Generic Contingency Plan Capacity Management

Scottish Ambulance Service National Risk and Resilience Department Generic Contingency Plan Capacity Management Incorporating the Resource Escalatory Action Plan - REAP (Including Out of Hours and Winter Planning arrangements) Version 4.7 November 2014 Doc & page: Page 1 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

Scottish Ambulance Service National Risk and Resilience Department Generic Contingency Plan Capacity Management. Resource Escalatory Escalation Plan (including Out of Hours and Winter Planning arrangements) Contents Contents and Summary 2 1 Introduction 3-4 2 Capacity Management Planning Rationale 4 3 Related Policies & Plans 5 4 Co-ordination Arrangements 5 5 Capacity Modelling - ACC 6 5 Capacity Modelling Operational Service 7 6 Resource Escalatory Action Plan REAP Introduction & Background 8 Intention, Actions, REAP levels, Triggers 9-11 Table 2 Triggers for Implementation 12 Table 3 Mitigating Actions 13-14 Intelligence Gathering, Co-ordination and Assessment of Information & 15-16 Structure Appendix 1: National Co-ordination Centre Reporting Template 17-18 7 Contact Details 19-20 8 Divisional / ACC Local Action Plans 21 9 Local Winter Planning Arrangements 21 Summary This plan describes the operational planning and consequence management arrangements that should be applied to assess and control pressures on operational capacity. This includes pressures arising from both predicted and unpredicted demand. The principles of this plan should be applied regardless of the cause of the capacity challenge or the time of year at which the pressure arises. However, it is recognised that the plan is most likely to be implemented during the winter and festive periods and therefore it contains lessons and experience gathered from managing activity over several winters, where such arrangements have been required. It is designed to contain usable information to assist with the management of surge demand, including that caused by medical conditions commonly encountered over the winter. The plan consists of a generic central framework supplemented by local Divisional level Plans. The Service aims to consult widely with all relevant stakeholders, particularly at local level and explore jointly means of managing the consequences of additional demand, as a key output from this plan. The plan requires users to assess pressures and capacity and then sets out triggers for escalation and implementation through various stages of activity. In this, it establishes a framework for action by ACCs and the Operational Service against those triggers to support operational decision making and safeguard the most critical aspects of service delivery. It also aligns closely with the existing Scottish Ambulance Service Pandemic Outbreak, Extreme Weather, Fuel Business Continuity and other Contingency plans. Doc & page: Page 2 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

Scottish Ambulance Service National Risk and Resilience Department Generic Contingency Plan Capacity Management. REAP (including Out of Hours and Winter Planning arrangements 1. Introduction There is a necessity to maintain a comprehensive contingency planning framework to manage the consequences for the ambulance service of a level of demand rising to a point where it exceeds the ability of the Service, or other parts of the healthcare system, to meet that demand. This may arise when, either in isolation or in combination, there is a rise in demand or a reduction in the capacity of those organisations to deliver services. Changes to the system of delivery for unscheduled care have driven the requirement to plan for a failure of out of hours services or other health services, due to the consequences of internal or external threats to service continuity. Should such a situation arise, health care provision may need to be planned or delivered differently, services prioritised or re-scheduled and partnership working, including mutual aid, extended or special contingency arrangements invoked. For example, this plan may need to be implemented in circumstances when: a. There is a significant surge in demand for services provided by the ambulance service, NHS 24 or an NHS Board for which that organisation does not have the capacity to compensate immediately (e.g. a flu outbreak, extreme weather challenge or significant major incident which could escalate to the point where the ambulance service, NHS 24 or an NHS Board is unable to sustain or provide a service compatible with patient safety). b. There is a significant reduction in the capacity of the Ambulance Service, NHS 24 or an NHS Board, which severely restricts its ability to respond to patent demand or deliver care (e.g. understaffing - major staff sickness, localised IT system failures, wider failures of service continuity, including external suppliers of goods and services, which could escalate to the point where the ambulance service, NHS 24 or an NHS Board is unable to sustain or provide a service compatible with patient safety). c. Escalating demand exceeds the capacity at Divisional level to provide services within an appropriate timeframe. Doc & page: Page 3 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

