for quarters 3 and 4 and flex capacity has been identified for that period. Trust escalation triggers were reviewed and new triggers shadow monitored during September for roll out 1st October Elective activity during the Christmas and New Year period is focused on inpatient waiters and urgent cases only, and the Bank Holiday Plan Summary gives guidance to the Divisions on what is required. The Daily Schedule of Services gives assurance that the plan has been met. A post bank holiday recovery plan is included in the Bank Holiday Plan. Plans are in place and being implemented to increase ambulatory care pathways to maximise the number of patients managed without inpatients stay i.e. day cases, outpatients, primary care. Divisional and Corporate flex capacity has been identified within the UH Bristol Escalation Plan to meet the peaks in demand (as supported by the bed model). The Trust sitrep is circulated at least twice a day to key internal and external partners (including to the Bristol Royal Infirmary based BrisDoc provided GP Support Unit which informs the GPs on an individual basis of the escalation status at the Trust). Recruitment is in progress to have over-establishment for Medical and Nursing staff to ensure robust staffing levels. Annual leave and over-time payment protocols are being reviewed to ensure optimum staffing levels and skills available for holiday periods and to support reduction in bank and agency usage. Daily demand is determined by using a six week rolling predictor formula plus actual elective numbers. The shortfall of capacity i.e. the number of discharges outstanding is determined at 8.30am and 2.30pm. There is a daily leadership and flow meeting for Medicine to identify definite and potential discharges for the day and the following day. The Reverse Triage protocol will be fully rolled out by 1st October BLUE list of patients suitable for transfer to South Bristol Community Hospital is monitored daily. Standard Operating Procedures for acquiring To Take Away (TTAs) to support the discharge of patients prior to 12.30pm have been developed, fit for purpose discharge lounge opened on 16th September 2013 with projected usage of twenty five patients per day to increase early bed availability. Real time recording of discharge and transfer patient data is in place to support early discharge, bed management and reducing the time beds are empty. The complex discharge project that began earlier in the year will continue to improve communication with social services and community partners regarding complex discharge using a patient logger and improvements to the section 2 and 5 process. A criteria lead discharge project is in place to optimise weekend discharges. In addition, optimum 14

15 divisional discharge numbers have been set for each bank holiday, weekend and weekday and are included in the Bank Holiday Plan. A Rapid Assessment, Triage and Treatment (RATT) policy to address ambulance queues, is in place and used throughout the year. The Trust s mortuary capacity consists of twenty eight standard spaces, twenty four additional spaces and some trolley spaces, a total of sixty to sixty five spaces. Standard usage is around thirty five to forty spaces. In times of escalation, local agreements with other acute hospitals and funeral homes will apply to provide additional capacity if required. Emergency Access Steering Group reviews performance on a weekly basis to identify issues/risks to be resolved Weston Area Health NHS Trust Weston Area Health NHS Trust (WAHT) has provided assurance that the planned elective workload will be managed reducing variation in activity whilst still maintaining Referral to Treatment targets. Collaborative working with local health and social care partners is in place to support achievement of outcomes. The trust has got admission avoidance initiatives in place, through introduction of more senior staff input in the initial assessment of referrals and self-presenting patients. Bed capacity has been increased for escalation, and there will be an identified Duty Manager and Executive to provide operational support to the Clinical Site Team. Additional beds will be managed according to the Opening Temporary Additional Bed Capacity Policy alongside the escalation plan. Supplies to stock the additional ward areas will be purchased and available on site from November A Medical Physician on call will be doing ward rounds and seeing patients that are highlighted as needing medical review to support discharge. The Discharge Team will be available throughout the Bank Holiday period to support timely discharge. The Trust has also invested further in the discharge action team and is reviewing the way this team works to maximise performance. Additional ancillary staff are recruited to support the additional ward areas, and annual leave will be managed as per guidelines on maximum numbers that can be agreed to be off to maintain services with a plan that no bank and agency will be requested on bank holidays. The Collaborative Care Team service will continue to provide support to patients who require additional support in the short-term to return home safely, to enable the Trust to stop unnecessary admission to hospital to facilitate their timely discharge from hospital. This service will be expanded in winter 2013/14 using the winter funding to cover Somerset patients. The Ambulatory Care Centre will work alongside the Emergency Department throughout the winter period in order to avoid unnecessary admissions. Additional ambulatory care capacity will be established in the community through the Ambulatory Care Centre in Clevedon Community Hospital. 15

