SUBJECT: NHS Lanarkshire Winter Plan 2009/20010

Meeting of Lanarkshire NHS Board Lanarkshire NHS Board 14 Beckford Street Hamilton ML3 0TA Telephone 01698 281313 Fax 01698 423134 www.nhslanarkshire.co.uk SUBJECT: NHS Lanarkshire Winter Plan 2009/20010 1. Purpose The purpose of the paper is to describe the actions that will be taken by NHS Lanarkshire and Partner Agencies to address anticipated additional pressures on health and social care services over the Winter period 2009/2010. Again this year there will be two four day periods of weekend/public holidays and it is anticipated that demand, particularly for the Out of Hours Service will be particularly high on the two weekends of 26th/27th December and 2 nd /3rd January. For the Acute Division, demand on beds and services is expected to be at its highest in the period immediately following the public holiday period i.e. from early January 2010. In preparing this year s plan, close links have been made with the Board s Pandemic Flu Plans and many of the contingencies used during the winter planning period are already in operation. In addition, recommendations from the Winter Pressures report produced by Dr Daniel Beckett (Appendix 1) and presented to the National Emergency Access Delivery Team have been fully taken into consideration and acted upon. The report outlines the proactive measures as well as contingency measures that will be put in place as part of an agreed escalation policy and builds upon the whole system plan developed in previous years. The plan and its ongoing execution are informed by a process of information capture, monitoring and reporting linked to an escalation policy that in turn will release additional capacity into the system if required. Details of the additional capacity and costs associated with implementation of the plan are provided within this report. The winter plan requires an extensive communication plan for both staff and the wider public to ensure awareness of individual and collective roles and responsibilities and guidance to the public on the actions they should take to keep well or how to access services when required, particularly over the festive period. It is worthy of note that during the latter part of October there has been an early indication of the sorts of pressures that may be experienced over the winter. This increase in pressure has been felt both within hospital services and also in the Primary Care Out of Hours Service. Page 1 of 10

In regard to the former, considerable work is now under way to ensure that discharge processes are as streamlined as possible across all sites and that there is a clear coordinated response from both Primary Care and Social Work Services. Planning and work undertaken now will aid the implementation of the Winter Plan and has focused attention on critical areas. Within Out of Hours the need to flex capacity across the week and new staffing compliments has been a good early preparation exercise. 2. Partnership Involvement The winter plan has been prepared on a whole system basis with involvement by all Partner Agencies including NHS Lanarkshire, North and South Lanarkshire Councils, Scottish Ambulance Service, NHS24, NHSL Out of Hours Service and staff partnership. The plan has been endorsed and will be led by the Winter Planning Steering Group. An event is planned for 3 rd November where all agencies will be represented, to build upon previous development events and look in more detail at some of the key challenges for this year. 3. Organisational Arrangements The winter plan is an actively managed document and will continue to be refined up to and during the winter period as required. All agencies will look to work together to respond to emerging winter pressures. This will be facilitated through twice daily conference calls which will assess pressures across the system on a daily basis to enable an appropriate response. Further conference calls will be instigated at weekends if necessary as part of the escalation process. Fortnightly meetings of key staff from all Partner Agencies have commenced to ensure that an assurance can be given to the Board and Scottish Government on progress. In addition, key staff will identify and raise areas of concern with the appropriate Executive Director. 4. Key Elements of the Winter Plan The winter plan has 7 key areas that describe the contribution that each Partner Agency will make to the delivery of an efficient and effective winter plan. These are: Primary Care/General Practice Primary Care Out of Hours/NHS24 Acute Division Local Authorities Scottish Ambulance Service Whole System Monitoring, Reporting and Escalation Communications Key services are finalising very specific and detailed Action Plans to ensure the smooth implementation of the plan. Page 2 of 10

These key services will link in with General Practitioners, Community Pharmacists, Local Authorities, NHS24, Scottish Ambulance Service and a range of other services to develop their Action Plans, and will continue to communicate the plans to them as they develop. The following elements of the winter plan aim specifically to address the risks which might occur over and above normal planning processes in regard to service delivery at this time of year, and proactively manage those risks before and during the festive period. 4.1 Primary Care/General Practice A range of measures will be put in place to address some of the issues which arise within vulnerable groups of patients, such as: Delivery of the flu vaccination programme to the population at risk, over 65s and staff, as well as the commencement of the H1N1 vaccination programme Remind patients to ensure they have adequate supplies of medication during public holiday periods Proactively visit vulnerable groups using the SPARRA data, and specifically those patients identified as being part of Care Management Carry out risk assessments on other vulnerable groups by Locality; this should include Carers as well as those they care for. Complete the sustainable roll out and delivery of the Care Homes Enhanced Service. Measures will also be put in place which will, in some cases, prevent admission and/or facilitate discharge from the acute service. These will include: Extended working days for District Nurses with the ability to react more quickly to facilitate speedier discharges. Locality specific plans which set out staffing levels, escalation plans, access to home loan equipment and availability of local services during the crimson period Robust protocols around the access to beds in GP Hospitals will be in place and disseminated 4.2 Primary Care Out of Hours/NHS24 Again this year, a number of measures will be put in place to ensure that patients are seen and treated by the most appropriate service, and in the most appropriate environment. In anticipation of winter pressures, a new rota management system, IQUS, is now in operation in OOH which will support efficient rota management and by providing online access will assist staff in booking shifts and verifying their own commitments. Page 3 of 10