d. There is a significant reduction in the capacity of the local Health Board to provide services (e.g. too few medical staff to sustain centre, systems or infrastructure failures.) Note: Services over Festive Periods. Routine practice closure for 4 consecutive days on two consecutive weeks will occur in certain years. In addition to pressures due to capacity challenges within NHS out of hours services, trends for 999 calls indicate that demand may rise from between 10% - 150% above normal Friday night levels at certain times over that period. The patient care consequences and potential for uncompensated major incident at special events over the festive period and a certain other times also contribute to the pressures on the Service, requiring the implementation of this plan. 2. Capacity Management - Planning Rationale In order to plan effectively for the impact of escalating demand, reduced resources or other unanticipated disruption, including significant systems or infrastructure failure, an assessment of existing demand and capacity is necessary together with an accurate assessment of the impact and range of consequences likely to impinge on service delivery. At given levels of escalation, a pre-determined consistent framework for action is required to support decision making and to manage and preserve the mission critical aspects of the operational service. Therefore, managers, with the assistance of risk, resilience and business continuity colleagues have been required to consider the likely consequences of any realistically foreseeable occurrence on service delivery, and consider the action required to best maintain critical services and to identify any action that could reasonably be taken in advance of an adverse situation to reduce the impact. Generic action in preparation for a capacity management challenge may include participating in immunisation programmes, issue of PPE or other buffer stocks, predetermined increases in operational or other staffing or deployment of special resources such as personnel, vehicles (including four-wheel drive) or equipment, to cover anticipated pressures. Preparation may also include training of additional staff or volunteers in specific priority duties and effective, planned communication with external stakeholders. A common understanding of these planning assumptions, and the development of consistent interagency contingency plans, escalation triggers, communications and management policies may be of particular value in reducing the adverse effect of disruptive challenge. Internally, the Service has been advised to continue to develop policies to underpin its ability to enhance capacity or reduce demand at times of peak pressure, introduce alternative arrangements for Service delivery, identify staffing and logistical requirements, consider the likely cost implications and where necessary, ensure that arrangements are appropriately validated through exercises and audit. Doc & page: Page 4 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

3. Related polices and plans: Pandemic Outbreak Contingency Plan Fuel Business Continuity Plans Divisional / Departmental Business Continuity Plans Major Incident Procedure ACC Procedures Crisis Management Plan Risk Management Policy Incident Reporting and Risk Registers Seasonal Influenza Vaccination Programme Health and Safety Policy Output from Local Out of Hours / Unscheduled Care Groups and Strategy Project Boards SGHD Exception reporting requirements (distributed annually) SAS National Command and Co-ordinating Centre (SAS-NCCC) Procedures UK Ambulance Service Mutual Aid Procedures (National Ambulance Resilience Board) Preparing Scotland Scottish Resilience Preparing for Emergencies Scottish Government Health Directorates Scottish Government Health Directorates specific plans and procedures National and Local Service Bulletins 4. Co-ordination Arrangements a. External: Scottish Government Resilience Advisory Board (RABS) SGoRR (O) RABS Sub-Groups other mechanisms as relevant CBRN, Fuel etc. CONTEST Board Regional Resilience Partnerships x 3 Local Resilience Partnerships NHS Resilience Health and Safety and Infection Control Team Territorial Health Boards (x14) Usual liaison arrangements with SGHD, NHS Boards, HPS, NHS24, VAS etc. Other Ambulance Services (National Ambulance Resilience Unit) b. Internal Executive Team through established reporting, (Reporting to the SAS Board) SAS National Command and Co-ordinating Centre (SAS-NCCC) (if established) Senior Management Team Daily Conference calls Operational Management Team Resilience Committee Divisional Management Teams / Local Operational Management Teams Partnership Forum National and Divisional / Departmental Health and Safety Committee National and Divisional / Departmental Clinical Governance mechanisms Clinical Governance Committee Fleet Department Doc & page: Page 5 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

5. Capacity Modelling a. ACC staffing required at stated levels of demand (updated by ACCs Dec 14) Ambulance ACC Inverness Edinburgh Glasgow DR Site Paisley ** Maximum number of operable call taker workstations Maximum number of operable dispatcher workstations 6 in ACC 12 in ACC (3 duel with PTS) 2 Clinical Advisor 1 Supervisor 4 in ACC 1 Manager 2 Supervisors 8 in ACC (2 can be utilised as call taker if required) 1 Supervisors 14 in ACC (5 duel with PTS) 1 Supervisor 2 Clinical Advisor 10 in ACC 1 Manager 2 Supervisors 1 Trauma Desk 10 Dispatchers 8 Call Takers 1 Clinical/Supervisor 10 Dispatchers 8 Call Takers 1 Clinical/Supervisor Number of call takers / dispatchers required at normal levels of OOR demand 3 Call takers 3 Dispatchers 1 Supervisor 1 Clinical Advisor 6 Call takers 6 Dispatchers 2 Supervisors 2 Clinical Advisor 7 Call takers 10 Dispatchers plus 2 Supervisors 2 Clinical Advisors 10 Dispatchers 8 Call Takers 1 Clinical/Supervisor Number of call takers / dispatchers required at normal levels of OOR demand + 10% Number of call takers / dispatchers required at normal levels of OOR demand + 50% Number of call takers / dispatchers required at normal levels of OOR demand + 100% 3 Call takers 3 Dispatchers 2 Supervisor 1 Clinical Advisor 4 Call takers 3 Dispatchers 2 Supervisor 1 Clinical Advisor 6 Call takers 4 Dispatchers 2 Supervisors 1 Clinical Advisor 7 Call takers 6 Dispatchers 2 Supervisor 2 Clinical Advisor 9 Call takers 7 Dispatchers 2 Supervisors 2 Clinical Advisor 12 Call takers 8 Dispatchers 2 Supervisor 3 Clinical Advisors * Note: Insufficient workstations currently available to achieve this level of peak staffing. ** DR Site contains 13 ICCS Positions 8 Call takers plus 2 supervisor 10 Dispatchers plus 2 Supervisors s 2 Clinical Advisors 11 Call takers plus 2 Supervisor 10 Dispatchers plus 2 Supervisors 2 Clinical Advisors 15 Call takers plus 2 supervisor and 1 Paramedic Advisor 10 Dispatchers plus 2 Supervisors 3 Clinical Advisors 10 Dispatchers 8 Call Takers 1 Clinical/Supervisor 10 Dispatchers 8 Call Takers 1 Clinical/Supervisor 10 Dispatchers 8 Call Takers 1 Clinical/Supervisor Doc & page: Page 6 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