16 4.1.3 North Bristol NHS Trust North Bristol NHS Trust (NBT) has provided assurance that they will prioritise essential services over the winter period and during escalations. Elective procedures and individual case needs are prioritised and elective activity will be decreased in the first two weeks of January with a corresponding increase in day case activity, supported by regular monitoring and review of daily predicted activity as well as any supply chain issues. Seasonal pressure wards have been identified and escalation activities will be monitored at daily bed meetings. There are ward opening and closure plans in place for the whole trust, and NBT will open and close additional capacity to ensure provision of safe care to patients. The Trust has a rolling six predictor toll against which it manages, on a daily basis, the demand versus capacity. This is used at each bed meeting and its position indicates where, if feasible, extra capacity is. Additional staffing plans are in place to deliver personalised annual leave and agreed bank and agency nursing cover when required. There is a detailed medical team action plan which includes deployment of junior and senior staff and locum appointments during periods of increased activity. Each Head of Nursing and Clinical Director has been asked to provide detailed action planning for the Christmas Bank Holiday period and the first two weeks of January. These plans are to be with the Director of Operations by 14 November The recruitment for all additional emergency department winter staff commenced 25 th September Repatriation policy and Outlier plan will be enacted. Regular detailed information on discharge targets based on predicted admissions is to be provided to further support discharge performance to enable capacity without compromising access times and patient experience. Multi-disciplinary team discharge is in place. Additional Percutaneous Endoscopic Gastrostomy (PEG) and emergency endoscopy slots are to be arranged to support admission avoidance during peaks in admissions. Hot Clinics and Out Patient Departments activity (Trauma and Orthopaedic) are to be increased to support ED attendance avoidance. However cancellation of non-urgent clinics and diverting of clinical staff to inpatient work will be considered when absolutely necessary. Plans are being progressed with Emerson s Green Independent Sector Treatment Centre (ISTC) for options for elective activity and on-going work to specifically support the period following Christmas and New Year Bank Holiday. The Trust s current mortuary capacity consists of fifty three spaces in Frenchay Hospital and forty eight spaces in Southmead Hospital. At peak times, the mortuary staff will work with Bereavement Services, the Coroner s contract Funeral Directors and other FDs to ensure no body is held in the mortuaries any longer than is necessary. Frenchay is considerably busier than Southmead and there is an arrangement (as part of the Trust s funerals contract) whereby bodies can be moved out of Frenchay across to Southmead if there is space available there. There is also an opportunity to transfer deceased to the mortuary at the Bristol Royal Infirmary (BRI) where they have a large overflow space. Contingencies are in place should additional 16

17 capacity be required at a short notice e.g. due to large number of flu-related deaths, prolonged bad weather or concerns that the pattern of holidays/weekends is likely to lead to a delay in the deceased being collected. 4.2 Intermediate care Bristol Community Health Bristol Community Health (BCH) has a 24/7 Rapid Response service in place in Bristol. BCH are supporting patient flow within the acute trusts with the Hospital Inreach Service and wider intermediate care initiatives to reduce time spent in the Emergency Department. An Intermediate Care Service is provided in partnership with Bristol City Council. Patients can be discharged to intermediate care centres for rehabilitation to release pressure on inpatient beds. A Directory of Services is in place for referral from NHS111 for South Bristol Urgent Care Centre and Intermediate Care Services. The Community in-reach hub and newly developed discharge co-ordination centre will reduce delays in facilitated discharges; and when required, Intermediate Care staff will be deployed to accelerate discharges from hospitals. Out of hours intermediate care will support the rehabilitation service if the service experiences increased pressure. Single Point of Access will prioritise urgent care referrals for intermediate services. The Intermediate Care Escalation Plan that is in place details actions to prioritise service responsiveness to ensure delivery Bristol Adult Social Care Intermediate care and enabling staff to continue delivering service are identified as priority during escalation North Somerset The Single Point of Access is the referral and communications channel for Intermediate Care services, in North Somerset. The service provides coordinated information for referrers and service users, accessible via phone, fax or South Gloucestershire Access to Intermediate Care services in South Gloucestershire is arranged via the Joint Community Access Point, co-located with the Local Authority for the health community (including the ambulance service and NHS 111) and secondary care. Locality offices also offer direct access to services for GPs etc. An Adult Capacity Management plan is in place covering all locality based services details on how to flex resources to meet changing demands and manage pressure periods. Services are limited during the Out of Hours period, but Extended Care Nursing will available as well as the Night Sitting service via Extended Care and Community rehab seven days a week from 9am till 5pm. 17

