Capacity Plan incorporating the Resourcing Escalatory Action Plan (copy for external circulation) Index No: Capacity Plan (REAP) Page 1 of 8
1. BACKGROUND 1.1. For many years the London Ambulance Service (LAS) NHS Trust has worked at, or near, capacity. This has caused a degree of vulnerability in the delivery of patient care, due to lack of available resources at times of peak demand. 1.2. This lack of available resources can arise for a number of reasons. The two main reasons for over capacity are: 1.2.1. additional demand that is above a level that can easily be absorbed e.g. as a result of a heat-wave 1.2.2. decreases in available staffing to manage and respond to demand e.g. as a result of absence from work due to illness 1.2.3. the worst case scenario associated with capacity planning is a rise in demand above a level that can be absorbed within routine staffing and a simultaneous reduction in available staffing to manage and respond to demand e.g. in the case of a flu pandemic 1.3. There have been occasions (e.g. increased demand during extremes of temperature or during pandemic flu waves) where the LAS has produced a specific plan to deal with anticipated capacity issues. 1.4. The NHS now accepts that over capacity can occur at any time of the year and has introduced the philosophy of Whole System Capacity Planning (HSC 2001/014). The response by Ambulance Services in the United Kingdom has been to produce a nationally agreed series of triggers associated with changes in demand and capacity. 1.5. To support these triggers each service has developed a series of actions associated with each level of the six levels of pressure described within the Resourcing Escalatory Action Plan (REAP). 1.6. The six levels of REAP are: REAP Level 6 Potential Service Failure REAP Level 5 Critical REAP Level 4 Severe Pressure REAP Level 3 Moderate Pressure REAP Level 2 Concern REAP Level 1 Normal service Index No: Capacity Plan (REAP) Page 2 of 8
1.7. The LAS has a bespoke series of actions associated with each REAP level. This plan sets out the triggers for each level of REAP, the associated actions and who owns those actions. 2. INTENTION 2.1. It is the intention of the LAS to maintain a high level of patient care within national patient waiting time standards (response times) to the communities of London when experiencing capacity pressures. 2.2. During periods of high pressure, the LAS will consider a variety of tactical options that are considered most suitable to deal with the over-capacity situation. 3. DEMAND AND CAPACITY IMPACTS 3.1. Modelling undertaken on behalf of the UK ambulance services has indicated the following impacts against the national patient waiting time standards when either demand increases above levels that can easily be absorbed or capacity reduces. 3.2. The national patient waiting time standards are: 3.2.1. Immediately life threatened patients (Category A) arrive within 8 minutes of the emergency call being made 3.2.2. Serious but not immediately life threatened (category B) arrive within 19 minutes of the emergency call being made 3.3. Table 1 below sets out the impact on Category A performance against the national standard when demand and resource variations are applied. Table 2 sets out the same impacts for Category B performance against the national waiting time standard. Demand Increase Resource decrease 0.0% 2.5% 5.0% 7.5% 10.0% 15.0% 50.0% 100.0% 0% 75% 73.8% 72.7% 72.1% 71.0% 68.7% 35.3% 0.0% 5% 72.0% 71.0% 69.9% 68.7% 67.2% 64.3% 28.1% 0.0% 11% 68.0% 66.5% 64.6% 63.3% 61.2% 57.3% 14.8% 0.0% 16% 63.5% 61.4% 59.3% 56.5% 45.7% 36.3% 14.6% 0.0% 21% 56.3% 46.5% 35.5% 33.2% 32.2% 29.0% 14.4% 0.0% Table 1 A8 Demand Increase Resource decrease 0.0% 2.5% 5.0% 7.5% 10.0% 15.0% 50.0% 100.0% 0% 95% 94.3% 94.2% 93.7% 93.4% 92.4% 52.6% 0.0% 5% 93.5% 93.1% 93.1% 92.1% 91.6% 90.2% 39.7% 0.0% 11% 92.0% 91.3% 90.6% 89.9% 88.6% 86.8% 13.6% 0.0% 16% 90.0% 89.0% 87.5% 85.9% 82.6% 53.8% 13.6% 0.0% 21% 84.1% 70.3% 51.1% 43.2% 42.7% 40.1% 13.3% 0.0% Table 2 B19 Index No: Capacity Plan (REAP) Page 3 of 8
3.4. Any protracted Major Incident, or series thereof, would likely have an adverse effect on patient waiting times. This in turn would lead to a set of circumstances at which REAP level would likely be raised. 4. ACTIONS 4.1. The tactical options that may be considered are identified in Appendix A, the Resourcing Escalatory Action Plan (REAP). 4.2. Each level of REAP has associated actions that are designed to release capacity into frontline operations to manage the increasing demand or increase capacity. 4.3. It should be noted that ambulance services are organisations where the majority of its resources are routinely deployed to frontline operations, as such there is limited scope to release significant amounts of additional capacity. 