Capacity Modelling - continued b. Operational Service anticipated effect with increasing levels of demand Operations Operations Operations Function A&E Service PTS ACC Number of staff to meet normal Local core service rotas Local core service rotas Core service rotas levels of demand Overall Close Dialogue with NHS stakeholders / Category 1 and 2 responders / RRPs required for all functions and again on identification of threat, with assistance from NRRD. Standard preventative and mitigating actions (vaccination, training, fleet) Normal service delivery Close Dialogue with NHS stakeholders Standard preventative and mitigating actions Normal service delivery Close Dialogue with NHS stakeholders Standard preventative and mitigating actions Normal service delivery Increase in overall demand / decrease in availability / capacity Additional increase in overall demand / decrease in availability / capacity Additional increase in overall demand / decrease in availability / capacity Need to maximise shift cover to maintain performance and prioritise additional areas for support Unable to staff non-core shifts. (have used maximum use of relief, O/T and re-allocation) Have utilised additional support from SORT (at additional cost) Unable to sustain cover at some stations / locations (shut down locations according to priority) Managers, other staff with operational experience deployed operationally Missed list patients not transported, re-ordering required Reduced support to A&E service concentrating on priority PTS only Additional FPOS / First responder / VAS Required, deploy to A&E Close liaison with Hospitals Insufficient capacity to accept P3 patients No support for A&E service Look at support from other agencies, joint working and Voluntary Aid Society Dynamically manage capacity through escalation plans. Increased Overtime usage Fatigue, sustainability issues apparent Use of dual trained call taker/dispatchers Review of Skill Mix e.g. call taker/dispatcher Increased Overtime usage, potentially increasing staff fatigue, not sustainable in long term Consider using former ACC staff and staff trained as call takers Additional increase in overall demand / decrease in availability / capacity Additional increase in overall demand / decrease in availability / capacity Additional increase in overall demand / decrease in availability / capacity External assistance identified as necessary, Police, Fire, MCA etc. Insufficient capacity to maintain core shifts at some locations Identified need to re-order shift cover and redeploy staff within / between Divisions Need to redeploy staff from specialist operations re-deploy trainers into management/operational roles Need for mutual aid identified. (Continued dialogue with planning partners regarding support) Unable to maintain specialist operations Air Ambulance, SORT. UK Mutual Aid required to sustain CAT A. Cat B triaged and prioritised Insufficient capacity to attend all Cat B evaluate Cat A - further prioritisation of category A calls. Respond to assessed life threats only. All calls actively triaged. Necessity to use of volunteers within communities (small voluntary groups) Deployed assistance from all emergency services, MOD etc. Sustainability in question Prioritisation required Insufficient capacity to accept P2 patients Insufficient capacity to accept all P1 patients, prioritisation in place. No capacity for P2, P3 patients Imminent failure - Resources to be targeted to high-risk patients / key tasks only. Need to engage all alternative voluntary, statutory and commercial service / transport providers Fatigue, morale, welfare and sustainability issues Reduce / suspend IHT activity Use of external staff trained in EMD i.e. RAF Personnel or selected operational staff to maintain patient safety. MACU and other PDA protocols suspended for all but confirmed or protracted Major Incidents Re-deploy Administration staff into support positions Return to paper systems Serious risk of long delays in call pick up times and activation. Unable to handle non emergency calls 999 calls only. GP line shut down. Unable to sustain 3 ACCs merge into 2 or 1 Centre Fatigue, morale, welfare and sustainability issues Doc & page: Page 7 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