18 4.3 Learning Disabilities University Hospitals Bristol NHS Foundation Trust Trust s Learning Disabilities Liaison Team (LDT) has strong links with the Community Learning Disabilities Team (CLDT) across Bristol. A clinical alert system is in place to make pre-admission links and provide the necessary support and advice. CLDT are actively involved in the discharge planning for these patients Weston Area Health NHS Trust A small number of people with a Learning Disability use the services of Weston General Hospital (0.3% elective admissions, 0.9% emergency admissions in last 6 months) A higher number present in the emergency department but are discharged successfully. The lead nurse for Learning Disability services at the Trust liaises closely with the community team based at Partnership House for complex admissions, discharges and admission avoidance North Bristol NHS Trust Multi-disciplinary team consisting of a social worker, an occupational therapist and a physiotherapist is planned to be in place in January to work with discharge nurses to allow timely discharge with support for those patients with learning disabilities. The Trust has access to two learning disability nurses for advice and support. NBT LD team liaises and works with community services LD teams in South Gloucester and Bristol Bristol Community Health BCH provides a co-located service. There is a shared vulnerable adults list and plans for contacting these service users. Joint plans are in place for the identification of a core team to direct the support where needed North Somerset Community Partnership NSCP will be extending a capacity model into learning disabilities to enable appropriate service at all times. The Community Team for People with Learning Disabilities (CTPLD) is a joint team across NSCP and North Somerset Council. Systems are in place between Weston General Hospital and the CTPLD to inform over planned admissions and to provide support to unplanned admissions. This service is available Mon-Fri during office hours. Additionally, a Community Liaison Nurse is in post to work with community and hospital services to support people with LD thus preventing unplanned hospital admission and to facilitate discharge. 18

19 4.3.6 Bristol City Council Adult Social Care The usual Health and Social Care (HSC) assessment processes apply and if required, liaison with a LD Liaison Nurses and multi-agency community colleagues is implemented through multi-disciplinary team with appropriate social work support. Those with exceptional needs are managed in liaison with the LD Liaison Nurse and social workers. Agreement for funding to aide discharge can be achieved outside normal processes North Somerset Adult Social Care Traffic light system in place for all planned admissions, plus work takes place before admission to support any communications needs. The CTPLD is made aware of all hospital admissions and will work with the Acute Trust to support timely and appropriate discharge South Gloucestershire Hospital Liaison Nurses (HLN) are in post for Frenchay and Southmead Hospitals. There is an open referral process for any individual, family member, carer or professional to this service for an assessment of needs. The HLNs have good links with the Community Learning Difficulty Teams and the community based Social Workers who will make referrals. For planned admissions the HLNs will support the Hospital with pre-admission appointments, Mental Capacity Assessments, identification of reasonable adjustments, assessment of whether extra support is required during the admission, and identification of any potential discharge problems (such as change in need) that may delay discharge. Systems are in place to alert the hospital social worker of any issues and additional assessments that are required to support timely discharge. Any additional support that is required to ensure the safety of the person with Learning Disabilities on any ward or department is the responsibility of the hospital. HLNs will liaise with the individual, carers and Ward to identify needs and liaise with the Matron if extra support is required. 4.5 Mental Health Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) will endeavour to ensure that safe, optimally swift, responsive and effective services continue throughout the winter period to minimise the risk of adversely impacting partner organisations. AWP have confirmed that, although Acute Trusts experience a winter-related seasonal surge in demand, historically this has not proved to be a problem for AWP. In fact, evidence demonstrates that demand falls within AWP over the Christmas and New Year period. Increase in demand on Intensive Services is usually experienced in January and on Recovery Services in February. Where there is a risk of an increase in demand for mental health services, e.g. over the Christmas or New Year period, Local Delivery Units will assess this risk, based on historical demand modelling to ensure that the proposed service provision is adequate. If demand threatens to outstrip capacity, escalation plans will be activated with the aim of increasing capacity. This may be achieved by measures such as accelerated and supported discharge in to the community. 19

