NHS Harrogate and Rural District Surge and Escalation Plan 2014/2015

NHS Harrogate and Rural District Surge and Escalation Plan 2014/2015 Version Control 1

Version Comments By Date 1.0 Basic first draft KP 03.06.14 2.0 Amends to the draft KP 09.06.14 3.0 Comments received from Rob Penman KP 12.06.14 4.0 Partner plans added as hyperlinks KP 03.10.14 2

Contents Page Page number SECTION A-BACKGROUND INFORMATION 5-29 1. INTRODUCTION AND PURPOSE 5-14 1.1 Supporting Activities 7-8 1.2 Assessment of Demand 8-10 1.3 Lessons learnt 11 1.4 Lessons learnt from 2013/2014 11-13 1.5 Improvement Plan 13-14 2. GOVERNANCE/RESILIENCE STRUCTURE 14-17 2.1 Emergency Preparedness 14-15 2.2 System Resilience Group (SRG) 15-16 2.3 SRG roles and responsibilities 16-17 2.4 Clinical Governance Infrastructure 17 3. HaRD CCG SURGE AND ESCALATION GROUP 17-22 3.1 Membership 17-20 3.2 Roles and responsibilities of HaRD CCG Surge and Escalation Group 20 3.3 Organisation/partner updates 20-21 3.4 Communication to Area Team 21 3

3.5 Debriefs and Risk Management 21-22 4. MANAGING PATIENT SAFETY 22-23 5. ESCALATION AND DE ESCALATION PROCESS 23-27 5.1 Metrics and Reporting Mechanisms 23-24 5.2 Escalation Levels 24-26 5.3 Surge Plan Triggers 26 5.4 Escalation and de-escalation principles 26-27 6. SEVERE WEATHER CONTINGENCY 27-28 7. COMMUNICATIONS AND ENGAGEMENT 28-29 7.1 Flu 29 7.2 Norovirus 29 SECTION B-OPERATIONAL PLAN: ACTION CARDS 30-47 4

SECTION A-BACKGROUND INFORMATION 1. INTRODUCTION AND PURPOSE The purpose of the escalation and surge plan is to ensure that the health and social care systems across the Harrogate and Rural District Clinical Commissioning Group (HaRD CCG) area are coordinated to respond quickly and appropriately to any increased needs and/ or service demands experienced within the area, which put pressure on the system. This paper evidences that robust resilience arrangements have been put in place across the HaRD CCG area health and social care organisations to enable the Harrogate and Rural District area to provide the capacity to maintain quality and to continue with the delivery of safe services during the expected variations in demand, and the various challenges that occur all year round but are especially challenging over the winter period, whilst continuing to meet local and national performance standards. All health and social care organisations within the HaRD CCG area have developed individual resilience plans, based on demand analysis, with clear escalation/deescalation plans and on-call arrangements where relevant. These plans all contribute to the system wide plan for the HaRD CCG area. It is vital that there are robust plans for operational readiness throughout the year. Historically, the HaRD area has managed to respond well to heightened pressures from surges, for example winter pressures. The existing processes have coped and there are effective examples around urgent care such as the Fast Response Teams. The main anticipated issues HaRD area may experience particularly around the winter period are outbreaks of D&V and flu and then staffing issues as a result of such outbreaks. 5

The risk that individual system pressures may impact upon the HaRD area health and social care system resilience are possible. It is reassuring to note that since the launch of NHS 111, there has been a decrease in demand in Out Of Hours service and no major adverse impact on Emergency Departments or the Ambulance Service. However the winter weather of 2013/14 was not severe and therefore the NHS 111 service and the wider system was not tested to its full extent. The escalation and surge plan describes how the health community will: respond to periods of high demand caused by seasonal pressures, infection control, flu or adverse weather, by ensuring that there is a coordinated and planned response to create service capacity to meet additional need especially during the winter months; ensure the high quality services are maintained, and the financial and performance pressures are managed; use escalation triggers to ensure an integrated and shared process between primary care providers, secondary care providers and social care; performance manage organisations to oversee and manage pressures in the system, especially the winter period. The key aims of this plan are: to ensure that essential health and social care services continue to be provided safely and effectively over any period of pressure (such as adverse weather, infection control and seasonal pressures) to work together as equal partners in a whole system to manage our capacity and capability to improve system resilience 6

to ensure, through co-ordinated communication and marketing, that our public are informed to make the right choice when accessing health and social care services and where necessary ensuring timely messages to warn partners and our public of any issues that impact on health and social care services to effectively link into the wider North Yorkshire county and Regional resilience and assurance process 1.1 Supporting Activities The most significant identified risks to service provision are: Key or widespread staff absence Industrial dispute Fuel strike Severe weather Pandemic Influenza or other infectious diseases Loss of or access to Health and Social Care Buildings Computer/Network failure Telephony failure site or network specific Utility Failure (electricity or gas) Individual service level business continuity plans are based on on-going risk analyses and profiling of activity conducted by all partners. These risk analyses and activity profiling highlight possible risks each organisation may face regards the most significant identified risks as detailed above. The business continuity plans then describe the actions required in the event of such risks to mitigate the risk and to ensure usual business activity is maintained. This could be having escalation plans, divert policies and emergency preparedness and resilience plans. 7