6. Resource Escalatory Action Plan - REAP Capacity Management Contingency Plan and Resource Escalatory Action Plan (REAP) 1. Introduction a. Since 2004, the Scottish Ambulance Service has maintained a Capacity Management Contingency Plan which has been implemented during times of capacity challenge. This plan was developed by NRRD to meet the needs of the Service, including arrangements for re-prioritisation and suspension of activity, structured reduction in service provision and redeployment of personnel. The triggers in this plan were originally common with those developed and set by NHS 24. b. The Scottish Ambulance Service originally rejected the adoption of the REAP plan used by the other UK Ambulance services as it was less sophisticated than the existing Capacity c. To ensure consistency across UK Ambulance Services with impending pandemic outbreaks the NRRD worked with UK Ambulance Colleagues in the production of a revised UK REAP plan. This plan was adopted to ensure consistency, allow comparability and a common language when dealing with issues at a UK level and due to its relative simplicity. d. The plan has been designed to work in conjunction with the SAS Pandemic Outbreak Contingency Plan, Major Incident Plan and Business Continuity Plans at a local level, all of which are designed to manage capacity issues. e. The REAP component of the plan has been developed further to be more effective as a decision support tool. 2. Background a. Unlike the operational model within some other emergency services, it is recognised that Ambulance Services work operationally at, or near, capacity, especially in urban areas for much of the time. This fact causes a degree of vulnerability in the delivery of patient care, due to lack of surge capacity, an inability to make available additional resources to deal with significant increases in demand. b. There have been occasions, e.g. Winter Pressures, when the SAS has established its Strategic, National Command and Co-ordination Centre (SAS-NCCC) to monitor performance, report on the processes which may impact on the ability of the Service to maintain performance against targets and allocate resources across operational divisions consistently in accordance with national priorities c. This Plan follows the REAP model, but with triggers and specific measures provided by the operational Divisions and ACCs for implementation when the Service is operating at capacity. Doc & page: Page 8 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

3. Intention a. It is the intention of the Scottish Ambulance Service to continue to deliver a high level of patient care for the population of Scotland when experiencing capacity pressures, in keeping with the ethos and strategy of the Service. This recognises the need to maintain public confidence and the good reputation of the Service. b. During periods of high demand pressure, the SAS will consider a variety of operational, tactical and strategic options that are considered most suitable to address the prevailing operational situation. These options are designed to safeguard the most critical and vulnerable patients, by re-deploying resources from other functions in order to protect mission critical activities. c. REAP recognises the benefit of a national organisation to support functions through the application of internal mutual aid. d. There will be an overall REAP level for the Service. This should be expressed by the Chair of the daily conference call. Each Division and NRRD will declare a REAP level, which will contribute to a national REAP level. National REAP level 4 and above require to be authorised by a member of the Executive Team. e. Each Divisional Team or function should also be aware of their individual REAP level for that function. f. The determination of the REAP level is made on the basis of a combination of factors, not on performance alone. g. Declaration of a REAP level results in the actions specified at that level being available to managers responsible for their implementation. There is an expectation that unless circumstances dictate otherwise, the actions identified in the plan will be implemented. 4. Actions a. The decision to implement the level of REAP resulting in escalation will be driven by those with responsibility for the delivery of that sector of core business. b. Decisions may be made at a national level for the benefit of the Service overall. Therefore, this may result in resources being redeployed from an area of lower concern to one with a greater need. c. All Managers must be fully conversant with the contents of this plan and the actions required to implement it. d. When a REAP Level is declared the responsible person should ensure due consideration is given for implementing the actions that will mitigate any capacity issues. This should be discussed at Daily conference call. e. Managers must be aware of when it is appropriate to notify the Director of Service Delivery (On-Call Executive Team or deputy) to escalate the plan to the next level in order to implement a necessary action. f. Table 1 shows the different REAP levels which will be applied: Doc & page: Page 9 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

g. Table 2 illustrates the triggers for determining the REAP level. h. Table 3 illustrates mitigating action. i. General Managers, or their deputy, may use this guide to determine the level of impact within their area of responsibility and should declare an appropriate level to allow them to take the action specified in the plan to reduce the impact. j. The National Operations Manager will be responsible for determining the Services (National) REAP level at any given time. Table 1: National REAP Levels REAP Level 6 Potential Service Failure REAP Level 5 Critical REAP Level 4 Severe Pressure REAP Level 3 Moderate Pressure REAP Level 2 Concern REAP Level 1 Normal service Doc & page: Page 10 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

5. Key triggers a. Each trigger has several components which are weighted. Judgement is required to consider whether enough components have been met to activate the trigger. Each trigger results in an escalation of the level and then requires actions to be taken as a result. A&E Cat A performance is not intended to be a trigger to move to a higher level. Performance should be regarded as a consequence rather than a trigger. b. The weighting applied to each factor affecting performance within the plan should be applied and an average position selected to reflect the position within a Division or across the Service. c. Triggers are designed to take into consideration predicted activity over a period of time such as an operational shift and in anticipation of the forthcoming situation, rather than a snapshot of events at a given time. d. In addition to the key triggers, failure of mission-critical or vital support departments or functions may trigger an escalation of the REAP levels and will be declared as necessary. When taking action in this plan, the relevant managers must refer to their own local Business Continuity Plans for local contingency arrangements. e. General Managers or Heads of Service / Department may also choose to activate parts of the plan in their Areas / Departments, if their local Area / Department is coming under sustained pressure even though National plan escalation has not been triggered. f. Changes to the national REAP level will be notified to All Active Users through the Splash Report by the National Operations Manager (NOM) and the REAP Status Board on the Intranet (@SAS) will be updated should the REAP rise to or above Level 3. Doc & page: Page 11 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

