NHS Fife Winter Plan

NHS Fife Winter Plan 2012 2013 File: NHS Fife Winter Plan Page 1 of 36 Date of Issue: October 2012

Contents Heading Page Contents 2 Administration 4 Document Location 4 Consultation 4 Revision History 4 Approvals 5 1. Introduction 6 1.1 Fife Partnership Working 6 2. Scottish Government Guidance for 2012/13 7 3. Aim 8 4. Escalation Levels, Triggers and Reporting 9 4.1 Winter Hub 10 4.2 Escalation Process and Communication 11 4.3 Beyond Red Escalation 12 4.4 Mitigating Strategies 12 4.5 Summary of Impact 13 4.6 Cold Weather 13 4.7 NHS Fife Whole System Escalation Framework 14 5. Operational Resilience 19 6. Areas of Consideration 19 6.1 Severe Weather 19 6.1.1 Mitigating Strategies 20 6.1.2 Summary of Impact 20 6.2 Norovirus 20 6.2.1 Mitigating Strategies 21 6.2.2 Summary of Impact 22 6.3. Pandemic Influenza 22 6.3.1 Mitigating Strategies 22 6.3.2 Summary of Impact 23 7. Capacity Management 23 7.1 Background 23 7.2 Horizon Scanning 23 7.3 Ability to maintain effective flow 23 8. Performance Monitoring, Management and Support 24 8.1 Winter Reporting 24 8.2 Infection Control 24 8.3 Pandemic Influenza Reporting 24 File: NHS Fife Winter Plan Page 2 of 36 Date of Issue: October 2012

9. Governance 25 10. Communications Winter Plan 25 10.1 Objectives 25 10.2 Overall Approach 26 10.3 Delivering the Objectives 26 10.3.1 Objective 1: General Awareness 26 10.3.2 Objective 2: Internal Understanding 26 10.3.3 Objective 3: Service User Communication 27 10.3.4 Objective 4: Liaison with Stakeholder Groups 27 10.4 Seasonal Flu 27 11. Risk 28 Appendix 1 Reporting Structure for Red and Beyond Red Status 29 Appendix 2 Group Members for Red and Beyond Red Alerts 30 Appendix 3 Improving Flow and Emergency Access Improvements 31 Appendix 4 Appendix 5 Plans to maintain and provide additional or surge capacity over winter 2012/13 NHS Fife out of Hours Service Contingency Planning Winter and Festive Period 2012/13 32 35 File: NHS Fife Winter Plan Page 3 of 36 Date of Issue: October 2012

Administration Document Location The source of the document can be found on the NHS Fife intranet at: To be inserted Consultation The following people were consulted in the development of this document: Name George Brown George Cunningham Carla Donnachie Gillian Fenton Val Hatch Vicky Irons David Livingstone Ruth Lonie Fiona Mackenzie Alasdair MacLeod Yvonne McCallion Mollie Tevendale Andrea Wilson Andrea Fyfe Title Emergency Planning Officer Acting Director of Acute Services Area Service Manager, SAS Acting Locality General Manager for G & NEF CHP Deputy General Manager for D & WF CHP General Manager, G & NEF CHP Infection Control Manager Communications Manager Local Clinical Service Manager for K & L CHP Service Manager for Older People, Social Work Integrated Admission and Discharge Manager Associate Nurse Director Director of Clinical Directory Divisional General Manager Emergency care and Medicine Revision History Release Date Version Summary of Changes August 2012 1.0 Draft for comment August 2012 1.1 Changes made after consultation September 2012 1.2 Changes made after consultation October 2012 1.3 Changes made after consultation October 2012 1.4 Changes made after consultation October 2012 1.5 Changes made after consultation October 2012 1.6 Changes made after consultation October 2012 1.7 Changes made after consultation October 2012 1.7 Final Draft removed File: NHS Fife Winter Plan Page 4 of 36 Date of Issue: October 2012

Approvals This document has received the following approvals: Name Signature Title Date of Version Issue George Acting Director 19/10/12 1.7 Cunningham of Acute Services SMT 22/10/12 1.7 Distribution of Plan This document has been distributed to: (Will be completed once approved by Board) Name Department Date of Issue Version File: NHS Fife Winter Plan Page 5 of 36 Date of Issue: October 2012

1. Introduction NHS Boards have a key responsibility to undertake effective winter planning to ensure that the needs of vulnerable and ill people are met in a timely and effective manner despite increases in demand on services or a mismatch between demand and capacity for services. This can happen at any time of the year but commonly in winter activity rises, there are infection outbreaks (Norovirus in particular), the weather conditions can be adverse and pandemic influenza is more likely than at other times of the year. NHS Fife manages the local health system, manages knowledge, assesses needs and works with community partners to ensure that services are fit for purpose, meet the needs of patients and are cost effective, and, despite the pressures described above. The purpose of this document is to describe the arrangements put in place by the NHS Fife and partner organisations so that throughout the winter (including the Christmas and New Year holiday) period the following are maintained: Safe and Effective care Access to urgent services Access to elective services Patient flow throughout the whole system Waiting time guarantees A Pandemic Influenza will require additional measures/plans due to the population group likely to be affected, i.e. children and adults of working age. The impact on health and social care provision being greatest in relation to the provision of critical care facilities for children and in the number of staff likely to be affected; features not present in previous pandemic flu outbreaks. Although generic references to pandemic flu responses are referred to within this plan, it does not outline specific operational responses. For specific information please refer to the NHS Fife Pandemic Influenza Plan. 1.1 Fife Partnership Working The Fife healthcare community endeavours to deliver health care based on a delivery system that provides care and advice giving the population of Fife confidence that care will be provided at home whenever possible and in hospital when that is clinically necessary. In this model, capacity begins with the capacity of people to care for themselves; embraces the capacity of general practices; community health and social care services that provides support at home; and includes the capacity of the hospital and nursing home sectors to meet the needs for more complex medical, nursing and rehabilitative care. Fife Council, as the commissioning partner for social care shares this approach and we actively prioritise this model with partner service providers. Every winter the escalation plans of providers are reviewed for evidence that planned responses to escalation are in terms of helping patients flow through the health and social care system (a home to home based model of care with an emphasis on increased capacity created in community based services rather File: NHS Fife Winter Plan Page 6 of 36 Date of Issue: October 2012