All partner organisations are responsible for monitoring activity and determine their own anticipated peaks and surges due to trend analysis. This will also identify where additional staffing is likely to be required, or when contingencies such as opening up escalation beds may be expected, so appropriate mechanisms can be put into place to deal with these predicted surges/increased activity to ensure patient safety is optimized. Documentation of supporting activities includes: NHS HaRD CCG Business Continuity Plan Harrogate and District Foundation Trust (HDFT) Winter Resilience Plan North Yorkshire County Council (NYCC) Cold Weather Plan Yorkshire Ambulance Service (YAS) Winter Planning Strategic Briefing Tees, Esk and Wear Valleys Foundation Trust (TEWV) Business Continuity Plan NHS 111 Surge and Escalation Plan 2014 HaRD GP OOH severe winter plan It is the partner organisations responsibility to share with the surge and escalation group all on-call rotas and contact details, in particular over the Christmas period where opening times will differ to the usual opening times. It is anticipated that during the winter period there will be a North Yorkshire and Humber CCG on-call rota. However this rota is not known yet at the time of writing this plan but it will be added into the plan at a later date. Please see here to see Area Team s on-call manager and on-call Director and here for Major Incident contact numbers. HDFT on-call rota can be accessed here. 1.2 Assessment of Demand 8

Extreme weather and in particular extreme cold weather can lead to deterioration in the health of vulnerable people such as older people, those suffering from chronic or severe illness (e.g. heart conditions or respiratory illness), and people suffering from decreased mobility, homeless people, and those who cannot afford to heat their homes sufficiently. Each winter sees a number of excess deaths resulting from a range of factors made worse by periods of cold weather. Snow and ice increase the likelihood of road collisions and falls, as well as making it more difficult for those who normally care for themselves to do so if they are unable to visit the shops or pharmacy for example. In some cases mental health can also be affected. Evidence shows that if there is a sustained cold spell, emergency admissions increase due to the number of incidences of heart attacks, strokes, influenza like illnesses and respiratory conditions. Vulnerable people, particularly those with long term, chronic conditions are particularly susceptible. These winter pressures invariably lead to an increased requirement for community health and social care capacity as the increase in acute admissions to hospitals results in the greater need for the discharge of patients into the community. Norovirus is most prevalent over the months of October to March. The presence of Norovirus can substantially reduce the bed capacity available across the health and social care organisations as no admissions or discharge can be made to these areas. All partner organisations have referenced infection control management in resilience plans and whole system contingencies for outbreaks of Norovirus are outlined below:- Infection prevention and control teams co-opted as required to escalation and surge project team. HPA Norovirus control measures in place in hospital and community settings. Debriefs following outbreaks or end of season outbreaks to take place in the escalation and surge monthly meetings and be updated on risk plan. Extra communications and information for care home providers on management of norovirus. 9

Severe weather can also have an impact on our ability to deliver services as a result of difficulties in travelling around the county, staffing issues due to illness or carer problems if for example schools had to close, or even loss of utility supplies. All these factors have a significant impact on managing any surges and the system as a whole. The Christmas and New Year bank holiday periods are particularly crucial to plan for due to staff from health and social care taking periods of annual leave, the closure of primary care services, including GP surgeries and Pharmacies and the possibility of reduced bed capacity in Local Authorities. A heatwave can affect anyone, but the most vulnerable people in extreme heat are: older people, especially those over 75 babies and young children people with a serious chronic condition, especially heart or breathing problems people with mobility problems, for example people with Parkinson s disease or who have had a stroke people with serious mental health problems people on certain medications, including those that affect sweating and temperature control people who misuse alcohol or drugs people who are physically active, for example labourers or those doing sports Partners involved in the surge and escalation group have assured HaRD CCG that they have all undertaken extensive detailed demand analyses within their respective organisations to ensure they can effectively predict peaks and troughs in their activity, and reduce anticipated risks by putting in place mitigating actions. 10

1.3 Lessons learnt Existing controls that were put into place in previous years such as Patient flow meetings, a discharge lounge, weekend and bank holiday arrangements and staff rotas remain to be used at HDFT due to these evaluating well in regards to managing surges. These controls are also used to help identify peaks and surges in activity. Previous analysis of weekend admission profiles demonstrates that there are fewer admissions, on average, on a weekend and bank holidays than on week days, however, bed occupancy often rises due to the significantly reduced level of discharges. Therefore in October 2013 HDFT increased the numbers of medical staff during the weekends at HDFT. This ensured that Consultant ward rounds could happen over the weekends with a view to increasing the number of discharges over the weekend period. The Acute Trust also recruited additional nursing staff to be available on the medical and surgical wards and within a pool to support the surge and escalation plan. HaRD CCG also commissioned YAS to provide an additional discharge service over the weekends over the winter period to help patient flow and alleviate bed pressures. 1.4 Lessons learnt from 2013/2014 Despite the mild winter, HDFT did experience bed pressures for a prolonged period, starting earlier than normal in October and lasting beyond the official end of the winter period (31 st March 2014). Compared to other acute trusts across North Yorkshire and Humber, HDFT had the lowest bed occupancy pressures and fewest Norovirus outbreaks. This implies limited bed capacity represents a real risk in future years and therefore work needs to be continued in looking at patient flow and the scheduling of elective surgery during periods of known increased bed pressures (such as winter). 11

