NHS England (South) Surge Management Framework

NHS England (South) Surge Management Framework

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NHS England (South) Surge Management Framework Version number: 1.0 First published: August 2015 Prepared by: Louise Marchant Classification: OFFICIAL The NHS Commissioning Board (NHS CB) was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes. 3

Contents Contents... 4 1 Executive Summary... 5 2 Purpose... 6 2.1 Definitions... 7 2.2 Terminology... 8 2.2.1 Expectations... 8 3 Governance... 9 4 Roles and Responsibilities... 11 5 Handover/ Diverts... 14 Appendix 1... 16 Minimum Actions by providers and CCGs to be taken BEFORE moving to whole system Black (this is NOT an exhaustive list)... 16 Appendix 2... 18 Minimum Expectations of NHS England (South Local Team) at Alert Status Black (Level 4 escalation)... 18 Minimum Expectations of NHS England (South) at Alert Status Black (Level 4 escalation)... 18 Appendix 3... 19 Serious Incident Investigation (SI Investigation)... 19 Appendix 4... 21 System Operational Situation Report... 21 Appendix 5... 23 The Joint Decision Making Model... 23 Appendix 6... 24 Acute Trust Divert Governance Flowchart... 24 To update the table of contents - right click on the contents table and select Update field, then update entire table 4

1 Executive Summary The NHS Commissioning Board (NHS England) Emergency Preparedness Framework 2013 states NHS funded organisations must: set out how surges in demand will be managed. 1 It notes that Clinical Commissioning Groups (CCGs) through their planning and prevention role in Emergency Preparedness, Resilience and Response (EPRR) should include relevant EPRR elements (including business continuity planning) in contracts with provider organisations in order to: reflect the need for providers to respond to routine operational pressures e.g. winter. 2 It goes on to say that the accountable emergency officer (Director with the EPRR portfolio) will be responsible for: ensuring the organisation has a robust surge capacity plan that provides an integrated organisational response and that it has been tested with other providers and parties in the local community(ies) served. 3 Pressure surges are not a phenomena uniquely linked to winter. They can happen for a number of reasons and at different times of the year. This framework provides a high level overview of the arrangements which should be in place across the South. Local arrangements should build on this to ensure appropriate system resilience and response. 1 NHS England., 2013, NHS Commissioning Board Emergency Preparedness Framework 2013, Section 8.9, pg.20 2 Ibid., Section 9.13, pg.31 3 Ibid., Section 9.18, pg.35 5

2 Purpose This document sets out the principles and processes to support NHS England (South) teams and local urgent care systems to manage surges in demand by mitigating clinical risk and maintaining patient safety by providing a consistent and coordinated approach to the management of pressures. This framework will: set out minimum expectations at Level 4 of escalation (Appendix 2); clarify roles and responsibilities; set consistent terminology/ definitions; and define communications processes. This framework is designed for all System Resilience Groups (SRGs or equivalent) and constituent members within NHS England (South) region. 6

2.1 Definitions An essential part of managing peaks in demand is the ability to communicate effectively and consistently of internal pressures to partner organisations thereby aiding the co-ordination, and implementation of the appropriate actions in each organisation. As such, the following definitions should be applied during times of surges in demand: Definition of Escalation Statuses for SRGs GREEN Escalation Level 1: patient flow management. Business as usual. Capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. Commissioned levels of services will be decided locally. AMBER RED BLACK (whole system) Escalation Level 2: mitigation of escalation the local health system is starting to show signs of pressure. Focused actions are required in organisations showing pressure to mitigate further escalation. Enhanced coordination will alert the whole system to take action to return to green status as quickly as possible. Escalation Level 3: whole system compromised actions taken in Level 2 have not succeeded in returning the local health system to Level 1 and pressure is increasing. The SRG is experiencing major pressures compromising patient flow urgent action are required across the local health system by all partners. Escalation Level 4: severe pressure and failure of actions pressure continues to escalate leaving the local health system unable to deliver comprehensive emergency care. There is potential for patient care and safety to be compromised and a Serious Incident (SI see Appendix 3) is reported by the affected organisation(s). Decisive action must be taken to recover capacity and ensure patient safety. To note it would be extremely rare and the reasons exceptional for a single organisation to declare Black status whilst any of the Local Health Economy (LHE) partner organisations were reporting pressure less than Red level. 7