than in-patient units). This may involve altered risk thresholds at times of extreme pressure. Co-operation between different parts of the health and social care system continues to improve supporting partnerships that will help to deal with the pressures that winter, Norovirus, adverse weather and a pandemic flu outbreak would bring. The developments described in this winter plan are not designed to last just a few months; they are part of the long-term local strategy and the commissioning of responsive services that meet patient need. Although every effort has been made to prepare for winter by developing contingency plans and escalation procedures it is recognised that from time to time all agencies are likely to be functioning under extreme pressure and that there will be an increase in demand for health and social care services during this period. This plan describes a process for planning and preparation, good practice and collaboration, management and contingency planning to deal with problems as they arise. The final plan will represent the achievements of a wide range of providers working in partnership. NHS Fife has worked hard to harmonise procedures across Fife and acknowledge the procedures in place for enabling Fife residents admitted as emergencies to Hospitals in Tayside to be discharged in a timely manner. It will continue to work closely with Fife Council in improving services across the area, and in planning for the challenges posed by a growth of an ageing population, and the complex needs posed by people with long term conditions. It is an essential part of the approach that winter partnership working, capacity planning and rational escalation policies are continued all year round to meet pressures as they arise. 2. Scottish Government Guidance for 2012/13 The Scottish Government Preparing for Winter Guidance for 2012/13 was issued on the 31 August for comment. Within the guidance, NHS Boards were asked to implement seven Priority Actions to help manage their winter service pressures which were designed to help utilise capacity and optimise patient flow. They are: Agree and test escalation policies for management of in-patient capacity across the whole system. Undertake detailed analysis and planning to effectively schedule elective activity (both short and medium-term) based on forecast emergency and elective demand, to optimise whole systems business continuity. This should specifically take into account the surge in activity in the first week of January. Agree staff rotas in November for the fortnight in which the two festive holiday periods occur to match projected peaks in demand. These rotas should include services that support the management of inpatient pathways, (e.g.) diagnostics, pharmacy, phlebotomy, AHPs, etc. File: NHS Fife Winter Plan Page 7 of 36 Date of Issue: October 2012

3. Aim Optimise patient flow by implementing Estimated Date of Discharge as soon as patients are admitted or scheduled for admission with supporting processes (e.g.) multi-disciplinary board rounds. This will support the proactive management of discharge and ensuring there are no delays in patient pathways. Ensure that appropriate medical staff is available, and that AHP rotas are structured, to facilitate the discharging of patients throughout weekends and the fortnight in which the two festive holiday periods occur in order to maximise capacity. Agree anticipated levels of homecare packages that are likely to be required over the winter (especially festive) period and utilise Intermediate care options such as Rapid Response Teams, enhanced supported discharge or reablement and rehabilitation (at home and in care homes) to facilitate discharge. Ensure that communications between key partners, staff, patients and the public are effective and that key messages are consistent. Additional areas worthy of consideration were highlighted through the review of 2011/12 Winter plans, both national and local, and through discussions with key individuals. These include: Reducing levels of boarding from Assessment Units, and within the first 48 hours of care. Better consistency in predictive modelling. Evaluating the accuracy and effectiveness of PDD processes. Local agreement on direct purchase of home care by ward staff. Recognising and removing specific barriers to patient discharge These points have been considered in the preparation of NHS Fife s winter operational contingency plans. The aim of the Winter Plan is to: 1. Support the health and social care community to respond to periods of increased and/or unusual demand, or periods of adverse conditions, by ensuring that service flexibility and capacity is at optimal levels as winter approaches. 2. Provide assurance and support for business continuity between all parts of NHS Fife and between NHS Fife and their partner organisations. File: NHS Fife Winter Plan Page 8 of 36 Date of Issue: October 2012

3. Provide prompt service responsiveness during the winter months especially in relation to flexibility and capacity. 4. Clarify escalation triggers, promoting an integrated, shared and consistent process between primary and secondary health care providers and partner agencies such as Social Work. 5. Describe agreed communication and reporting channels to enable appropriate responses to be made in the event of escalation due to increase in activity and/or reduced capacity. 6. Clarify information needs to increase the accuracy and timeliness of the above. The partnerships developed in the planning for the management of winter pressures will be a crucial element of the handling of predicted or unforeseen circumstances and increased escalation. The plan refers to the winter preparedness of: NHS Fife Operational Division Dunfermline & West Fife CHP Glenrothes & North East Fife CHP Kirkcaldy & Levenmouth CHP Primary Care Emergency Service (PCES) NHS24 Fife Council Scottish Ambulance Service The plan is structured to prepare for the challenges of the winter period by focusing on and checking preparedness against the Scottish Governments seven Priority Actions as outlined within The Scottish Government Preparing for Winter Guidance for 2012/13 (outlined above in section 2). This is a dynamic live document that will be reviewed, adapted and changed as needs are identified. 4. Escalation Levels, Triggers and Reporting The aim for previous winters was to agree a consistent approach to escalation across the Fife healthcare community. Following review it is recognised that the definitions and triggers used have not always accurately reflected the impact for the system as a whole. The principles of escalation have been agreed across Fife s providers as per the framework (section 4.7). Escalation procedures were discussed, reviewed and tested at a tabletop exercise during the NHS Fife Winter Planning Event that took place on 11 September 2112. Representatives attended from NHS Fife s Operational Division File: NHS Fife Winter Plan Page 9 of 36 Date of Issue: October 2012