The working relationship of the surge and escalation group identified that some of the patient flow issues were due to systems and processes not being in place, or not being as robust as they should be between HDFT, YAS and Social Care. This was particularly apparent in regards to patients in need of being discharged to step down facilities at Station View and out of area discharges/repatriation. Both of these issues resulted in increased instances of delayed transfers of care. Weekly dial in s by partners of the surge and escalation group worked well up until February. From then on, very poor attendance was experienced at the weekly dialins and the face-face debrief meeting. This is of concern and needs addressing with support of the Urgent Care Working Group. Moving forward the surge and escalation group have agreed to pilot completing a weekly electronic template over any surge periods (such as the winter period), with only dialling in when pressure is experienced in the system and a conversation between the partners needs to take place. The weekly dial in s to area team identified there is no easy way to establish how the Primary Care system is dealing with surge and escalation issues. It is unclear how best to resolve this issue, but it would be useful to know about infective outbreaks or weather related illnesses being presented in Primary Care. The winter period flagged up that it would be useful to know of issues/pressures being experienced by our geographic neighbours who are outside of the North Yorkshire and Humber Area Team as this could help to predict potential diverts coming into our area. The winter monies funding in Primary Care (in particular) worked really well with 10% of the winter money being made available to Primary Care to offer additional GP or Nurse appointments in January February 2014 which equated to an additional 4566 face to face appointments were offered and 94% of those offered were taken up. Practices reported these significantly eased pressures on appointment systems. 12

These additional GP or Nurse appointments are likely to have significantly reduced demand on NHS111, GP OOH and A&E. The winter monies used in Secondary Care provided extra support for Therapy Services within Ripon Community Hospital, weekend medical ward rounds therefore supporting 7 day working. The funding also allowed extra support within the Community Fast Response team, extended hours for the Ambulance discharge crews and additional Critical Care provision (purchased by the Specialist Commissioning team). All these aided patient flow and ensuring appropriate care and support for patients in the most appropriate setting. 1.5 Improvement Plan Action Responsible Completion date organisation (s) Use a different format CCG to lead on creation of October 2014 (electronic) for weekly reporting between the partners instead of weekly dial-in s electronic template Develop repatriation/out of YAS (PTS) and HDFT July 2014 area protocol Improvements to be made HDFT and Social Care October 2014 between HDFT and Social Care (particularly Station View) to ensure better patient flow and less bed blocking Bed capacity to be HDFT October 2014 reviewed and mitigating actions put in place Liaise with geographic CCG October 2014 13

neighbours to ensure aware of issues pertinent to their area Improve monitoring/anticipated outcomes and outputs for any project funded by winter monies in order to be able to evaluate effectiveness and value for money. In particular need to bear in mind the Better Care Fund and the impact integration will have on evaluating interventions Develop business cases as to how winter monies may be best spent, therefore ready for any funding streams Better use of the voluntary and community sector organisations (links to above improvement) UCWG/CCG Aug 2014 UCWG/CCG Aug 2014 UCWG/CCG Aug 2014 2. GOVERNANCE/RESILIENCE STRUCTURE 2.1 Emergency Preparedness NHS England (North Yorkshire & Humber Area Team), all NHS provider organisations and both Local Authorities are defined as Category One responders in 14

relation to major incident or emergency planning and will plan and prepare accordingly. These arrangements are managed through the Local Health Resilience Partnership (LHRP) and are not included in this framework. Commissioner accountability for NHS emergency preparedness, resilience and response systems (EPRR) sits with the Area Team. Clinical Commissioning Groups are defined as Category Two responders and as such their duty is to support in responding to a major incident. Please see HaRD CCG EPRR policy. CCGs do however have a responsibility to ensure business continuity in the event of an emergency and to ensure business continuity out of hours. CCG business continuity plans describe these arrangements. HaRD CCG also has a sustainability development management plan that looks at the way commissioners improve both the sustainability of an organisation, and the way it provides services and interacts with people in the community. It is about striking the right balance between the three key areas of financial, social and environmental sustainability when making commissioning decisions. This framework is therefore specific to the on-going operational management of the local health and social care partner s response to surge and escalation. It incorporates a surge and escalation response but does cover not the system-wide emergency preparedness. 2.2 Surge and Resilience Group (SRG) The SRG has met regularly throughout the year (formally the UCWG) and been instrumental in the agreement of a strategic plan for urgent and planned care in the locality. It has received reports from the Surge and Escalation Group and NHS 111 Clinical Governance Group. The membership and terms of reference of the group are under review to ensure that it contributes effectively to the local transformation and integration agenda. Membership of the SRG includes senior representation from health and social care partner organisations. 15