Staffing Issues a) Doctors: specific effort has been made to recruit new doctors to support the service throughout the winter period. A successful campaign targeting newly qualified registrars has strengthened the pool of doctors available by 16. The festive rota has been posted and it is anticipated that all doctor shifts will be filled. b) Clinical Support Workers: will be utilised at Monklands and Hairmyres PCEC s during the peak periods over the festive period to assist with patient flow. c) Other clinical staff: the pool of clinical staff working in the OOH period is widened over the winter period with CPN s, Pharmacists and additional nurses working to PGD s to handle advice calls and overflow triage calls from NHS 24. d) Hub Staff, Receptionists and Drivers: Extra hub staff are required to manage the activity throughout the festive holidays; Receptionists are require for the two Friday and Mondays; Drivers are required for minibus and cars on the Friday and Mondays, and also for the extra two cars for the two Saturday, Sunday and Mondays. e) Management: An on-call rota with weekly review meetings is in place for the OOH management team. Service Issues A number of initiatives are being developed or have already been deployed for use over the winter period to support the safe and effective management of calls, especially to assist in absorbing demands at peak periods. a) A&E Referrals: agreements are in place with each A&E department re the transfer of appropriate patients from A&E to OOH services; currently c600 patients per month are transferred in this planned manner b) The professional line: allows direct contact with the OOH service rather than contact with NHS 24. This number has been widely communicated to Care Homes and Pharmacies and is well used by these professionals in accessing care. c) Pharmacists: following a successful pilot, a team of 15 Pharmacists have been recruited. Their role will encompass providing telephone advice on medicine related matters, on minor illness and where relevant advise on the management of flu symptoms and by using PGD prescribing anti-virals d) Nurse Advice: a team of 16 nurses have been trained to provide telephone advice by using PGD s for managing flu symptoms and prescribing anti-viral medication. These staff are a flexible resource that can be deployed when a local outbreak of flu occurs Page 4 of 10

e) CPN: following a successful pilot over the last 2 years at the festive period, CPN s will be recruited to support the OOH service by providing telephone advice to patients calling with mental health issues. These calls are notoriously lengthy and are more appropriately handled by skilled CPNs. This year, CPN s will also be provided with access to their own clinical system, Genesys f) Nursing Homes: nursing homes can refer patients directly to the OOH service via the professional line and an aide memoir will be sent to all homes prior to the festive period g) Community Hospitals: work is underway with consultants looking after patients in long stay wards to look at systems for reducing the number of inappropriate admissions h) Clinical Staff Handbook: a new handbook has been developed for all clinical staff to assist in efficient running of the service i) Referral from practices and return visiting: following a successful pilot last year practices can refer patients for a return visit by the OOH service using an agreed proforma j) Care Management Patients: the potential to alert clinical staff to the fact that a patient is part of a care management programme and has a care plan in their home will be explored with the aim of providing this information via Special Patient Notes on Adastra. k) Festive Meeting: all staff working in the OOH service will be invited to a Festive Meeting on December 10 th to appraise them of the Winter Plan and to receive feedback on outstanding issues or concerns 4.3 Acute Hospital Service Management Information Daily multi disciplinary bed management meetings will be held on each acute hospital site during the winter period. Frequency of meetings will be increased during the main winter period. Meetings will address all operational issues that impact on the effective management of the hospital. Consultant medical staff will have an increased awareness of bed management issues. Emergency Demand, Capacity and Activity The Emergency Response Centre (ERC) will operate Monday to Friday between 8.00 am and 6.00 pm and provide a single point of access for General Practitioners who wish to make emergency referrals to any acute hospital site. Page 5 of 10