and CHP s; Scottish Ambulance Service; and Fife Social Work Department. Recommendations and action points were incorporated into final versions of the NHS Fife Winter Plan and Escalation Procedures. The list below reflects the principles agreed in relation to the management of escalation locally. One provider having to escalate to a level beyond green does not mean that all providers are in the same position. Providers not in escalation must demonstrate capacity in order to remain at green or amber and look at how they can use this capacity flexibly in order to enable the whole system to return to green. Escalation status of each provider is based on the process detailed within NHS Fife s Escalation and is shared across the health and social care community on a daily basis throughout winter. The system as a whole may escalate beyond green even if some providers are still at green dependent on the overall ability of NHS Fife to manage capacity and demand and admit emergencies. 4.1 Winter Hub Information on the escalation level for each provider will be submitted to the morning capacity meeting (8.45 am) and collated by the Personal Assistant to Director of Clinical Delivery into a virtual hub on a shared web space. The LMG Leads, LMG Development Co-ordinators, Integrated Admissions & Discharge Manager and Director of Clinical Delivery and other Senior Managers will have access to this. The management of the Winter Hub will commence on the 5 November 2012 and will be operational for 18 weeks. During these 18 weeks Monday Friday 8.30am 5.00pm, the on call Senior Manager of the day will have responsibility for facilitating and co-ordinating the use of the escalation procedure. The on call Senior Manager of the day responsibilities includes: Determining the whole system R.A.G status based on the information provided as outlined above at the morning capacity meeting Initiating communication of whole system R.A.G status through text to identified Senior Managers in Health and Social Care when whole system status is RED or Beyond RED. Identifying when discussions need to take place with key decision makers out with the daily planned capacity meetings. Arranging and chairing a teleconference at the 12.00 noon capacity meeting if required with identified people across the system to make decisions and progress the necessary action. File: NHS Fife Winter Plan Page 10 of 36 Date of Issue: October 2012

To receive a progress update from any area that has taken an action at the daily capacity meetings (when necessary or deemed appropriate) The Escalation procedure doesn t preclude any existing Management responsibility in ensuring that services and systems are operated safely and effectively. The on-call manager Operational Division will take responsibility over weekends to determine escalation status and communicate this to the Director on call and at the Monday morning capacity meeting. 4.2 Escalation Process and Communication The daily capacity meetings will normally be the mechanism to discuss the severe pressure that the whole system is experiencing and to ascertain solutions to these pressures. If the on call Senior Manager for the day along with colleagues at the morning capacity meeting determines that the whole system is in RED or beyond RED status, they will arrange for a text message to be sent to all of the identified Senior Managers (Appendicies 1 and 2). The purpose of the text message is to inform everyone of the significant pressure in the system and to advise if a further teleconference call is required. The teleconference call if required will take place at the 12 noon capacity meeting and each area will be responsible for identifying actions to increase capacity as detailed within their local contingency plans in preparation for the conference call. The actions that are agreed at any teleconferencing call will be the responsibility of the lead for that particular part of the system to take forward, with the support of other members of the teams as required. The additional teleconference may require more attendees than those who are part of the capacity meetings. Additional resource will be invited as and when required. Weekend Planning A weekend planning meeting is held on a Thursday at midday within the operational division. This meeting is attended by the Divisional General Managers, the Directorate Nurse Managers, the Bed Manager, the Clinical Coordinator who will be working on a Saturday and Sunday, thedischarge Support Nurse, the LMG leads representative, the Nurse Bank Manager and the on call Senior Manager (Operational Division) for the forthcoming weekend. Where unable to attend, these individuals should nominate deputies who can make decisions or provide information on behalf of their service. At this meeting provisional information will be available on a template around weekend staffing and capacity. In addition, the provisional predictor information will also be available. Provisional weekend plans, contingencies and actions will be agreed based on the information available. File: NHS Fife Winter Plan Page 11 of 36 Date of Issue: October 2012

On a Friday an e-mail update of the template will be provided by the Bed Manager no later than 1400hrs (whom failing a nominated deputy) based on the updated information around staffing and capacity. On a Friday morning, the predictor will be revised to reflect the opening bed position and distributed to the agreed distribution list. Where capacity and / or staffing issues are outstanding at Friday midday, a decision will be made at the midday capacity meeting by the on call Senior Manager for the day as to whether a teleconference will be arranged for the Friday afternoon with those staff who have attended the weekend planning meeting to agree further actions. A weekend conference call chaired by the on call Senior Manager (Operational Division) will take place at 1100hrs on a Saturday and Sunday. This will be participated in by Duty Charge Nurses, the A&E Floor Coordinator, the Clinical Coordinator, and where required, the on call Senior Manager (Operational Division) may convene additional teleconferences over the weekend. On a Monday morning the Director of Clinical Delivery (whom failing a nominated deputy) will inform NHS Fife SMT members of the current status and any issues which have occurred in the previous week to allow decisions to be made around any additional actions proposed or which may be required by health should the situation deteriorate. 4.3. Beyond Red Escalation If each part of the system reaches the stage where appropriate action has been taken to try and resolve the pressures and this has not been possible, and as a whole system we are unable to do anything further (Beyond RED), the on call Senior Manager of the day will be responsible for informing the Head of Older People s Services, Fife Council, the Acting Director of Acute Services and General Manager, Glenrothes and North East Fife CHP who will consider what additional actions need to be taken. 4.4 Mitigating Strategies Each provider will develop and share a range of actions that will be taken to manage capacity at each level of escalation. These will aim to maximise the use of the capacity and services already in place and the referral routes and flow to those services. Work has been undertaken throughout 2012 to improve flow (Appendix3) and additional contingencies for winter have also been considered (Appendix4). The Primary Care Emergency Service has developed robust plans for effective delivery of out of hours services in partnership with NHS 24 and other key partners (Appendix 5). Escalation at beyond red status will require actions and consideration of the implementation of Business Continuity Plans in addition to contingency plans which will create extra capacity either in community services or in bed capacity File: NHS Fife Winter Plan Page 12 of 36 Date of Issue: October 2012

within 24-48 hours. These actions have been identified in advance within local Contingency and Business Continuity Plans. 4.5 Summary of Impact A common understanding of escalation across the health and social care community. Appropriate and agreed actions at all levels of escalation including green i.e. what should happen every day to mitigate the risk of being unable to maintain: Safe and Effective care Access to urgent services Access to elective services Patient flow throughout the whole system Waiting time guarantees 4.6 Cold Weather NHS Fife is an integral member of Fife s Strategic Co-ordinating Group (SCG) and is involved in the planning and maintaining of multi-agency SCG plans. Such plans include the Extreme Weather. This plan includes chapters on Extreme Heat, Extreme Cold, Extreme Rainfall and Flooding Incidents and other extreme weather and natural events. In cases of extreme prolonged cold weather the NHS Fife CHPs will, in conjunction with local social services, support the community and primary care staff in: Identifying individuals who are at particular risk from extreme cold. These people are likely to be already receiving care. Identifying any changes to individual care plans for those in high risk groups, including those with chronic illness or severe mental illness. Possible strategies may include initiating daily visits by formal or informal carers to check on people living in their own home. Working with the families and informal carers or at-risk individuals and to put simple protective measures in place as required. Reviewing surge capacity and the need for, and availability of, staff especially if the weather is forecast to last for a prolonged period of time. Further information on Major Emergency procedures can be found within the NHS Fife Major Emergency Plan. File: NHS Fife Winter Plan Page 13 of 36 Date of Issue: October 2012