The Area Team will seek assurance from the SRG that a framework is in place and that this takes a strategic overview of capacity issues across the region where necessary providing support to CCGs as required. It is the responsibility of the SRG members to ensure organisational commitment to the surge and escalation plan and that arrangements are in place for SRG members to maintain their own internal organisation-specific plans to support a partnership approach to system surge and escalation issues. The SRG meet monthly with dates having been set through the 2014/2015 period. The SRG has 3 sub-groups. One is the surge and escalation sub group. It is this sub-group who the operational responsibility for the implementation of the surge and escalation plan report to. The sub-group s role is to develop, implement and review the framework. It will be proactive and reactive in monitoring local system indicators and will manage and lead a coordinated response. The operational Project Group will meet by exception when there is pressure being experienced across the system and will complete weekly electronic updates which will be shared across all members to ensure a partnership approach is taken to unblock pressures being experienced within the system. All partners have agreed to what their triggers for escalation are, their escalation levels and the mitigating actions they will take when these triggers are reached and escalation occurs. 2.3 SRG roles and responsibilities: Approve and sign-off the Surge and Escalation Plan for 2014/2015. Provide strategic overview and leadership to the surge and escalation process 16

Devolve responsibility for the day to day senior operational management of the surge and escalation plan to the surge and escalation group (details listed below) Ensure all partners (both SRG and the surge and escalation group) engage with the plan and undertake any actions/requirements in a timely manner 2.4 Clinical Governance Infrastructure Now that NHS 111 is a fully established service Clinical Governance is managed by the NHS111 NY&H Clinical Governance and Quality Contract Escalation Board. This board has been meeting monthly but from May 2014 the frequency of meetings has reduced to bi-monthly. The Board is attended by the CCG Urgent Care Lead and the terms of reference of this Board can be seen here. 3. HaRD CCG SURGE AND ESCALATION OPERATIONAL GROUP This group was established in the autumn of 2012, reconvened in September 2013 to co-ordinate, manage and improve whole system resilience during the winter period (1 st November 2013-31 st March 2014) in the HaRD CCG area. Over time what was historically the winter plan has now evolved to be a surge and escalation plan. Therefore the group will convene at any point over the year, when surges/pressures across the health and social care system are experienced and not just limited to over the winter period. The lead organisation for the Surge and Escalation Group is HaRD CCG. 3.1 Membership: The membership of the group can be seen in the below Table (Table One) 17

Table One: Membership of the HaRD CCG Winter Planning Group Contact Email and mobile Organisation HaRD Clinical Commissioning Group Dr Rob Penman (Clinical Lead Chair) Rob.penman@nhs.net 01423 799318 07932 658 283 Kate Parker Kate.Parker4@nhs.net 07814 454281 Harrogate and District Foundation Trust: Acute and Community North Yorkshire County Council Kirsty Stead Linda Denham Kirsty.stead@hdft.nhs.uk 01423 554409 07866 510 697 Linda.denham@northyorks.gov.uk 07966 901 069 Yorkshire Ambulance Service James Webb James.webb@yas.nhs.uk 07976796599 Primary Care Dr Rob Penman Rob.penman@nhs.net 01423 799318 18

07932 658 283 Out of Hours service Matt Walker Matt.walker@hdft.nhs.uk 07795020393 Mental Health Caroline Gomersall Caroline.gomersall@nhs.net 07919 542 271 NHS 111 Mark Leese Mark.leese@yas.nhs.uk 07909 001702 Patient Transport Service Eileen Wood eileen.wood@yas.nhs.uk 07789741467 The surge and escalation group may wish to bring in/seek advice from (and possibly commission) other organisations, particularly the voluntary and community sector who may have services that the surge and escalation group feel would be useful to provide to mitigate against any pressures in the system. For example organisations that works in the rural areas, organisations who work with specific target groups (such as older people). The voluntary and community sector can often help to bridge the gap between health and social care and help with the seamless service of care. This will be increasingly important in the light of the Better Care Fund where there 19

will be much work on health and social care better integrating and having a pooled budget to help improve the health and care of the HaRD population. 3.2 Roles and responsibilities of HaRD CCG Surge and Escalation Group The Project Group will meet by exception when there are pressures being experienced across the system. A weekly electronic form will be completed by all partners and cascaded out. This form will indicate each organisations current level of escalation (using the escalation framework) and any mitigating actions they have in place to deal with the current pressure. These forms will identify when a system wide approach is needed to reduce the pressure. Please click here to see details of the Surge and Escalation Group s Terms of Reference. The responsibility of the Surge and Escalation Group is to ensure that there are clear protocols for the co-ordination of the health and social care economy in order to maximise the use of community hospital bed capacity in liaison with local acute hospitals and any available local bed management system. The Surge and Escalation group reports to the Area Team. This is done via weekly dial in s by the Lead organisation (HaRD CCG) to Area Team. The Surge and Escalation group also reports to the UCWG when necessary. 3.3 Organisation/partner updates Weekly electronic updates will be completed by all partners as and when pressures are being experienced across the system including for the whole winter period (1 st November 2014 until 31 st March 2015. The coordination of this electronic form will be the responsibility of the lead organisation (HaRD CCG). Click here to see the electronic update form. Key actions of the surge and escalation group after receiving the electronic form will be to agree the current alert status and agree actions. 20