Table 2: Triggers for implementation of a REAP level (based on range of factors affecting the Service) REAP Level 6 5 4 3 2 Demand 25% Service Activations > 15% above norm Service Activations 10% -15% above norm Service Activations 8% -10% above norm Service Activations 5% - 8% above norm Service Activations 2%- 5% above norm Abstractions 25% Abstractions within the Service have increased by > 15% over normal seasonal levels. Abstractions within the Service have increased by 10%- 15% over normal seasonal levels. Abstractions within the Service have increased by 8-10% over normal seasonal levels. Abstractions within the Service have increased by 5%-8% over normal seasonal levels. Abstractions within the Service have increased by 2%-5% over normal seasonal levels. Control Room Issues 25% Abstractions within Control have increased by >20% over normal seasonal levels. Abstractions within Control have increased by 15% over normal seasonal levels. Abstractions within Control have increased by 10% over normal seasonal levels. Abstractions within Control have increased by 5% over normal seasonal levels. Abstractions within Control have increased by 2% over normal seasonal levels Factors Affecting Performance External Influences 10% Supply chain / Fleet / Adverse Weather / external event issues are having a national / UK impact Supply chain / Fleet / Adverse Weather / external event issues are having a significant impact on an ACC area / multiple Divs Supply chain / Fleet / Adverse Weather / external event issues are having an impact on more than one Division Supply chain / Fleet / Adverse Weather / external event issues are having a more widespread impact on activity (Division) Supply chain / Fleet / external event issues are having a limited local impact on activity. (Sub Division) NHS Internal Influences 15% Extensive major critical infrastructure issues have been experienced for a period of 24hours and are expected to continue for an unspecified time. Hospital closures to admissions causing catastrophic difficulties Increase in IHT s causing increase in demand and displacement of resources. Extensive major critical infrastructure issues have been experienced for a period of 24hours and are expected to continue for an unspecified time. Hospital closures to admissions causing severe difficulties Increase in IHT s causing increase in demand and displacement of resources. Hospital closures to admissions causing major difficulties Increase in IHT s causing increase in demand and displacement of resources. Extensive major critical infrastructure issues have been experienced for a period of up to 24hours and are expected to continue for a specified time of no more than 24 hours before resolution. Hospital / Dept closures to admissions causing moderate difficulties Increase in IHT s causing increase in demand and displacement of resources. Critical infrastructure issues have been experienced for a period of 12hours and are expected to continue for a specified time of no more than 6 hours. Hospital / Dept closures to admissions causing minor difficulties. Increase in IHT s causing increase in demand and displacement of resources. Limited Critical infrastructure issues have been experienced for a period of 6 hours and are not expected to reoccur. (e.g. ACC systems failure) 1 Service Activations < 2% above norm Abstractions within the Service are within normal seasonal levels. Abstractions within Control are within normal seasonal levels. No reported supply chain difficulties No severe external events are a threat to activity No hospital delays over 20 minutes / in keeping with accepted norms. No critical infrastructure issues Doc & page: Page 12 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

REAP Level Table 3: Mitigating Actions Responsible Person Increase Capacity Control Change process - Control Increase Capacity Field Ops Change Process Field Ops Manage Demand Command and Control 6 5 4 National Gold Commander National Gold Commander National Gold Commander International mutual aid Move all available staff to front line duties. Identify staff for national coordination centre Deploy volunteer back room staff trained in short call taking course or dispatcher course. Utilise other emergency service staff etc Engage with community groups for assistance National / UK mutual aid Identify staff for national coordination centre Suspend all training/, secondments and projects Increase Airwave users within Control for dispatch Utilise PTS/OOH/NHS24 Control staff Postpone non-critical training. Caveat leave request approvals Request those on leave and off duty to consider working. Suspend non-critical meetings Deploy VAS Control trained staff Redeploy admin staff to ACC Identify staff for national Command and Co-ordination centre Establish home working within support roles Request Doctors assistance in Control to triage health professional requests Use clinicians to supervise non clinician triage protocol. Agree no-send policies with SG and triage all calls. Consider suspension of CAT C and if required Cat B. consider triage response to CAT A Increase Clinical Advice and triage Dynamically manage capacity issues within control Where appropriate further increase support from NHS 24, VAS, NHS Boards Deploy operationally experienced managers, 1 st aid and FPOS trained to calls Set up special incident desk Ensure issues referred for decision / management cell Dynamically manage capacity issues within control Where appropriate further increased clinical and call taking support from NHS 24 & increase further Paramedic Advisors and call takers Fleet to be represented in the NCC International mutual aid Deploy clinician with non clinical driver (PTS VAS, volunteer, other emergency services, MOD etc.) Suspend annual leave Review SORT/HEMS deployment Engage with community groups for assistance National mutual aid Suspend all training/ secondments and projects Bring in additional/ retired/wider health Service staff where possible Deploy volunteer back room staff Review SORT/HEMS deployment Suspend non-mission critical training. Request those on leave and off duty to consider working. Increase numbers of FPOS / 1 st responders redeploy to other locations Consider redeployment of Community Resilience staff to frontline duties FPOS Staff to low acuity duties Consider support from local health board clinically trained staff and review skill mix. Review treat and discharge education for all paramedics Consider use of other AHP/nurses / other health professionals, community volunteers to respond Consider most appropriate Patient Report Form On-going dialogue with NHS Boards, consider colocation of managers Review the skills mix on A&E, using PTS, VAS etc. Review attendance at Nursing Homes without prior Doctor approval Intensive liaison with HBs Reduce IHT Gauge support from other Emergency Services Prepare for mutual aid Concentrate trained staff in single response vehicles to make initial assessment / triage Deploy selected PTS to A&E / Ist Response Outsource fleet servicing Deploy VAS/PTS to undertake low acuity A&E workload Consider flexible redeployment of staff to effect best A&E mix Actively review all IHT s Agree no-send policies with SG and triage all calls. Consider suspension of CAT C and if required Cat B. consider triage response to CAT A Review all PTS P1 only Only undertake critical emergency inter hospital transfers Doctors admissions extended time to 4 hours at patient triage by Doctor Consider stopping attending CAT C Calls. Respond only to CAT A and remaining CAT B calls. Triage all calls Reduce or suspend noncritical IHT Review all PTS activity except P1,Renal, Oncology and Discharges Review attending private events Stop work to Day Hospital Units and Outpatients Reduce or suspend P2/3 PTS Maximise fleet availability, suspend routine maintenance activity NCCC Provide Direction, leadership, command and control, all key functions represented 24/7 media, comms and engagement UK co-ordination centre 12/7+ All Ops Directorate Managers on duty 24/7 cover Attend RRPs and SG meetings Policy decisions required Consider declaration of major incident Ensure Media and external communication is maximised NCCC to direct resources and functions to meet national priorities up to 24/7 Consider declaration of major incident UK co-ordination centre 12/7 Tactical managers 24/7 Seek suspension of performance targets Full engagement NHS / ES / SG Set up NCCC to collate information, monitor performance and provide SITREPS to SGHD. Fleet rep in NCCC Consider declaration of major incident Conversation with RRP partners Audit local compliance with plan. National daily conference call Operational conference calls 4h Tactical managers on duty 12/7 Operational Mgrs on duty 24/7 Consider open national management talk groups for communication Consider management shift plans to ensure 24/7 cover Doc & page: Page 13 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