2.2 Terminology It is not normally expected that escalation would be a cause of a declared major incident as escalation is a result of general capacity and demand rather than pressure caused by a specific event. Whilst it is recognised that there may well be actions that are common to escalation levels 3 and 4 and major incident plans, the latter should not be confused with general escalation due to wider resilience structures and processes in place. As such, local Acute Hospitals may declare an internal significant incident during times of great pressure or Business Continuity Incident where they activate their Business Continuity arrangements but should reserve the declaration of a major incident for when an organisation requires the formal multi-agency response as defined within Local Resilience Forum (LRF) plans. For example fire, flood or infectious disease outbreak. Colleagues are asked to ensure that appropriate use of language accurately reflects the severity of the incident in plain language. 2.2.1 Expectations Individual SRGs are expected to manage the escalation and de-escalation processes at a local level. This framework does not seek to define or prescribe the detail of coordination arrangements in place for Green (Escalation Level 1), Amber (Escalation Level 2), and Red (Escalation Level 3) status; these should be determined locally. Each SRG should have in place agreed protocols and actions for operational and tactical measures to be taken by individual organisations. Only when all escalation measures have been exhausted and the system is not recovering will organisations act from a position of last resort. As such, external assistance may be required. The trigger for request for extended external assistance (to access further capacity beyond SRG boundaries) will be the declaration by the SRG of whole system Black status (Escalation Level 4). See Appendix 1 for minimum expectations before declaring whole system Black. 8

3 Governance The table and information below reiterates the governance and accountability for all levels of incidents and how these relate to NHS England, System Resilience Groups, CCGs and providers. Responsible Organisation NHS England (South) NHS England (South - Local Team) CCG Framework or Plan NHS England (South) Surge Management Framework / NHS England Incident Response Plan NHS England (South) Surge Management Framework / NHS England Incident Response Plan/ Local Health Resilience Partnership Plans System Resilience Group/ Organisational Resilience and Capacity Plan/ Surge Capacity Plan NHS England (South) Surge Management Framework Escalation Level 4 (for information) Escalation Level 4 Escalation Level 1-3: An incident that can be managed by local organisations coordinated by the lead CCG Providers Provider Surge Capacity Plans An internal incident that can be managed by a single provider Expectations Each SRG is to have in place a whole system escalation plan that describes triggers, actions and timescales for resolution during times of surges in demand. For example: o o o o o regular conference calls; monitoring and sharing data through daily reporting via local information systems/ dashboards e.g. CMS; handover/ ambulance divert policy; managing A&E four hour performance; and Primary Care and NHS 111 out-of-hours arrangements. Each partner to have a robust, clear and up to date local escalation plan which has been signed-off at organisational Board level. All plans need to be accepted, aligned and signed-off by SRG partners. 9

Each SRG to ensure plans are fit-for-purpose and support the relevant assurance process. CCGs remain accountable and will retain oversight for their commissioned services (including Commissioning Support Units (CSUs)) who may provide a surge management function), and joint responsibilities for co-commissioned services. Any assurance conducted by NHS England to check consistency of plans will be measured against this framework. Plans should be reviewed and updated annually taking into account any lessons identified. 10

4 Roles and Responsibilities This section set out the roles and responsibilities to be undertaken at times of surges in demand by the CCG and NHS England. Where CCGs have commissioned CSUs to provide surge management function, the majority of roles and responsibilities in the table below will on a day to day basis be carried out by the CSU. CCGs/ CSUs should agree locally exactly how CCGs are kept abreast of the situation and what reporting will be required by CCGs to help them to discharge their legal duties (Health and Social Care Act 2012) including keeping on-call Directors briefed so that they can respond to surge related matters out-of-hours if local arrangements required them to do so. CCGs/SRGs retain accountability for local surge management and must retain oversight of their local situation. Organisation Role/ Responsibility CCG/ CSU Proactively lead the SRG response to pressure surges, on a day to day basis (both in and out of hours) To keep in touch with the day to day situation across the patch and be aware of any developing issues. This includes information on community services, mental health etc. Maintain oversight of the LHE and social care system and monitor receipt of hot/ cold/ flooding alerts and ensure appropriate actions are taken in response. Be aware of the measures taken by commissioned partners to address increased demand for NHS services. Ensure that providers maintain timely updating of local information systems e.g. CMS system to provide a complete picture of the pressures in their patch. Broker agreements across the patch and ensure mutual aid is available if required to re-balance pressures (e.g., acute and community services). NB Where possible this must be primarily through co-operative and collaborative working with all providers of NHS services recognising the overriding imperative to the provision of safe and timely services. The CCG / CSU would be expected to arbitrate between local providers to ensure an appropriate outcome is reached, bearing in mind the above priority if this is not possible. If there is protracted 11