Members of the Surge and Escalation Group will commit to complete the update forms and attend any dial in s/meetings where necessary or to nominate a deputy who can make decisions and agree actions on their behalf should they not be available. 3.4 Communication to Area Team Once the UCWG have signed off the Surge and Escalation Plan for 2014/2015 this will then be shared with Area Team for assurance. A system wide status report will be delivered by HaRD CCG on behalf of the surge and escalation group on a weekly basis, to the Area Team via conference call or email. This takes place every Tuesday at noon. An action and decision log will be utilised to track actions and decisions made by this group. 3.5 Debriefs and Risk Management The surge and escalation group will continuously be monitoring the impact of the framework on local capacity management. This will ensure continual review of the framework and support decision making. The surge and escalation group will hold a debrief after every event that required the group to step up communication that required either a conference call or a meeting. As good practice the group will hold a debrief after the winter period has ended (after 31 st March 2015) to review lessons learnt, what worked well/what needs to be improved to help set improvement plans for the next surge and escalation plan (2015/2016). The surge and escalation group will review the metrics (see section 21

5.1) to evaluate effectiveness of the surge and escalation plan and to help shape improvements for the following year 4. MANAGING PATIENT SAFETY Managing patient safety is referenced in all the partner organisations templates and will be a key priority for the surge and escalation group. The team will use performance information to review the system resilience and focus on the following indicators of quality, safety and operational standards. The Surge and Escalation Plan 2014/2015 has been written with the Francis report recommendations in mind across all partners. Table Two Quality, safety and operational indicators Domain Clinical Quality Indicator Information source Effectiveness of care Number of NHS 111 calls answered within 60seconds Longest wait for a NHS 111 call to be answered Time spent for NHS 111 calls to be allocated to GPOOH Ambulance response (Red 1 & 2 s) Time in A&E Emergency admission rates 4 hour A&E target Emergency re-admission rates Re-attendance rates Average time from referral to assessment for mental health patients with no physical illness. NHS 111 sitrep NHS 111 sitrep Contract report from HDFT Daily sitrep and weekly fast-track report A&E SUS data A&E SUS data Daily Bed State Report A&E SUS data A&E SUS data TEWV monthly Q&P metrics Planned vs. actual transfers Delayed discharges Daily Bed Status HDFT Discharge dashboard/quality and performance /sitrep HDFT Discharge dashboard/quality and performance/sitrep Daily bed State Report and Social Care report 22

Patient experience Patient safety Number of escalation beds open Number of elective operations cancelled Percentage left without being seen. Complaints/concerns Family and Friends test Time to assessment/treatment Mixed Sex accommodation breaches Infection Control/HCAI s (including number of beds closed) Falls Daily bed State Report Daily bed State Report A&E SUS data Complaints received PROMS/Family and Friends Test A&E SUS data The Cube/Unify The Cube/Unify The Cube/Unify Falls Prevention Report 5. ESCALATION AND DE ESCALATION PROCESS 5.1 Metrics and Reporting Mechanisms Various metrics will be used to monitor capacity and demand across all partners in the HaRD area. The metrics used are the proposed whole system metrics from NHS England: Improving A&E Performance Gateway ref: 00062 which can be found at http://www.england.nhs.uk/wp-content/uploads/2013/05/ae-imp-plan.pdf These metrics are reported monthly in the SRG Dashboard, click here to access it. Reporting information the CCG and the surge and escalation group will obtain to help understand if pressures are being experienced in the system include: Daily Bed State Report (HDFT) 23

Department of Health weekly heat wave and cold weather alerts NHS 111 Sitrep s NYHCSU Sitrep s Daily outbreak reports (Infection Prevention Control Team) NYHCSU Weekly Fast-track data The above reporting information as well as the weekly electronic update templates completed by the partners will allow the group to determine the system wide level of escalation. Internally within the CCG, any issues will be escalated from the surge and escalation group lead to the Clinical Lead and the Chair of the SRG. 5.2 Escalation Levels All partners have made a conscious decision to use a similar language to the Ambulance Trust when communicating levels of pressure and demand. This is a system known as Resource Escalation Action Plans (REAP). REAP consists of 5 levels and allows for the integration of a series of triggers that have the potential to impact on the partners ability to maintain business as usual. These can include bed occupancy, acute attendances, staffing issues, infectious disease outbreaks, failures of diagnostic services adverse weather and major incidents. All partners have given assurance that their individual plans are in line with other partners and are synchronised/work in partnership. Linked to the above, YAS s Emergency Operations Centre (EOC) operates a Demand Management Plan (DMP). This aim of this procedure is to manage the 999 calls coming into the EOC and where these exceed normal parameters it describes the escalation action required to deal with additional activity. The REAP and DMP work together as part of YAS s operations business continuity management system. 24