3 2 1 Divisional General Managers NOM/ACC Managers Head of Service / Department NOM Redeploy suitably qualified staff for frontline duties Review all secondments Consider Deployment of additional/ bank/ ACC trained non-acc / retired staff Cancel non critical meetings Redeploy ACC not engaged in critical activity (Monitoring etc.) Notify Buddy arrangements of Service pressure Ensure paramedic advisors have adequate support Consider Deployment of operational staff with Control background Increase in clinical capacity by deploying Paramedic Advisors Service provision at normal levels, standard procedures apply Dynamically manage capacity issues within ACC & increase Paramedic Advisors or other clinical support for triage Where appropriate further increase support from NHS 24 or clinical staff located within the ACC Where appropriate increased support from NHS 24 Service provision at normal levels, standard procedures apply Review secondments Cancel non critical meetings Qualified staff/managers used for frontline duties Review supply chain resilience Consider on-call maintenance cover Consider additional hours for maintenance staff Prioritise workload in relation to demand. Redeploy vehicles from other locations Cancel non critical meetings Maximise relief deployments Maximise core shift cover Consider Increase in overtime for crews (in consultation with Director of Service Delivery) Consider deploying VAS Service provision at normal levels, standard procedures apply Consider Deployment of VAS/PTS to undertake low acuity workload Consider Deployment of dedicated capability to triage town activity hotspots. Deploy non-operational managers to A&E depts. to manage turnaround. Redeploy vehicles. Seek additional support from SORT (Overtime) Coordinate availability of 4x4 assets. Consider alternative care pathway Consider Deploy Operational A&E / Performance Manager to ACC and or Hospitals Service provision at normal levels, standard procedures apply Cease non core functions in Control Review attending Private Events Communication with NHS 24 and NHS Boards Reinforce PTS eligibility criteria Service provision at normal levels, standard procedures apply Operations conference call, twice or more daily Fleet representative required on conference calls Deploy Media campaign Provide dedicated local monitoring cell Adhere to local plan Provide regular SITREPS / exception reports to NRRD Consider open local management talk groups for communication Use of external media to issue message of using the service with responsibility in line with NHS and responders Consider special staff bulletin / open talkgroup message highlighting current pressures to operational staff Operations consider conference call, twice or more daily Local Conference Calls within Division / department Adhere to local delivery plans. Provide exception reports to NRRD Managers familiar with plan Produce communications plan Use of external media e.g. website, twitter to issue message of using the service with responsibility. Ensure operational staff are aware of REAP Level Service provision at normal levels, standard procedures apply. Standard operational model includes prevention and mitigation including staff vaccination, staff, vehicle and equipment availability. Management teams use historical data and live information to predict likely impact Doc & page: Page 14 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