Organisation NHS England (South Local Team) Role/ Responsibility failure to reach a conclusion favourable to patient care, NHS England may intervene to help reach a resolution. Liaise with local ambulance services over pressure levels affecting local trusts, and address issues including increased ambulance handover times etc. Ensure Trusts investigate at a senior (executive or nominated deputy) level the reasons for diverts (last resorts) and identify and apply the lessons to prevent reoccurrence. Advise NHS England if there are any actions that cannot be taken locally in partnership with CCGs. Ensure that all partner organisations are working effectively together to ensure that sufficient capacity is in place to deal with demand including patient discharges. Liaise with bordering CCG/ CSUs on any issues which may impact their own pressures. Commission additional resources (beds, staff etc.)/ ensure local CCG demand management initiatives are working during times of surge. Ensure a full investigation/ Serious Incident investigation takes place for providers reporting black and share these findings with the SRG. Ensure actions are implemented to prevent reoccurrence. Ensure that learning throughout and periods of demand for evaluation in the Spring to inform ongoing Operational Resilience and Capacity Planning (ORCP) and preparedness Ensure NHS 111 DOS is kept up to date in respect of any changes to community capacity. Ensure a debrief takes place following a system-wide black. Maintain arrangements to review daily pressure across the NHS. Put a process in place to inform providers of relevant alerts. Provide advice and guidance to CCGs on the handling of escalating situations. Where applicable locally NHS England to be informed of any agreed diverts. Agree reporting requirements at a local level. Work collaboratively with TDA and Monitor to agree a consistent approach to developing situations and actions expected as a result. Ensure that appropriate communication routes are followed if pressures affecting Trusts outside of the local area are likely to impact across boundary and vice versa. Implement coordination arrangements as pressure 12

Organisation NHS England (South) Role/ Responsibility levels increase across agreed thresholds (agree thresholds). Ensure that lessons learned events are held locally and updated plans reflect the actions identified and agreed. Share lessons across the LHE. Inform NHS England (South) and NHS England Comms (South) when local system pressure is likely to result in loss of confidence and reputation. Inform NHS England (South) for information only regarding system-wide black and actions being taken. Provide oversight and coordination to local NHS England teams where system-wide black applies across a number of areas in the region. Proactively brief and liaise other NHS England regions and central team as appropriate. Support local NHS England teams as required (resource). Liaise with Monitor and TDA where appropriate. 13

5 Handover/ Diverts The best practice standard for the timely clinical handover of a patient by an emergency ambulance crew to hospital staff is 15 minutes. (Flory, 2012) There are a number of reasons why this standard may not be achieved by a receiving hospital. This includes peaks in activity, availability of hospital staff and availability of a physical space to transfer the patient to within the Emergency Department (ED). It could also be due to reduced flow through the ED admissions process due to capacity pressures within the wider Acute Trust. Ambulance delays at acute trusts, the deflection of ambulances or the closure of a hospital ED can result in increased clinical risk to the patient. Delays increase pressure on other local services, increasing waiting times for patients in both the hospital concerned and in neighbouring Trusts. In addition, there is the potential for these effects to impact on the NHS response capability to 999 calls, both by the ambulance service and also the emergency departments. For these reasons, decisions around these types of issues cannot be made in isolation and should be made in consultation with commissioners see Appendix 6 for further detail. All local divert policies should only be considered in extremis and must reflect the following principles and form the basis for all capacity considerations and actions taken. NHS Managers must ensure a consistent and evidence based approach to decision making. The Joint Decision Making Model (JDM) (see Appendix 5) has been adopted by the NHS as an exemplar of good practice and should therefore be utilised. The SRG will have health economy escalation procedures in place to ensure that early action is taken to prevent a crisis rather than reacting once it has occurred. Patient safety and dignity takes priority over everything; all actions must be focused on providing patient access to definitive medical care. 14