Local escalation arrangements are in place between YAS and HDFT should turnaround times escalate beyond acceptable parameters. Hospital triggers for escalation are defined in HDFT s winter resilience plan. The hospital Trust patient placement meetings will be the forum in which the Trust s escalation level is determined. The chair of this meeting will activate escalation and de-escalation plans as necessary with the representatives of the multi-agency discharge group. The discharge group will communicate out to the wider partner organisations via the CCG using the emergency escalation email (Please refer to the communication segment in SECTION B of this report) In addition, any other of the partner agencies can alert to triggers, escalation and deescalation using this email address. The local health and social care partners have agreed to work with these definitions and triggers to ensure a system wide understanding of levels of escalation. An overarching HaRD CCG escalation level will be established based on an assessment of the service pressure levels within the HaRD area Health and Social Care organisations. The surge and escalation group will consider the pressures faced within the partner organisations and the collective contribution the group can make to support them. Each individual organisation will have its own specific pressure levels, at any given time. All HaRD Health and Social Care organisations have a responsibility to: know the current escalation level communicate any increasing pressure within services between stakeholder organisations and to the CCG 25

understand the escalation plan and to have a corresponding escalation plan for their service area take meaningful action, with the appropriate urgency, as the surge plan escalates. Communicate to the partners when de-escalation has occurred Area Team will provide the surge and escalation group with test scenarios to be able to test the robustness of the plan and the mechanisms involved in its responsiveness. Please note we will not have these at the time of submitting the surge and escalation plan as awaiting these scenarios from Area Team. However they can be added as an appendix at a later date. The outcome of how well the surge and escalation plan and the group responded to the test scenarios will help to further shape and influence the surge and escalation plan. 5.3 Surge Plan Triggers It is important to note that not all services will be exposed to the same pressures; however peaks in illness and weather conditions are likely to be common across all organisations. This provides reassurance that all organisations plan s uses the same/similar REAP system and are aligned/synchronised. Please refer to the Action cards in Section B to see each organisations triggers where they will need to move up the escalation framework and the mitigating actions each organisation needs to take. 5.4 Escalation and de-escalation principles 26

The following principles will underpin employment of the escalation and surge framework across the partner organisations. Capacity will be managed within organisations and as a coordinated system across the health and social care economy. Capacity management is a whole system issue and that may affect any of the partner agencies and this framework will be employed to support health and social care services out with the hospital system No action that would undermine the ability of any other part of the system to manage their core business will be taken by another one of the partner agencies without prior discussion. Managing patients at a time of increased escalation will require accepting and managing additional risk across organisations, as individual decisions on patient s care are taken, and competing pressures/targets are prioritised. Decision-making and actions in response to escalation alert will be within agreed timescales. The point of De-escalation will be communicated and agreed by all partners. 6. SEVERE WEATHER CONTINGENCY YAS has an Adverse Weather Plan (AWP) which covers both summer (Heat wave Planning) and Winter (Snow, Ice and Floods). The AWP has three levels of escalation for internal purposes. When level three is enacted YAS implements Operation Glacier, a further element of the adverse weather plan that includes circulation of a Situation Awareness Picture to all NHS partners on a daily basis. YAS has a significant number of 4x4 capacity built into its operational fleet. YAS also has contingencies in place to increase this number from commercial providers if this is required, making this facility available to the wider health economy if required. 27

NYCC Integrated Passenger Transport team, together with NYCC Emergency Planning Unit also have a prepared a list of 4 x 4 vehicle providers within the county. Locality based lists will be shared with HAS operational managers and local health managers If HAS Managers feel that a 4x4 vehicle is needed then they should contact the Integrated Passenger Transport team directly on 01609 535867. The DH has also issued its heat wave plan which offers guidance on how to protect the population from heat-related harm. The plan can be downloaded from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/31059 8/10087-2902315-TSO-Heatwave_Main_Plan_ACCESSIBLE.pdf 7. COMMUNICATIONS AND ENGAGEMENT A number of local and regional marketing and communication campaigns will be delivered. Communication of wider public messages on weather resilience (for example) will be managed by the CSU communications department at North Yorkshire and the Humber. Communications to the general public will utilise a range of media which includes CCG internet sites, social media e.g. Twitter and local media newspaper and radio for preparatory messages and any immediate messages that may need to be communicated over the course of experienced pressures. The CSU are part of a network of communications teams across all of the partner agencies party to the escalation and surge framework. The teams will work together to coordinate and share information that can support and inform delivery of the framework. Please click here to review the communications plan that all partners will feed into. This is a working document so this document will evolve over time. 28

The impact of all communication and marketing campaigns will be evaluated as part of every debrief the surge and escalation group hold throughout the year. 7.1 Flu The local flu vaccination and public information campaign will be implemented by Public Health England and each provider organisation has staff vaccination programmes planned through their occupational health programmes. The Annual Flu Programme and supporting documents can be seen at: http://www.gov.uk/government/organisations/public-health-england/series/annual-fluprogramme NHS England Flu Plan 2014/15 is available to download at: https://www.gov.uk/government/publications/flu-plan-winter-2014-to-2015 7.2 Norovirus In 2013/2014 both acute and community settings did see outbreaks of Norovirus in the HaRD area. Norovirus can cause much disruption (such as bed closures in the acute setting) and therefore needs to be managed and dealt with appropriately and swiftly. Guidance on how to manage the outbreak of Norovirus in acute and community Health and Social Care settings can be accessed here: http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1317131639453 29