document, it is your responsibility to ensure it is the latest version 4.7 NHS Fife Whole System Escalation Framework Escalation Status Descriptor and triggers Type of Actions Taken Sign-off Communications / Meeting Structure GREEN The local health and social care economy is such that all organisations are able to maintain flow. Bed Capacity is available to meet demand for elective and emergency admissions to inpatient beds. Any 3 of the following triggers Daily Discharges from community list are more than admissions and no one is waiting longer than 5 days on the list. The number of people on Eddison is less than 65 with bed days lost no greater than 2000 The number of people on Eddison coming off is more than the number going on and the total number in VHK is 5 or less 7 day rolling discharge from emergency care is 45 or greater No 4 hour breaches for beds and sustained 98% performance Monitoring of admissions and discharges Monitoring of Boarder numbers Monitoring of LOS in Community hospitals and in ICASS teams Actions taken at weekly verification meeting to expedite discharges from community beds Regular in reach from community teams to identify patients for direct discharge to community teams Escalation plans in place, including an awareness in all teams/services of those people for whom delivery of care is absolutely essential (e.g. nondelivery of care could result in admission to hospital) Proactive discharge management from operational division N/A as this is normal status. Unless otherwise stated all organisations are noted as green and revert to green after six hours of elevated status unless otherwise declared. Normal capacity management meetings Nil additional communication required. File: NHS Fife Winter Plan Page 14 of 36 Date of Issue: October 2012

document, it is your responsibility to ensure it is the latest version Length of stay in IRT, Length of time for Home Care package to be put in place, length of time for social work or home care Assessment, length of time for allocation of nursing home place- Triggers to be determined. Steady state. AMBER System(s) starting to show signs of pressure. Focused actions are required internally in effected organisation(s). Aim is to return to green status ASAP. Other providers demonstrate available capacity. Any 3 of the following triggers Enhanced in reach from community teams to identify patients for direct discharge to community teams Actions taken at weekly verification meeting to expedite discharges from community beds All available bed capacity in system to be utilised On call senior manager of the day or out of hours on call manager ( operational division) made aware at morning capacity meeting and agrees any additional actions with relevant Managers On call Senior Manager of the day or out of hours on call manager ( operational division) discusses with colleagues if any additional meetings / conference calls required. Predicted Bed Capacity is unable to meet demand for elective and emergency admissions to inpatient beds. Predicted shortfall at the morning bed capacity meeting for next 24 hours is -30 or less for less than 3 days Weekly Discharges from community list are equal to admissions, The longest wait is greater than 5 days but Enhanced efforts to identify non complex patients for discharge or those who require restart of current care package of minimal support. Identification of patients suitable for Boarding Discussion with Tayside to prioritise patients for discharge File: NHS Fife Winter Plan Page 15 of 36 Date of Issue: October 2012

document, it is your responsibility to ensure it is the latest version less than 10 days The number of people on Eddison is between 65 and 75 with bed days lost no greater than 2400 The number of people in VHK on Eddison coming off is more than the number going on and the total number on Eddison in VHK is 7 or less. The status in Tayside is at amber Rolling average of weekly discharges from emergency medicine are between 30-40 Less than 98% performance for emergency access for 2 consecutive days and/or 4 hour breaches for beds for 2 consecutive days RED Internal actions taken in Amber have not been effective. A coordinated response across the whole system is required to make additional capacity available immediately. Any 3 of the following triggers Predicted Bed Capacity is unable to meet demand for elective and Acute Care: all elective surgery (except cancers) is considered for cancellation. All organisations are working together at senior level to manage patient flow. Additional contingency bed capacity plan is enacted with planned closure criteria established Mon-Friday On Call Senior Manger of the day in consultation with colleagues and Acting Director of Acute Services (or identified deputy) makes the decision to enact contingency plans and informs CE (or identified deputy) Mon-Friday On call senior manager of the day decides at Morning Capacity meeting whether managers across system should join 12 noon and 3.30 meetings Consideration given to conference call with members of Emergency File: NHS Fife Winter Plan Page 16 of 36 Date of Issue: October 2012

document, it is your responsibility to ensure it is the latest version emergency admissions to inpatient beds. Predicted shortfall is -50 or less for more than 3 days Weekly Discharges from community list are less than admissions, The longest wait is greater than 10 days The number of people on Eddison is 85 or greater with bed days lost greater than 2500 Community services: Consideration of Additional contingency capacity plans to be enacted Out of Hours and Weekends on call Senior Manger (operational Division) in consultation with Executive on Call makes the decision to enact contingency plans Access Core team. Public message avoid ED and use MIU. The number of people in VHK on Eddison coming off is more than the number going on and the total number in VHK is greater than 11 The status in Tayside is at red 7 Day rolling discharges from emergency medicine are less than 30 4 hour breaches for beds for more than 4 days BEYOND RED Extraordinary measures are/need to be taken. The provider is not able to operate. Escalation level cannot be reduced by actions within the provider. Essential and maintenance activity preparing to go to essential activity only as per business continuity plans Consideration that only emergency, urgent and essential care needs are being met. Mon-Friday On Call Senior Manger of the day in consultation with colleagues and Acting Director of Acute Services (or identified deputy) makes the decision As above but consideration of conference call/meeting is called between Emergency Access Core team, CE and Director of Social Work File: NHS Fife Winter Plan Page 17 of 36 Date of Issue: October 2012

document, it is your responsibility to ensure it is the latest version Majority of local providers are reporting RED. Any 3 of the following triggers Predicted Bed Capacity is unable to meet demand for elective and emergency admissions to inpatient beds. Predicted shortfall is -50 or less for more than 5 days Weekly Discharges from community list are less than admissions, The longest wait is greater than 15 days The number of people on Eddison is 100 greater with bed days lost greater than 2500 The number of people in VHK on Eddison coming off is more than the number going on and the total number on Eddison in VHK is greater than 20 The status in Tayside is at red to enact contingency plans and consider enacting business continuity plans and informs CE (or identified deputy) Out of Hours and Weekends on call Senior Manger (Operational Division) in consultation with Executive on Call makes the decision to enact contingency plans NHS Fife CE (or deputy), makes the final decision in consultation with partner CE (or deputy) about business continuity plans 7 day rolling average discharges from emergency medicine are less than 30 4 hour breaches for beds for more than 7 days and 8 hour and 12 hour breaches anticipated File: NHS Fife Winter Plan Page 18 of 36 Date of Issue: October 2012