Taking a patient to an alternative ED is only appropriate if: the closest receiving unit is physically incapable of providing the right care in a safe environment (Emergency Divert); or demand and / or delays result in Ambulances queuing for significantly prolonged periods, and existing escalation and surge management plans have not been effective (Formal Divert). All Formal Diverts must be investigated to prevent reoccurrence wherever possible and the requesting acute trust must complete a serious incident report within 48 hours and forward to their lead commissioner. No Acute Trust will close to life threatening 999 patients unless physically incapable of providing care and resuscitation facilities through fire or loss of access (Emergency Divert). Under no circumstances should diverts be used to protect elective beds or, to avoid excessive waits in Emergency Departments. A Divert request should only be made when: trusts have implemented their escalation and surge management plans to the full without reducing the system pressures to a safe level; system wide escalation has failed to alleviate system pressure to a safe level; and requesting acute trust have liaised and secured CCG support before progressing a formal request with neighbouring receiving acute trusts and the ambulance service. It is vital to ensure that appropriate governance arrangements are in place to support the divert decision making process. An overview of the recommended governance arrangements is detailed in Appendix 6. These protocols should be communicated and embedded with all partners and reflected in SRG plans. If and when these agreed plans are instigated the CCG will inform NHS England (South Local Team). 15

Appendix 1 Minimum Actions by providers and CCGs to be taken BEFORE moving to whole system Black (this is NOT an exhaustive list) Refer to local SRG plan CCGs to provide leadership at Director Level across local health economy boundaries as required Executive Directors from all partners have been involved in discussions and agree with escalation status Commissioners to act as the hub of communication for all parties. Local organisations to ensure command and control structures in place for appropriate executive level decision-making. Multi-disciplinary teams to be on wards (PTS, social care, community, MH, third sector, acute and others as appropriate). ED consultant to be present in the department 24/7 Consultant Physician to be present on wards or in ED 24/7 Surgical consultant to be present onwards, in theatre or in ED 24/7 Routine elective admissions have been cancelled Urgent elective admissions have been reviewed and, where possible, rescheduled or cancelled All discharge management processes are in place and are being fully implemented. Implement seven day discharging for the appropriate services (pharmacies, community) Continue to expedite discharges; instigate reluctant discharge process, increase capacity and raise access thresholds to prevent admission where possible DoS Lead to ensure that any changes to service provision are logged on the DoS, and that NHS 111 Provider is aware of changes to service provision and the nature of pressure on the system. Complete and submit the Black Escalation current situation report (Appendix 4) to NHS England (South Local Team). The situation report/ dashboard should be completed and submitted before each executive escalation call. 16

Daily teleconferences to take place, with agreed minutes and actions distributed to all partners. Contingency arrangements in places regarding staffing for next 24-48hrs. If system fails to de-escalate following the above CCG to agree a state of black escalation and CCG on-call director to notify NHS England (South Local Team) of system wide black via the on-call routes Report Serious Incident (SI) Black Summit If the system wide black status continues for longer than a period of 3 or 4 days then consideration should be given to holding a black escalation summit with all the executive directors from each organisation to understand the overarching clinical risk and patient safety issues. This should be convened and Chaired by the NHS England (South Local Team) to provide leadership and support to issues identified (this may involve regional clinical input/ engagement e.g. the Regional Medical Director), as well as agree actions to de-escalate the system. Membership should include TDA or Monitor representatives. 17

Appendix 2 Minimum Expectations of NHS England (South Local Team) at Alert Status Black (Level 4 escalation) Sign off the use of support (resources) from beyond locality boundaries Assist in the communications and media handling Share internally issues with direct commissioning services Provide on-call director representation for summit conferences as a participant Post-escalation: contribute to the Root Cause Analysis and lessons learnt process through the SIRI investigation (and sign-off) Direct commissioning ensure briefing role Keep NHS England (South) fully briefed Minimum Expectations of NHS England (South) at Alert Status Black (Level 4 escalation) Liaise with central team as appropriate Coordinate and sign-off the use of support from beyond regional boundaries Provide support and local advice to local NHS England teams Following a Black Summit a timely report should be provided regarding patient safety and care quality, and shared with the Regional Medical Directorate/ Operations and Delivery Directorate Review Strategic Executive Information System (STEIS) report 18