6.0 Intelligence gathering a. The key to managing the triggers in Section 4 is early identification of issues and potential for disruption. b. Any of the relevant resources of the SAS may provide evidence of capacity pressure. These may include: Executive through day-to-day reporting and SAS NCCC (if established), Management Team, Operational Management Team, Resilience Committee, SORT, NRRD, Business Continuity, Risk Management, Divisional Management, Local Operational Management Teams, Partnership Forum and Health and Safety Committee, HR Implementation Team, Fleet Department etc. c. External sources may include: Scottish Government Resilience Advisory Board, RABS other groups, SGoRR (O), Regional Resilience Partnerships (RRP s), SGHD Resilience, Pandemic Influenza Co-ordinators Team (SGHD), Health Boards (x14), Usual liaison arrangements with SGHD, NHS Boards, HPS, NHS24, Voluntary Aid Societies, other Ambulance Services (through Ambulance Service Network National Ambulance Resilience Unit), Local Authorities, Police, Fire, MOD, MCA etc. d. Clearly no exhaustive list can be prepared of all sources of information. Managers must be alive to the need for the collection and appropriate dissemination of information and intelligence that could indication the potential for a capacity pressure. Such intelligence should be reported on conference calls, through the chain of command, to the Executive Team Member On Call for consideration. Specific pressures should be discussed during operational conference calls. 6.1 Co-ordination and assessment of information 6.2 Structure e. General Managers (or their nominated deputy) will be responsible for assessing the key triggers and advising the Executive Team Member On Call (or Deputy) and NRRD when triggers have been reached. A review through a conference call will advise that this task has been carried out. f. The Executive Team Member On Call (or Deputy), will declare changes to the REAP level, which will then be advertised widely across the Service via the Intranet and confirmed on conference calls. g. Having been made aware of a developing, deteriorating or potentially serious situation, the Executive Team Member On Call (or deputy) may call a capacity management meeting at the necessary level, to take action. h. Core attendance (Conference Call) will vary depending on the trigger that has been reached, but will normally include a selection of the following: Executive Team Member On Call, General Managers, Heads of Service, NRRD, National Operations Manager, Head of Education and Development, WFP Manager, Fleet Manager, Information Analyst, PPU Manager, Communications and IT Services Manager, Finance Director. i. The duty Strategic Manager will lead the recovery effort, supported by all Departments. j. The National Operations Manager (or appropriate senior manager) will re-convene meetings, as required, to review progress and determine any necessary further actions/activity. Doc & page: Page 15 of 21 MH/NRRD/Capacity protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service

National Ambulance Coordinating Centre Daily Information Template Appendix 1: National Co-ordination Centre Reporting Template The following information should be returned on a daily basis by e-mail to the National Coordinating Centre (NCC) by 10.am. A summary position for all UK Trusts will then be compiled and returned to all Trusts by 12 am each day in preparation for the 13.00 conference call. CAT A Activity % of Norm CAT B Activity % of Norm CAT C Activity % of Norm Overall Activity % of Norm AMB Availability % of Norm FRU Availability % of Norm Fleet Availability % of Norm SORT/HART/USAR Availability % of Norm Control Room Availability % of Norm Hospital LAS SECAM SCAS SWAS EOE NEAS NWAS YAS EMAS WMAS GWAS IOW Scotland Wales N.Ireland 1 st December 2014 Equality & Diversity Impact Assessment November 2012 Doc & page: Page 16 of 21 MH/NRRD/Capacity Printed versions of this document are uncontrolled and may not be extant check the Service intranet or with the document author. The Scottish Ambulance Service title, crest, uniform & vehicle design are variously protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service 2005

Turnaround Delays None/Moderate/Severe Absence Levels Field Ops % above Norm Absence Levels Control Rooms % above Norm Absence Levels Support Staff % above Norm Essential Supply Chain Difficulties None/Moderate/Severe Requesting Mutual Aid Yes/No./Consideri ng REAP LEVEL 1 st December 2014 Equality & Diversity Impact Assessment November 2012 Doc & page: Page 17 of 21 MH/NRRD/Capacity Printed versions of this document are uncontrolled and may not be extant check the Service intranet or with the document author. The Scottish Ambulance Service title, crest, uniform & vehicle design are variously protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service 2005

7. Contact details a. Routes of Communication ACC ACC Primary and Contingency Routing if not answered North (Inverness) ACC (North ACC Emergency Planning) Re dial East or West Numbers (Duty ACC Manager Mobile not recorded) East (Edinburgh) ACC (East ACC Emergency Planning) Re dial West or North Number (Duty ACC Manager Mobile not recorded) West (Glasgow) ACC (West ACC Emergency Planning) Re dial East or North Numbers Other Divisions and Departments (Duty ACC Manager Mobile not recorded) Normal arrangements apply NHQ Via local ACC, Edinburgh ACC for National Departments b. Routes of Communication SAS National Command and Coordination Centre (SAS- NCCC) Primary Contingency c. Routes of Communication NHS 24 NHS 24 Public Access NHS 24 North NHS 24 East NHS 24 West Landline Mobile Landline Mobile Landline Mobile d. NHS 24 Dial-in details for conference calls: BT Meet-me dial-in number Participant Passcode e. NHS 24 Partner SPOC information: Partner Organisation Contact Role (e.g. Hub Duty Manager) Clyde Ayrshire & Arran Borders Dumfries & Galloway DGPSOC Fife Hub Forth Valley Hub Alloa Glasgow Telephone number 1 st December 2014 V 4..7 Equality & Diversity Impact Assessment November 2012 Doc & page: Page 18 of 21 MH/NRRD/Capacity November Printed versions of this document are uncontrolled and may not be extant check the Service intranet or with the document author. The Scottish Ambulance Service title, crest, uniform & vehicle design are variously protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service 2005