5. Operational Resilience As part of their duties under the Civil Contingencies Act 2004, NHS Fife and partner agencies have robust business continuity management arrangements in place that focus on being prepared for any disruptive event and consequence management. These arrangements are regularly tested to ensure they remain relevant and fit for purpose. NHS Fife s business continuity plans identify personnel considered to be essential to maintaining, both frontline and supporting services, and cover key disruptive risks such as cold weather and storm damage; loss of access to premises; disruption to utilities (e.g. gas, oil) and the supply chain (e.g. oxygen, blood); transport disruption; and staff movement/absences. Business continuity plans mitigate and manage these risks/critical activities and build on the lessons learned and practices adopted during previous periods of severe winter weather. NHS Fife s Business Continuity Manager is fully involved in all aspects of winter planning so that business continuity management principles are embedded within NHS Fife s winter plans. In the event of severe weather impacting on travel during the coming winter, NHS Fife has ensured that HR policies are in place so that appropriate travel advice messages and communications are provided to staff and the public. NHS Fife is an integral part of Fife Strategic Co-ordinating Group (SCG) and work closely with partner agencies to ensure that messages to the public are clear and consistent. NHS Fife works closely with Fife Council partners to ensure that communications with vulnerable groups are appropriate and consistent. Arrangements have been put in place, as part of NHS Fife s business continuity strategy, to ensure that access to resources, including staff, equipment and vehicles on a 24 hour basis, is maintained. Safe transportation to and from work for essential staff using 4x4 vehicles has been particularly effective during previous periods of severe winter weather. A Memorandum of Understanding between NHS Fife and the Scottish Land Rover Owners Club has been developed to outline the criteria and processes for accessing 4x4 volunteer drivers. NHS Fife should have in place mutual aid arrangements relating to a range of resources including staff, vehicles and service support. Particular attention should be given to the provision of services delivered in community settings or to vulnerable groups. 6. Other Areas of Consideration Lessons learned from previous winters have shown that some specific issues can either exacerbate or add additional pressure to the standard winter pressure escalation. These include: 6.1 Severe Weather Over the past few winters we have seen periods of severe weather that have led to business continuity pressures for all organisations. File: NHS Fife Winter Plan Page 19 of 36 Date of Issue: October 2012

Weather conditions such as severe ice, snow or heavy rainfall resulting in flooding can lead to consequences such as: Staff unable to travel and/or reach places of work or individuals Patients unable to attend appointments Ambulance services requiring support to reach individuals An increase in slips, trips, falls and fractures Family/dependent emergencies due to school closures or other carer demands Salt/grit supplies running low making site access hazardous 6.1.1 Mitigating Strategies All organisations have addressed issues presented by severe weather in their internal business continuity plans. Resilience strategies recommended include: Organising an Incident Response Team to manage the severe weather consequences, in particular the response to a very prolonged incident of adverse weather and plans to manage the recovery and catch up phase of the incident without causing a rise in escalation status. Have plans in place to access or increase 4x4 vehicles to support moving staff both in to work and out to vulnerable patients. Consider internal resources such as stock suppliers and contractors. Check contracts as necessary to assure the business continuity procedures of any vital resources or suppliers. Encourage staff to consider their own personal resilience strategies, i.e. alternative transportation methods, other suitable sites from which to effectively work and child care or other dependant back up plans. Ensure fair and transparent policy and procedures are in place regarding relevant issues i.e. severe weather policy, special leave and where possible share this information across partner agencies and throughout NHS Fife departments to ensure an equitable approach. 6.1.2 Summary of Impact Managing severe weather does require cross agency support and timely communication of the current picture and any cancellations or change to working practice is critical. However, these types of incidents present predominately internal business continuity pressures and if managed correctly these should not put excessive additional pressure on the escalation status of organisations. 6.2 Norovirus Outbreaks of diarrhoea and vomiting are common, widespread and can often be prolonged. In recent years Norovirus has seen repeated outbreaks causing disruption and ward closures for several months at a time. Previous outbreaks have led to consequences such as: Ward closures and delayed discharges and staff absences. File: NHS Fife Winter Plan Page 20 of 36 Date of Issue: October 2012

Stopping or limiting visitors, causing upset or challenging behaviour from loved ones. Confusion between agencies regarding infection control procedures and safe management and movement of patients. Patients being re-infected due to differing strains of Norovirus or other viruses. Complete or near complete break down of patient movement, requiring severe actions to be implemented. 6.2.1 Mitigating Strategies Information is essential to early awareness and action. HPS circulated updates are helpful, however they can only cascade the information they receive and hence tend to support retrospective analysis rather than forward planning. The importance of two-way sharing of information (via Health Protection) with others such as Nursing or Residential Homes will help improve the overall community picture of infection. Developing a culture of trust between providing organisations with transparent, clear and mutually agreed infection control guidelines for managing patients on closed wards. The following infection control principles are suggested: Providing a full patient history including movements from previously closed wards, or wards that have closed since the patient was moved (especially for inter-board transfers). Assessing a well patient from a closed ward in a side room. Carrying out an assessment via telephone or teleconference. Agreeing to urgently prioritise a delayed patient as soon as soon as a ward reopens. Receiving a well but potentially exposed patient into a side room until the Norovirus incubation period has passed. The consideration of a pro-active public health message which raises awareness of the impact of Norovirus. Emphasis could be made on the amount of time and planning that a hospital puts in to managing outbreaks and more importantly the detrimental effect on the experience of patients. The consideration of all available guidance and evidence from Health Protection Scotland and the Health Protection Agency currently available. If evidence of repeated infections is apparent this information may be critical to consequences of making a decision to cohort affected patients. Extending the availability of onsite expert advice from the Infection Control Team to include on site weekend cover may assist during large outbreaks. Weekend on-call cover is provided year-round, but current staffing levels would not allow on-site weekend cover for more than very short periods. Stopping or limiting visitors HPS together with Scottish Government Communications colleagues is drawing up a set of key principles for when a hospital or ward should close to visitors File: NHS Fife Winter Plan Page 21 of 36 Date of Issue: October 2012