SECTION B-OPERATIONAL PLAN: ACTION CARDS Standard responsibilities: Weekly electronic updates ACTION CARD A: COMMUNICATION RESPONSIBILITY Complete and submit the weekly update by 5pm every Monday during periods of pressure within the system and from 1 st November 2014-31 st March 2015 Send completed forms to kate.parker4@nhs.net Ensure a representative completes and submits the forms if you are unable to HaRD CCG will them collate all forms and send back out to the group for information purposes and to seek agreement of escalation level in the system See embedded document for update form details weekly update form.docx Emergency situation responsibilities: All partners All partners to complete the embedded form (below) should your own individual organisation be experiencing any form or pressures (i.e. Orange/REAP 2 upwards). submit the form to HARDCCG.HaRDsurgealert@nhs.net Please put as much detail in this form as possible, and what actions you require the other partners to do (if relevant) This form gets sent to HaRD CCG HaRD CCG then will cascade this information out to all partners, requesting any actions take place. NB The CCG is only available to action these emails in office hours only, NOT out of hours/during weekends/bank holidays etc. Therefore if the situation/escalation occurs out of hours, please consider contacting your own on-call Director/using your own internal procedures. Please also notify the CCG Director who is on-call (Pager Number: 07623 947 141) of the event, so they are aware. Need to check pager no-still correct? emergency escalation alert.docx All partners to email HARDCCG.HaRDsurgealert@nhs.net to inform HaRD CCG of de-escalation HaRD CCG to then cascade the de-escalation to the group (and wider if needs be) to confirm the pressures have been alleviated 30

Should the HaRD area s overall status reach Red or above, then once deescalation has occurred, the surge and escalation group need to hold a debrief session to consider lessons learned and take appropriate actions. These debriefs can be done via dial in, using the same conference line as the weekly conference call. The time and date of the debrief will be agreed by all parties and will take place as soon as possible once de-escalation has occurred. Please see the embedded document below that shows the debrief template surge debrief template.docx Contact details of the surge and escalation group: The embedded document below gives mobile numbers and email addresses of all those who sit on the surge and escalation group. surge and escalation group contact details. CCG staff only: Should individual organisations submit forms (if Red/REAP 3 and above), and require the CCG to cascade information out to GP practices and care homes, then this needs to be communicated out via the HaRD enquiries email address, not individual email addresses (hardccg.enquiries@nhs.net).jane E, Sasha and Jane M all have access to this generic account so can send the email out on your behalf. 31

ALERT: ACTION CARD B: FOR REPORTING AN EMERGENCY SENIOR PERSON TAKING CHARGE OF THE INCIDENT Emergency services where necessary. AT THE SCENE Other nearby premises or patients, staff and any other persons that may be affected by the incident. Service Manager or Out of Hours 1 st On-Call Manager when safe to do so. RESPONSIBILITIES: 1. First and foremost ensuring the safety of patients, staff and any other persons who may be affected by the incident. 2. Request response from emergency services where necessary. 3. Cordon off any area as appropriate to ensure the safety of patients, staff and others and to preserve the scene where necessary. 4. Inform other services of potential impact where applicable. 5. Contact other services for support as required to assist in addressing the initial risks and make the situation safe. 6. Initiate any local business continuity plans applicable to the incident. 7. Contact the relevant Service Manager or On-Call Manager, when safe to do so who, will decide on the level of escalation and response. 8. Continue to manage the situation and available staff until the arrival of the relevant senior manager and continue to provide support in co-ordinating a response to the incident. 32

ACTION CARD C: SYSTEM WIDE ESCALATION Each level is triggered by intelligence from Harrogate and Rural District area Health and Social Care organisations, either individually or collectively, or from the external environment. (Green = Level 1, Amber = Level 2, Red = Level 3, Black = Level 4 and Purple = 5). SURGE PLAN Level 1 (Green) SURGE PLAN Level 2 (Amber) SURGE PLAN Level 3 (Red) SURGE PLAN Level 4 (Purple) SURGE PLAN Level 5 (Black) Normal service Moderate Pressure on services Severe Pressure on services Critical Pressure on services Major Incident with service disruption The local health economy capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. The local health economy 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 Actions taken in Level 2 have failed to return the system to Level 1 and pressure is worsening. The local health economy is experiencing major pressures compromising patient flow. Further urgent actions are required across the system by all partners All actions in Level 3 have failed to contain service pressures and the local health economy is unable to deliver comprehensive emergency care. There is potential for patient care to be compromised. All services severely disrupted with the need to employ special measures to ensure essential services are provided. 33