20 AWP will work with local partner organisations to ensure clinical services to mental health patients are not unduly disturbed over the winter period. There will not be an increase in community staffing availability leading up to and for the duration of the Christmas and New Year period, although every effort will be made to fill vacancies through the internal Bank. Reviews have demonstrated that increased staffing over Christmas and New Year does not significantly improve or enhance service delivery. All Operational Directors and Managers will constantly review the pressures on all areas of the services they offer and will take action to provide additional resources to pressure points within the available budget, and communicate any difficulties with resourcing to the Resilience Manager for inclusion in the agenda of any extraordinary Trust Resilience Group meetings that may be called. These issues will also be escalated through the on-call managers, who are available 24/7 and can call on additional appropriate resources. Staff cover will be available as normal through the Intensive Teams. All 24 hour services will be maintained as normal i.e. In-patient units and Intensive Teams. All Community Mental Health Teams will be staffed to normal bank holiday staffing levels in the period between Christmas and New Year. All team members will identify potential vulnerable Service Users and/or carers and ensure that there is a robust care plan and care pathway in place. Individual care plans will identify the needs of Mental Health Service Users and care will be provided to meet those needs. Where applicable, AWP will work in partnership with Acute Trusts, community health service providers, local authorities and other specialist organisations such as prisons to ensure that the mental health needs of service users are met. The care planning process will identify the best outcomes for service users. AWP anticipates issues over funding. Placement into residential or nursing care will only be made on the completion of a full assessment and not be seen as a short term solution with long term consequences. Discussions will take place with the domiciliary care providers regarding their availability to take on any new work over the Christmas period. Individuals are identified through care plans and existing service providers. Managers will be available throughout the period to assist with the decision making process. All Local Delivery Units (LDU) will ensure that where there are critical activities, there are Business Continuity plans in place that support these in the event of failure. Any failure of critical activities is to be communicated to the Resilience Manager for inclusion in the agenda of extraordinary Trust Resilience Group meetings or for potential activation of the Incident Management Team. All LDU s will ensure that staff are aware of on-call arrangements and are able to access guidance from a senior managers 24 hours a day, including during bank holiday periods; and that staff adhere to normal working practices during the holiday period. Arrangements are in place across all Acute Trust sites in respect of urgent requests for mental health assessment through either Hospital Mental Health Liaison Team (where provided by AWP) or during out of hours through Intensive Team. A standardised 20

21 process of mental health triage is in place, which facilitates referral and subsequent assessment. Normal practices and procedures accessing relevant teams remain in place for the Christmas and New Year period. Within the BNSSG area, AWP is commissioned to provide seven day services only at Weston Area Health NHS Trust (WAHT). The service is provided by the AWP Intensive teams and their response is on a priority basis. Service Users will access emergency mental health services in the same way as normal, using the usual referral routes. AWP will need to be advised of the requirement for mental health assessment immediately post triage of a patient needing one. Hospitals need to inform the Intensive teams of the priority of the assessment on first contact. AWP will do its utmost to respond to assessment requests on a priority basis. For Inpatient Mental Health Services all LDU s will ensure that the Care Programme Approach for each service user is up to date before the holiday season to support timely discharge into the community when required. Safe levels of staffing and robust supply chains are to be ensured at each unit with agreed escalation if they cannot be maintained. If the admission criteria of acute trusts are raised as a result of surge, AWP may find it difficult to access physical medical care and will therefore need to provide a higher level of physical care than is normally offered. The decision to support this approach will be taken through clearly recorded decision making process. Community Mental Health Services will continue to accept referrals and manage these in the normal way. If there is an increase in demand which could lead to risk that service users are not seen within a safe period of time, this will be escalated to the senior management of the LDU. Service users will be given detailed information on how to contact teams during the holiday period. Local Service Delivery in Bristol AWP is commissioned to provide a Consultant Psychiatrist in UH Bristol. Mental Health Assessments are provided by Social Workers employed by the Local Authority, working in partnership with AWP. The request for a Mental Health Assessment is made by ED to AWP, AWP then cascade this request to the social workers including any priority given to specific patients. If a priority is given by a hospital, AWP would attempt to respond to that priority based on capacity and availability. This service is provided by the Liaison and Intensive teams. Service Delivery will be prioritised for emergency and urgent frontline services, particularly Bristol Intensive Team and inpatient wards. If necessary, staffing levels of wards and teams will be adjusted for any anticipated peaks in demand. Psychiatric Liaison in UH Bristol is provided by the acute Trusts with the exception of psychiatrists and Later Life nursing. AWP will consult on any required plans for adjusting staffing levels during the Christmas Period. The Bristol Intensive Team acts as gatekeeper for inpatient admissions and facilitates early discharge. The team will operate over the Christmas period and liaise with wards as required regarding timely discharge; and receive and respond to Primary Care 21