6.2.2 Summary of Impact Managing prolonged and widespread outbreaks of diarrhoea and vomiting can be intensive and cause severe consequences for bed management and patient movement both in and out of the provider site. Norovirus is a whole health community issue and good information, communication and trust is vital to reduce severity, length and impact. 6.3. Pandemic Influenza Following the H1N1 Pandemic of 2009 all organisations provided assurance that they have robust Pandemic Influenza Response plans in place, which remain valid should we see another untypical year of seasonal flu activity or another flu pandemic occurring. Anticipated consequences may include: A higher than normal rate of seasonal flu activity resulting in additional pressure on both community and acute services. Vulnerable members of the population suffering more severe or complex symptoms and requiring critical care treatment. Media interest and public concern with worried well members of the public presenting. 6.3.1 Mitigating Strategies Vaccination uptake this year remains a key priority with NHS Boards recognising that that this year s campaign will have the advantage of a single vaccine covering both seasonal and H1N1 strains, however the approach or attitude of staff towards vaccination will need attention to ensure they do not become blasé of the importance of flu vaccination. Learning from last years seasonal and H1N1 vaccination campaigns, NHS Boards must engage with Occupational Health departments early and formulate actions plans to encourage a high profile and accessible vaccine programme for their staff. This year NHS Fife has identified Flu Vaccination champions, one for each operational area of the Board, who have agreed to promote the campaign in their areas. There is an NHS Fife planning group, Chaired by the Director of Public Health and an OHSAS/Human Resources sub group which formulates the staff vaccination plan. OHSAS undertook a survey amongst line managers earlier in the year to get feedback on what were the most effective ways of providing vaccination session and there is a plan to use the OHSAS mobile van to improve access. To promote awareness amongst staff, messages have been communicated through payslips and posters distributed throughout NHS Fife. Details have also been posted on the Intranet and only regular e-mail bulletins. One of the outcomes of H1N1 was the production of Critical Care Plans outlining how NHS Boards would increase Critical Care capacity should this be required at short notice. Some NHS Boards started the advance purchase File: NHS Fife Winter Plan Page 22 of 36 Date of Issue: October 2012

of critical care equipment following this and it was recognised that these plans remain valid as part of the Boards toolkit of plans. Organisations are asked to be vigilant to any untypical seasonal flu activity and have reporting and management plans in place for any flu related activity. 6.3.2 Summary of Impact Organisations are well prepared and tested on their management of influenza like illness activity and their individual response plans and reporting requirements. Although it is not anticipated, from experience in managing H1N1, a local spike in severe cases, a mutation of the current strain or indeed the emergence of a new and/or more virulent influenza could undoubtedly trigger a response which would cause a rise in escalation status. The aim of the NHS Fife Pandemic Influenza Plan is to describe operational actions designed to help the organisation manage periods of high pressure, whilst maintaining the highest possible quality of patient care. 7. Capacity Management 7.1 Background Increases in activity during winter are small compared to overall activity and should not normally in themselves lead to increased escalation. However over winter and other holiday periods there are a number of other factors which may also occur such as, public holiday leave, severe adverse weather conditions, Norovirus outbreaks which can severely impact on the health and social care services ability to deliver care to patients. 7.2 Horizon Scanning The primary concerns of this winter are in relation to: Ability to maintain effective flow of patients through the system Norovirus outbreak Severe weather Influenza outbreak 7.3 Ability to maintain effective flow The work being undertaken as part of the Improving Flow and Emergency Access programme is helping inform and provide solutions to improved and sustainable flow throughout the whole system (Appendix1) all year round. Additional actions have also been agreed to enhance this work over the winter period. These are outlined in Appendix 2. File: NHS Fife Winter Plan Page 23 of 36 Date of Issue: October 2012

8. Performance Monitoring, Management and Support Local activity information will be monitored weekly by the Improving Emergency Access Core Team and Daily at the morning capacity meeting by the on call senior Manager of the day who collectively will manage the appropriate response in order to: Support maintenance of emergency, urgent and unplanned care provision Promote effective provision of, and partnership between acute care, secondary care and community services Contribute to emergency and escalation response Support and approve maintenance or changes in elective activity levels 8.1 Winter Reporting The routine information areas regarded as key to effective winter escalation and, if necessary, influenza planning and management are: A&E access times Volumes and changes in non-elective admissions to Operational Division and transfers to community hospitals Volumes and changes in discharges from Operational Division and Community hospitals and services Number of delayed transfers of care and time in delay Numbers of Boarders Critical care capacity Unplanned cancellations of elective activity Additional capacity opened in system Ambulance activity and performance 8.2 Infection Control Internal Outbreak notifications are circulated across the health, social care and education community by HPS. These reports consist of: Number of patients affected Number of staff affected Note of symptoms experienced Number of empty beds (if relevant) Likelihood of when the ward/unit can re-open (care home, ward, school) 8.3 Pandemic Influenza Reporting Should a pandemic occur over the winter period, specific information relating to pandemic flu will be reported as required, dependant on the nature of a pandemic and requirements of individual agencies. Frequency of reporting will be reviewed in the event of escalation. The agreed reporting areas to the Incident Control Team are likely to include: File: NHS Fife Winter Plan Page 24 of 36 Date of Issue: October 2012