ACTION CARD D: PROCEED TO DIVERT The diversion of patients should only be taken when trusts do not have a single bed into which a patient can be placed including having opened escalation areas. Please refer to Appendix XXX (HDFT Winter Resilience Plan) and Appendix XXX (HaRD CCG Divert Policy) Request for patient diversion must be escalated to the Executive Director oncall as soon as the request has been made. Executive Director on-call to ensure all pre diversion arrangements have been exhausted Executive Directors to contact the CCG On-Call Director by pager to ensure that all primary care support has been maximised and obtained agreement to progress with the formal divert request Any diverts to be actively managed to support removal of the divert within 4 hour period Executive Director and the CCG On-Call Director to communicate to all health economy partners as a matter of urgency that a diversion of patients is occurring NB: Under no circumstances should a diversion be used to protect elective beds, or to avoid excessive waits in Accident and Emergency Departments. 34

ACTION CARD E: MITIGATING ACTIONS DURING ESCALATION-CCG S GREEN: Monitor hospital and community situation AMBER: Notifications received from organisations and monitored. Offer support as required RED: Cascade status alert across the health and social care system Co-ordination of the escalation response across whole system to ensure alternative pathways to admission are utilised Notify NHS England s Local Area Team; CCG On-call Director and Chief Executive Utilise business continuity plans to create capacity and ensure continuity of service Instigate mutual aid where appropriate Make risk based assessment of best use of capacity and resource across the whole system to maintain patient safely and meet demand PURPLE: All actions listed above Take decisive action to alleviate pressure Alert neighbouring Trusts and Ambulance Services and seek support Provide and receive mutual aid to staff and services across the system Review the escalation status every 2 hours Stand-down from purple alert once review suggests the pressure is alleviating Post escalation review BLACK: All actions listed above Contribute to communications regularly Provide mutual aid Alert neighbouring services to seek support Notify NHS North of England Risk based assessment on best use of capacity, and support shift of resources Review 2 hourly Stand-down once pressure alleviated 35

ACTION CARD F: MITIGATING ACTIONS DURING ESCALATION-HDFT ACUTE SERVICES ESCALATION ALERT TRIGGERS MITIGATING ACTIONS GREEN: Occupancy <85% at HDFT site. No pressures elsewhere in wider North Yorkshire / Leeds system that would impact on AMBER: Occupancy at 86% - 90% in HDFT. A&E performance under pressure Monitor hospital and community situation Contact On-take and on-call consultants to ensure speciality patients in A&E are assessed rapidly Maximise flow through UCC/AEC and CDU Maintain usual admission/discharge arrangements Operations Centre monitor and manage internally RED: HDFT site occupancy at 95% - 99%. A&E performance is below 95% All actions listed above Utilise actions from major incident and business continuity plans to create capacity and ensure continuity of services CEOs involved and agree escalation Implement additional ward rounds Urgent elective admissions to be rescheduled / cancelled Consider opening additional beds / overflow areas, including staffing Pharmacy support discharge by prioritising TTO drugs Liaise with EMAS to prioritise discharges. Utilise alternative transport for discharges Assign staff to attend patients being held in ambulances PURPLE: HDFT fully escalated and all non-urgent electives cancelled. A&E Escalation plan attached All actions listed above Take decisive action to alleviate pressure Contribute to system wide communications to update on status Provided and receive mutual aid to staff and services across the system Stand-down from black alert once review 36

suggests the pressure is alleviating Post escalation review BLACK: Major Incident declared either receiving or supporting at any hospital in the region. Or Mass Casualty Incident declared. Or All actions listed above Contribute to communications regularly Provide mutual aid as appropriate Stand-down once pressure alleviated Contribute to root cause analysis and lessons learnt process HDFT cancelled all elective activity and fully escalated A&E Escalation plan attached in full. 37

ACTION CARD G: MITIGATING ACTIONS DURING ESCALATION-HDFT COMMUNITY SERVICES ESCALATION ALERT TRIGGERS MITIGATING ACTIONS GREEN: Normal levels of activity. No undue pressures AMBER: Pressured managed internally. Significant increase in demand but manageable Significant staff sickness, but managed within own resources Adverse weather forecasted RED: Increased pressure resulting in need to prioritise workload Reduced staff requiring use of bank staff Poor weather conditions impacting on journey times and capacity Monitor hospital and community situation Daily review of workload within teams Rapid response teams to provided support as appropriate to alleviate pressure Review patients on see and keep to avoid admissions All actions listed above Utilise actions from major incident and business continuity plans to create capacity and ensure continuity of services All community teams to review all patients awaiting assessment to expedite discharge or transfer Consider increasing capacity Patients at home waiting admission to be referred to community teams PURPLE: Weather impacting on ability to travel. Requiring deployment of 4X4 vehicles if weather related Requirement for instigation of walking model due to weather Major staff sickness, not managed via internal bank staff, resulting in need to deliver essential services only All actions listed above Take decisive action to alleviate pressure Contribute to system wide communications to update on status Provided and receive mutual aid to staff and services across the system Stand-down from black alert once review suggests the pressure is alleviating Post escalation review Mutual aid in place between health and social care. Walking model instigated. BLACK: Major issues affecting ability to deliver essential services. Major or prolonged bad weather impacting on ability to deliver service Major staffing shortage not All actions listed above Contribute to communications regularly Provide mutual aid as appropriate Stand-down once pressure alleviated 38