4.4. Some of the actions associated with the REAP levels are designed to manage incoming demand in a different way. As we move through the REAP levels, additional actions including the Emergency Operations Centre (EOC) Extreme Over Capacity Plan will begin to target responses to those who, based upon clinical need, are in most need of an emergency ambulance. 5. KEY TRIGGERS 5.1. The triggers set out in table 3 below will apply. 5.2. Each trigger has several parts. Judgement is required to consider whether enough parts have been met to activate the trigger. (See Section 6). 5.3. Each trigger can cause an escalating level of the REAP to be activated. 5.4. Some of the triggers are measured against statistical data, presented weekly by the Management Information department (Appendix F). The trigger is activated when the data differs considerably from the al accepted value. The current al values are attached, at appendix B, for reference. 5.5. In addition to the key triggers, failure of mission-critical or vital support departments, may trigger any of the REAP levels and will be declared as necessary. When taking action in this plan, senior managers must refer to the LAS Business Continuity Plan. 5.6. Assistant Directors may also choose to activate parts of the plan (up to and including REAP 3) in their Areas, if their local Area is coming under sustained pressure but the LAS plan has not been triggered. 5.7. Changes to the REAP level will be emailed to All Active Users within which the rationale for the change will be set out along with the review period. The Pulse website will be updated to reflect the change. 5.8. Each major service building has a status board to indicate to all staff the current REAP pressure level. Local managers are responsible for updating the status board and bringing this to the attention of their staff and explaining what the change means. 5.9. The following post holders are responsible for declaration of each of the following REAP levels across the Service: Index No: Capacity Plan (REAP) Page 4 of 8
5.9.1. REAP 1 Normal Service 5.9.2. REAP 2 Concern Deputy Director 5.9.3. REAP 3 Moderate Pressure Deputy Director 5.9.4. REAP 4 Severe Pressure Director 5.9.5. REAP 5 Critical Director /Deputy CEO 5.9.6. REAP 6 Potential Service Failure Senior Management Group Index No: Capacity Plan (REAP) Page 5 of 8
REAP Level 6 5 4 3 2 1 Performance Cat A > 15% 65% Cat A 10 15% 70% Cat A 5 10% 80% Cat A 3 5% 85% Cat A <3% 90% All national performance indicators achieved Factors Affecting Performance Demand Abstractions Control Room Issues External Influences NHS Internal Influences > 30% above 25% -30% above 20% - 25% above 15-20% above 10 15% above < 10% above 15% over al 15% over al 10-15% over al 10-15% over al 5-10% over al EMS are within al Control have increased by >20% over al Call abandoned rate > 20% 60% calls answered within 5 seconds Control have increased by 15% over al Call abandoned rate > 15% 75% calls answered within 5 seconds. Control have increased by 15% over al Call abandoned rate < 10% 85% calls answered within 5 seconds Control have increased by 15% over al Call abandoned rate >8% 90% calls answered within 5 seconds Control have increased by 15% over al seasonal levels Call abandoned rate 5% 92% calls answered within 5 seconds Control are within al Call abandoned rate < 2% 95% calls answered within 5 seconds Supply chain difficulties mean trust supplies are at a critical level. UK Alert level is raised. Supply chain difficulties mean trust supplies are at a critical level. UK Alert level is raised. Supply chain difficulties are not manageable. UK Alert is raised Supply chain difficulties are manageable. Severe events are having a wide spread impact in a region. Supply chain difficulties are short lived. Severe events are having a limited local impact on activity. No reported supply chain difficulties. No severe events are a threat to activity. Hospital delays are being experienced at multiple sites for a sustained period. Major critical infrastructure issues have been experienced for a period of 24hours and are expected to continue for an unspecified time. Hospital delays are being experienced at multiple sites for a sustained period. Major critical infrastructure issues have been experienced for a period of 24hours and are expected to continue for an unspecified time. Hospital delays are being experienced at multiple sites no evidence of reduction. Major critical infrastructure issues have been experienced for a period of up to 24hours and are expected to continue for a specified time of no more than 24 hours. Hospital delays are being experienced at multiple sites. Critical infrastructure issues have been experienced for a period of 12hours and are expected to continue for a specified time of no more than 6 hours. Hospital delays are being experienced at a single site. Critical infrastructure issues have been experienced for a period of 6 hours and are not expected to reoccur. No hospital delays over 20 minutes. No critical infrastructure issues. Table 3 Index No: Capacity Plan (REAP) Page 6 of 8