CHP weekly status report on influenza consultations and staff absence related to flu symptoms. Operational Division units daily reporting of numbers of patients with (or suspected as having) pandemic influenza. All deaths within the community possibly linked to pandemic flu reported on a weekly basis. Full details are outlined within the NHS Fife Pandemic Influenza Plan. 9. Governance The reporting framework for governance purposes is: Scottish Government NHS Fife SMT Director of Clinical Delivery Daily Capacity Meetings /Winter HUB D & WF LMG G & NEF LMG K & L LMG Ops Division 10. Communications Winter Plan 10.1 Objectives In dealing with winter specific issues the role of communications is to support operational activity and the objectives are four fold: To complement general awareness activity undertaken by the Scottish Government Health Department, NHS Fife, Fife Council and the Scottish Ambulance Service; To promote internal understanding and awareness of winter related issues and the impact they have on the service we provide as well as delivering operational information for staff such as impact on travel to work, requests for volunteers to stay on site in extreme conditions, business continuity and safety messages; File: NHS Fife Winter Plan Page 25 of 36 Date of Issue: October 2012

To support staff in communicating with Service Users in the event of any disruption to normal services; and As appropriate to liaise with communications teams of stakeholder and partner organisations to ensure clarity and consistency of messages. 10.2 Overall Approach The communications team is represented on the Winter Hub so that it can both be briefed and advise members of it on communication actions that need to be taken. Key strategic messages that need to be promulgated will be discussed and agreed within this forum. Day to day messaging will operate within the parameters agreed by the team. The NHS Fife Strategic Management Team will be briefed at the Monday morning SMT meeting by the Director of Clinical Delivery. Further updates may be provided, the frequency of which being determined by the severity or otherwise of winter related issues. Whilst actions below relate to specific objectives, it is likely that the impact of actions will be felt across the target audiences of each objective and that there will not always be such clear demarcation. For example, depending on the level of the alert, dedicated phone lines could be set up to provide information and advice which would benefit staff, Service Users and other agencies. 10.3 Delivering the Objectives 10.3.1 Objective 1: General Awareness When necessary, NHS Fife will: Use its media contacts to promote relevant messages (especially local radio) Display in the main NHS Fife sites poster style information Publish information on the NHS Fife website, Facebook page and Twitter page Circulate information to key stakeholder groups who might be contacted for support from Service Users. 10.3.2 Objective 2: Internal Understanding Staff will be made aware of any underlying issues, the severity of any alerts, steps being taken by NHS Fife to support service delivery, advice that should be given to Service Users and reminders of where updated information can be obtained. Examples of good practice and responses above and beyond the call of duty will also be communicated in order to recognise staff achievements in going the File: NHS Fife Winter Plan Page 26 of 36 Date of Issue: October 2012

extra mile to overcome difficulties caused by any winter issues. The content of the winter plan and its availability will also be communicated. The main channels for doing this will be: NHS Fife Intranet to provide latest information, key messages and easy access to steps being taken to deal with any issues Distribution of this information via line managers to all staff Production of notice board material 10.3.3 Objective 3: Service User Communication The role of the Corporate Communications Team is to act as a facilitator and provider of information, in support of front line staff whose responsibility it is to ensure Service Users supported by them are advised speedily and appropriately: Ensure key messages are directly communicated via line managers to teams to communicate to Service Users; Ensure compatibility with other messages being disseminated by other parts of the health community; Liaise and organise the translation of any material into required languages; Ensure stakeholder groups (e.g. service user groups, carer groups, volunteers, charities) are also advised of actions being taken; Produce appropriate supporting website messages and alerts including where appropriate audio information; Communicate in a way which reassures and does not promote anxiety; and In the event of major upheaval, media to be targeted, particularly radio with appropriate information. 10.3.4 Objective 4: Liaison with Stakeholder Groups Maintain up to date contact data of relevant recipients Participate in any health community coordinating groups such as resilience forums and support activity arising. Ensure coordinated activity/consistent messaging where appropriate The team will regularly review its activity to ensure that it remains effective and proportionate to the winter issues which arise. 10.4 Seasonal Flu As part of the winter communications plan, the team will support efforts to maximise seasonal flu vaccinations by promoting the safety message of staff vaccination; highlighting the important role vaccination plays in continuity of File: NHS Fife Winter Plan Page 27 of 36 Date of Issue: October 2012

11. RISK service delivery; the logistics (e.g. timing, location and booking procedures of clinics) of vaccination programme. A number of risks to whole system delivery of health care exists all the time e.g. delayed transfers of care, infection control. However whilst efforts are made to mitigate these risks, they may increase in impact over the winter months. Risk is managed and reviewed regularly at the SMT (Risk) meeting. The Corporate Risk Register is reviewed, updated and escalated through the appropriate channels within the organization. In addition, when there is an increased risk of H1N1 or other pandemic influenza, the risks within this are recorded, in detail under Pandemic flu. NHS Fife and partner organisations have developed robust Business Continuity Plans to ensure core services can be maintained and delivered in the eventuality of a system challenge or failure. Managing winter risk is no different to managing any other type of risk and is a process that will be supported in the local health community by: Robust Business Continuity Plans Well delineated Escalation Process A whole system approach to the management of escalation Established Major Incident Plans, which can be invoked internally as required. File: NHS Fife Winter Plan Page 28 of 36 Date of Issue: October 2012

Appendix 1 Reporting Structure for Red and Beyond Red Status Out of hours and weekend Weekend On-call Manager (Ops Div) Chair teleconference call at 11am Saturday and Sunday to determine Escalation Status. Will contact on-call CHP Manager if required to alert. Mon-Fri-8.30am-5pm Morning Capacity Meeting (8.45am) (Chaired by On-Call Senior Manager of the day) Determines Escalation Status OD and LMGs Provide status update to morning capacity meeting by 9am PA to Director of Clinical Delivery Update Daily Report Publish on Virtual Hub Green Follow arrangements outlined within NHS Fife Whole System Escalation Framework (Section 4.7) Amber Follow arrangements outlined within NHS Fife Whole System Escalation Framework (Section 4.7) Red Follow arrangements outlined within NHS Fife Whole System Escalation Framework (Section 4.7) Mon Friday in addition: Send text message to group members listed in appendix 2 Determine if additional membership of 12 noon capacity meeting is required Beyond Red Follow arrangements outlined within NHS Fife Whole System Escalation Framework (Section 4.7) Mon Friday in addition: Send text message to group members listed in appendix 2 Separate text to Acting Director Acute Servcies, GM Glenrothes and NE Fife and Head of Older Peoples Service, Fife Council File: NHS Fife Winter Plan Page 29 of 36 Date of Issue: October 2012