Serious Incident Investigation (SI Investigation) Appendix 3 Information and Guidance for local NHS England On-Call Directors This guidance is linked to the national SI Framework http://www.england.nhs.uk/ourwork/patientsafety/serious-incident/ and the local procedures for reporting and monitoring SIs. This document covers only local NHS England directors on-call and relates to the local procedure which states that: Criteria for informing the NHS England (South Local Team) in the event of a Serious Incident Any serious incident being reported by a service commissioned by NHS England - Primary Care provider, specialist services, offender healthcare services, screening and immunisation. Any serious incident occurring within a CCG. Any Never Events. A serious incident within a CCG commissioned provider organisation where there may be media interest and/or where there are significant immediate healthcare or safety issues. Serious incidents requiring investigation should be reported on the Strategic Executive Information System (STEIS) within two working days of the incident being identified (by the organisation where the incident has occurred as per the SI Framework). 19

In addition, organisations identifying a SI should also contact the relevant commissioner by telephone to enable appropriate plans to be activated or media / communication teams to be alerted where required. Obtain minimum information: The organisation/practice/service reporting The name, designation and contact details of the person reporting The service involved and a summary of the incident A brief note of immediate actions taken by the organisation/service/practice Details of any media interest (or potential media interest) Details of any other agencies involved (e.g. police, fire service, local authority, etc.) Initiate any immediate action relating to patient safety and/or following Major Incident Plans In Hours If necessary, immediately alert the communications team.* Out of Hours If necessary, contact the on-call communications manager. Pass the information as soon as practicable (and within the same working day) to the: Directorate of Nursing Patient Safety Lead On the next working day, alert the communications team.* (if this is required) Quality & Safety Manager *If urgent notification to communications is not required, this may be left for the Patient Safety Lead or the Quality & Safety Manager to follow up. 20

Appendix 4 System Operational Situation Report System Operational Situation Report as of Local geographical Area (including contact no for queries) Current system operational state use escalation policy Green to Black status to describe this and supply broad narrative to complement rating CCG or SRG area submitting SitRep Submitted by: Contact Number: System Status: Green / Amber / Red / Black (delete as appropriate) Organisational Status Green / Amber / Red / Black (delete as appropriate): Acute 1: Acute 2: Acute 3: Community Provider: Our of Hours provider: Private Ambulance service: National Ambulance Service: 111 provider: Narrative:

Exceptional Operational issues Describe any specific operational issues or pressures in the local system that have occurred over the last two days or are currently ongoing. Actions taken or in progress Describe any agreed actions and timescales for delivery to mitigate system pressures NHS 111 To be completed by local team with lead commissioner responsibilities (please complete per provider) Forward Look/ Anticipated challenges Current call answering performance Current performance of calls abandoned Maximum time of call-back wait Average time for call-back wait Reasons for any under-performance issues and what local mitigating action that has been taken. Questions/decisions to be addressed by NHS England Time of next Teleconference and dial in details 22

The Joint Decision Making Model Appendix 5

Acute Trust Divert Governance Flowchart Appendix 6 Requesting Acute Trust at Internal Red Status AND Patient Safety Compromised Acute Trust Director on call contacts relevant CCG director on call; Risk assessment undertaken across local health system Acute Trust agrees need for ED divert with CCG Support Requirements / Actions and Decisions Logged Local System Black status declared Requesting Acute Trust contacts receiving Acute Trust to formally request divert Yes Divert Agreed No Requesting Acute Trust contacts Ambulance Control to request divert support Requesting Acute Trust notifies CCG Director on Call Ambulance can support Requesting Acute Trusts; Ambulance cannot support Notifies CCG Director on call Notifies External Partners SPOC Declares Divert status on NHS Pathway DOS CCG Director on call activates and chairs Strategic Teleconference with; Requesting Acute Trust Receiving Acute Trust Receiving Acute Trust CCG (if different) Ambulance Service If agreement cannot be made CCG Director on call informs NHS England Director on call via the NHS England on call Manager Divert Authorised Divert Ends All parties notified by Ambulance Service Requesting Acute Trust Completes Serious Incident Report to be forwarded to CCG within 48 hours NHS England Director on call will arbitrates between all interested parties via a Strategic Teleconference; If no agreement is reached can overrule or support CCG in identify alternative receiving trusts 24

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