Partner Organisation Contact Role (e.g. Hub Duty Manager) Grampian Hub Highland & Argyle Hub Lanarkshire Lothian Orkney Shetland Tayside Western Isles Telephone number f. Scottish Government Health Department Performance Management Division: Officials oncall: emergency contact details. Note: NHS 24 may be required to report to the Scottish Government Performance Management Division any issues and exceptions in respect of out of hours service and resources, including those of partner agencies. Therefore, if requested, partners must advise NHS 24 / SGHD of capacity or technological problems and implementation of contingency measures. Date Official Contact Number TBN TBN TBN Note: Normal office contacts can be used during working days between Christmas and New Year. Duty Press Officer: - Contact through general number g. Scottish Government Health Department EPU: emergency contact details. Department Official Phone Fax Mobile Pager Generic Email SG Health Department Resilience Unit Head of NHS Scotland Resilience Deputy: Out of Hours Pager No: Security team (fall back for pager) Deputy: 1 st December 2014 V 4..7 Equality & Diversity Impact Assessment November 2012 Doc & page: Page 19 of 21 MH/NRRD/Capacity November Printed versions of this document are uncontrolled and may not be extant check the Service intranet or with the document author. The Scottish Ambulance Service title, crest, uniform & vehicle design are variously protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service 2005

8. Divisional / ACC local action plans - General Common principles, as outlined in this plan apply. Territorial General Managers will be responsible, in liaison with appropriate representatives of NHS Boards, other planning partners and stakeholders, and in collaboration with National Operations Managers, for planning local provision and will manage local resources in the event of exceptional or extraordinary pressures on emergency services. National Operations Managers will be responsible for operational systems within those Centres. Adverse occurrences will be notified to the NRRD and Directors, as required, in keeping with existing risk management policy regarding escalation. Local arrangements in place currently vary, but typically may include: a. Regular dialogue with local NHS Managers at multiple levels (including NHS 24) and involvement in national and local project or working groups about capacity planning, including out of hours provision and consequences of service redesign. Local planning should include requirements for communication with patients. b. Area Service Managers / NOM s empowered to vary resource levels / patterns of work to take account of high demand or otherwise reduce the impact of disruption. c. A planned increase in staffing levels within the operational service and ACC at times of historical or anticipated peak demand. See the ACC winter plan for forecasting data. d. Variation to existing levels of PTS provision, including additional resources to limit any effect on the A&E service due to the needs of renal patients or for inter-hospital transfers. Typically would include additional discharge or patient transfer resources or additional support for renal or oncology patients. e. Redeployment of specific personnel with defined skills (such as ACC call taking or FPOS) to alternative duties. f. Regionalisation of resources such as relief staff, officers and vehicles. g. Provision of additional dedicated ambulance resources, including managers at major crowd gatherings to limit the effect of additional or surge demand on the Service. h. An understanding that it may be necessary in extreme circumstances to prioritise workload, scale-down or suspend the PTS, training or meetings and redeploy managers and support staff to assist the accident and emergency service / ACC. i. Management of local personnel and welfare issues. j. In the event that activity and resource allocation needs to be prioritised at a pan-scotland level, the Scottish Ambulance service, National Command and Co-ordination Centre will 1 st December 2014 V 4..7 Equality & Diversity Impact Assessment November 2012 Doc & page: Page 20 of 21 MH/NRRD/Capacity November Printed versions of this document are uncontrolled and may not be extant check the Service intranet or with the document author. The Scottish Ambulance Service title, crest, uniform & vehicle design are variously protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service 2005

provide this function and territorial Divisions will provide situation reports and other information to that centre. 9. Local Winter planning arrangements Each Division within the service is required to have local winter planning arrangements in place and have a document outlining the operational issues that they will face and the contingencies and actions identified to mitigate the seasonal capacity and demand issues. This plan will also incorporate local input from territorial NHS Boards and reflected in NHS Board planning arrangements. Local Annexes are owned by Divisions, ACC, Air Ambulance and critical support services and are working documents that are updated regularly to reflect the operational challenges. Updates are then sent to the National Risk & Resilience Department and the Business Continuity Advisor to facilitate and co-ordinate. Further information can be requested from NRRD. 1 st December 2014 V 4..7 Equality & Diversity Impact Assessment November 2012 Doc & page: Page 21 of 21 MH/NRRD/Capacity November Printed versions of this document are uncontrolled and may not be extant check the Service intranet or with the document author. The Scottish Ambulance Service title, crest, uniform & vehicle design are variously protected in European, UK & Scottish law. All copyright is retained by the Service. Scottish Ambulance Service 2005