Appendix 2 Group Members for Red and Beyond Red Alerts Title LMG Lead D&WF and counterpart health/social work LMG Lead Glenrothes and NE Fife and counterpart health/social work LMG Lead Kirkcaldy and Levenmouth and counterpart health/social work Integrated Admission and Discharge Manager Divisional General Managers General Managers Acting Director of Acute Services Medical Director Operational Division Head of Older Peoples Services Fife Council Service Manager Social Work Service Manager Home Care File: NHS Fife Winter Plan Page 30 of 36 Date of Issue: October 2012

Appendix 3 Programme Improving Flow and Emergency Access Work Stream Front Door Projects/Test of Change Implementation of GP hot line to senior A & E Doctor with a proposal to provide hotline to NHS 24 and SAS Fast track process for patients with minor injuries to decrease overall length of stay in A & E Redirection of patients, who do not require the services that A & E provide, to alternative care providers Acute Admissions and Speciality Flow Focus on achieving 50% of discharge activity before midday Reducing variation in daily discharge numbers Elimination of boarding Reintroduction of discharge lounge Nurse facilitated discharge Improved access to specialty beds Predicted Date of Discharge Community Flow Increased number of patients who retain their existing care package following an admission to hospital Reduction in waiting time for patients who require a new social work care package Increased number of patient transfers to community hospitals and community teams at the weekend and on public holidays Increased number of patients with a Predicated Date of Discharge (PDD) in Community Hospitals Standardisation of nursing documentation across acute and community Increased number of patients discharged before midday in Community Hospitals File: NHS Fife Winter Plan Page 31 of 36 Date of Issue: October 2012

Appendix 4 Plans to maintain and provide additional or surge capacity over winter 2012/13 Operational Division In addition to local operational plans to ensure that patient flow is maximised over the winter and festive periods the Operational Division has developed a surge capacity model for winter. It is intended that this surge capacity will be located within Victoria Hospital (VHK), available for a maximum of 6 months and will be opened as per the Surge Capacity Contingency Plan in response to agreed triggers as outlined in the escalation procedure. It is proposed that a maximum of 12 beds will be opened in response to the agreed triggers but that these beds will only be opened for short periods until immediate pressures are resolved. Local Management Groups (LMGs) The Local Management groups have identified three focus areas, with a number of actions in each to maintain flow and provide additional capacity over the winter and festive periods. These are: Staff Resource Management Managing Annual Leave Normal working arrangements will apply for ICASS and Social Care Staff over the festive fortnight, out with the designated public holidays. All Community ICASS and Acute AHP Staff, as well as Homecare will agree no/minimal annual leave during this period in order to ensure service continuity in respect of community response. Homecare Assessment Assessment capacity has been secured through volunteers, for the 26 th and 27 th of December and the 2 nd and 3 rd of January. This will leave only one day each week where assessment will not be available. ICASS Assessors over the Public Holidays ICASS Teams will provide cover on the 26 th of December and the 2 nd of January. Hospital @ Home Staff Nursing staff who are not fully deployed within Hospital @ Home due to a phased roll out will be fully integrated into the ICASS response in order to provide assessment and support services as required. File: NHS Fife Winter Plan Page 32 of 36 Date of Issue: October 2012

Community Developments Hospital @ Home Full roll out is anticipated across Dunfermline & West Fife, with part roll out in GNEF and Kirkcaldy & Levenmouth by Dec 2012. Providing increasing opportunities to prevent admission and support early discharge from acute care. Re-ablement Beds 8 beds will be provided within the Alan McLure care home facility in Glenrothes to support patients awaiting community resources and will be available from October 2012. Sheltered Housing Intermediate Care Units Glenrothes and Cupar areas will be available prior to Christmas with a minimum of 2 units in total to support patients awaiting housing and other community resources in the Glenrothes and Cupar areas. Maintaining and building on Community Flow Improvements Weekly meeting of Community Flow Group/ LMG Leads will review activity and flow data across the community system to ensure flow is maintained and adjustments made proactively. Map and monitor flow across a range of pathways including Care Home placement, community hospital admissions, discharges from acute to ICASS, Home care and Reablement and Hospital @ Home. Monitor delayed discharge numbers and bed days lost by reason, to focus improvement activity further, and agree actions on a weekly basis. Ensure anticipated Home Care capacity is in place by explored agreements with the Independent Sector for provision particularly over festive fortnight. This will include direct commissioning from hospital sector for small packages of care to support discharge. File: NHS Fife Winter Plan Page 33 of 36 Date of Issue: October 2012

Appendix 5 NHS FIFE OUT OF HOURS SERVICE: CONTINGENCY PLANNING WINTER AND FESTIVE PERIOD 2012/13 1. INTRODUCTION This plan covers both the ongoing winter period with its additional pressures on the health care system and the specific measures that PCES have planned for the Festive period. This year, as in the previous festive periods PCES have reviewed the Business Continuity plan to ensure our contingency plans remain robust, current and able to deal with all technical and operational issues. 2. WINTER PLANNING Additional recruitment and training has taken place for both admin and clinical staff to ensure as flexible a work force as possible are in place to meet the needs of the service. All staff groups within the service have an active bank of staff that can be called on to provide cover for annual leave and short notice sick leave. PCES does not plan to significantly increase staffing levels over the winter period unless required through significantly increased activity. Activity is closely monitored during the winter months and reviewed along with guidance from HPS and SGHD. 3. FESTIVE PLANNING PCES is aware that due to the public holidays it is a time of greatly increased demand putting pressure on the services we provide. All clinical and admin rota s have been completed and are full. We have reviewed our workforce planning this year in line with the statistical evidence we have for the patient profile of attendance. Additional staff have been put in place for all skillsets. An emergency list of short notice volunteers will be available to ensure cover is available for any absence. The on call management rota will be operational throughout the festive period to support the service. File: NHS Fife Winter Plan Page 34 of 36 Date of Issue: October 2012