6. HOW TO USE REAP 6.1. REAP should be used as part of a forward looking planning process that forecasts performance and service delivery over the next week by assessing the likely impact of the key influencing factors. The LAS will determine the appropriate REAP level for the coming week on the basis of this analysis and forecast. For national consistency, the LAS will review the appropriate REAP level and publish any changed level. 6.2. Six REAP levels have been identified. Once assessed, the various factors that influence demand and predicted likely performance the appropriate REAP level should be selected. This will contain measures which, if implemented effectively, will protect Trust performance at the national target levels. 6.3. There are a wide variety of factors that can affect performance demand, absence, external factors (weather, supply chain disruption, security threat, hospital issues etc) and internal factors (fleet issues, infrastructure problems etc). 6.4. The figures contained in the influencing factors section of table 3 above are intended for guidance only. They should be used to help inform judgement about what is likely to happen to performance. 6.5. The REAP plan and the REAP levels apply to the whole organisation. The current level will be widely publicised. Every manager has a responsibility to know the current level. It is expected that all staff will have an understanding of the REAP levels and know what is required of them. 6.6. Each operational manager and head of department has a responsibility to understand the plan and to have a corresponding implementation plan for their area of operation. All areas of the Service are required to take meaningful action, with the appropriate urgency, as the plan escalates. 7. INTELLIGENCE GATHERING 7.1. The key to dealing with the triggers in Section 5 is early identification of pressure building in the system. 7.2. Any of the relevant resources of the LAS may provide evidence of over-capacity. These may include: Director/Deputy Director of Operations, Assistant Directors, Ambulance Operations Managers, Resource Centres, Fleet Management, Emergency Bed Service, Emergency Operations Centre, Crew Staff, Communications Dept. and Emergency Planning Unit. 7.3. External sources may include The Dept. of Health, Strategic Health Authority (London), Public Health, Primary Care Trusts, Acute Hospitals, non-health organisations (e.g. The Metropolitan Police Service), the media, the Met office. 7.4. Clearly no exhaustive list can be prepared and all management elements of the LAS must be alive to the collection of information/intelligence that could be thought to lead to over-capacity Index No: Capacity Plan (REAP) Page 7 of 8
within the LAS. Intelligence should be reported to the Deputy Director for consideration. 8. CO-ORDINATION AND ASSESSMENT OF INFORMATION 8.1. The Deputy Director will hold responsibility for assessing the key triggers and advising the Director and Gold when triggers have been reached. A weekly return will advise the Director that this task has been carried out. 9. STRUCTURE 9.1. Having been made aware of the developing/deteriorating situation, Gold will call an over-capacity meeting, if appropriate dependant on the nature and expected duration of the capacity issue, at the necessary level, to take action. 9.2. Core attendance will vary depending on the trigger that has been reached, but will include a selection of the following: Director/Deputy Director Ops, Assistant Directors Ops, Gold, Silver(s), the Director responsible for Business Continuity, senior EOC and UOC managers, appropriate AOMs, Head of Education and Development, Director of H.R, Director of Service Development, Head of Emergency Preparedness, Senior Resource Manager, Emergency Bed Service Manager, Head of Operational Support Department, Fleet Manager, Information Analyst, IM & T Manager, PTS Manager, Communications Dept. Manager, Finance Director, Voluntary Ambulance Service Managers. 9.3. The duty Gold will lead the recovery effort, supported by all departments. 9.4. Gold (or appropriate senior manager) will re-convene meetings, as required, to review progress and determine any necessary further actions/activity. 10. SUPPORTING DOCUMENTS 10.1. Dependant on the nature of the capacity issue it may be appropriate to consider the intentions and action set out in this plan in conjunction with the following LAS policies, procedures and plans (not an exhaustive list): 10.1.1. Major Incident Plan 10.1.2. Strategic Pandemic Flu Plan 10.1.3. Operational Pandemic Flu Plan 10.1.4. Heat-wave Plan 10.1.5. Business Continuity Plan 10.1.6. Event plans (specific) 10.1.7. EOC Extreme Over Capacity Plan Index No: Capacity Plan (REAP) Page 8 of 8