Links will be established with the Scottish Ambulance Service (SAS) to enable the ERC to order ambulance transport where this is considered appropriate. Nurse Bank will prepare an action plan to meet predicted demand at peak periods. An out of hours bed management and four hour access escalation plan will be in place to alert on-call managers to activity pressures at an early stage. During the winter period, the ERC will offer General Practitioners alternative options to hospital admission including: * Respiratory Nurse Specialist * Diabetes Nurse Specialist * Rapid Response Team * Cardiology (for patients with stable new Atrial fibrillation) Agreed criteria will determine access to those services. During January, the ERC will offer General Practitioners access to advice from Consultant staff. This advice will be available Monday to Friday between 9.00 am and 5.00 pm. Out of hours advice will be provided by the On-Call Consultant. Advice will include alternatives to hospital referral including access to an early outpatient appointment. System Watch and local information will be used to inform winter planning. This will include projected activity and discharges. During January and March, there will be increased and extended hours staffing in response to the anticipated increase in activity. The triage of patients from Accident and Emergency to Out of Hours will be intensified during the winter period where services are co-located. There will from November be deployment of three Mints Major Nurses in the Emergency Receiving Unit of each site (MMC Funding). Existing Flow Co-ordinators will from November be converted to Clinical Support Workers with enhanced skills operating between the Emergency Receiving Unit and Accident and Emergency on each site. At Monklands Hospital an area will be established for use by Medicine for the Elderly to assess patients and determine future action. This will be part of a pilot process under Lean. Increased bed capacity has been identified for the main winter period. This will include opening up to 30 additional beds at Hairmyres (21) and Monklands Hospitals (4) and at Parksprings (5). This will include, as a last resort, the cohorting of delayed discharge patients into one inpatient area. Access to those beds will require Director level approval. All off site beds will be maximised with agreed criteria for access to GP Hospital beds. Critical Care beds will increase from 5 to 6 beds on each site during the winter period. Elective Demand, Capacity and Activity Elective surgical activity will reduce between 23 December and Monday 11 January. Theatres will continue to operate for emergency and cancer patients. There will be an increase in day surgery over the festive period. Page 6 of 10

Medical elective activity will reduce during the first full week in January to support increased consultant ward rounds and advice to General Practitioners through the ERC. Decisions to close wards for operational reasons will only be made with Director level approval. The Infection Control Team (ICT) will liaise with senior managers/clinicians if wards require to be closed. Discharges The level of discharges over the holiday and winter period will be improved. Daily ward rounds (Monday to Sunday) will be undertaken by a consultant (an appropriate designate). A rota of clinical staff will be prepared to deliver daily ward rounds. Estimated Date of Discharges (EDD) will be prepared for each patient within 24 hours of admission and reviewed daily. Additional emergency diagnostic capacity will be established to expedite discharges and/or admission avoidance. Enhanced weekend clinical support services will operate during the winter period. A multi agency meeting will be held each week to review all patients designated as delayed discharges. There will be scrutiny of discharges (comparable with admissions) to ensure timeous discharge of patients. There will be joint monitoring of discharges with agreed escalation arrangements in place. Annual Leave Rotas will be prepared to cover all staff to ensure delivery of the winter plan. This will include annual and study leave and all family friendly policies. The Medical Directors will ensure that an appropriate number of consultant medical staff are on site to deal with the predicted activity over the two week festive period. Boarding It is intended that the boarding of patients will be kept to a minimum. Patients will not be admitted directly into non speciality ward areas. Support Services During the winter period AHP services will be maintained with a particular focus on medical and surgical receiving units, rapid response, orthopaedic and care of the elderly inpatient areas. There will be access to the Scottish Ambulance Service (SAS) and patient transport during the winter period. This will be informed by advance Page 7 of 10

planning of patient discharge and effective transport management on each site. Access to additional transport will be required to facilitate discharge. There will be increased non clinical support services e g portering and linen. National Guarantees The Acute Division will continue to deliver national waiting time guarantees during the winter period. Priority will however be given to emergency admissions over routine elective procedures. An increase in activity of in excess of 10% will indicate a pandemic. 4.4. Local Authorities North and South Lanarkshire Councils have been an integral part of the Winter Planning process. The provision of additional staff will speed up the assessment process and facilitate discharge. This should lead to minimising the number of delayed discharge patients and Adults with Incapacity in Acute hospital beds to an agreed level. Protocols will be agreed on access to home care, in particular to the issue of restarting home care after discharge. Access to dedicated social work resource in the acute hospitals at weekends and on public holidays will be explored again this year. 4.5. Scottish Ambulance Service The Scottish Ambulance Service has indicated their preparedness to respond to requests for additional ambulance transport provided advance notification is given of the nature and extent of that additional demand. It is intended to again utilise the Predictive Data Analysis Tool to predict demand implications for the Scottish Ambulance Service. Due to financial pressures this year, the SAS cannot provide additional services without additional funding and an estimated cost is provided at Appendix 3. As in previous years non Scottish Ambulance Service ambulance providers will be commissioned to augment the service provided by the Scottish Ambulance Service particularly at weekends. 4.6. Whole System Monitoring, Reporting and Escalation Following the establishment and further development this year of the Emergency Response Centre, the ERC, will be the focus for the collation of all incoming intelligence on service delivery and service pressure with responsibility for collating, assessing, evaluating and as appropriate disseminating the information. It will also retain complete information on rotas and contact points for all managers/clinicians identified on each rota. A full set of all rotas will be mapped onto one table to cover the entire period. These rotas will also cover Local Authority, Scottish Ambulance Service, Out of Hours and NHS24. Page 8 of 10

Information will be channelled into the ERC on a daily basis using the Daily Performance Report and disseminated accordingly. This information will include: Early indications of any clusters of infection in the community Early indication of any outbreaks Daily status of the Scottish Ambulance Service Daily status of the Out of Hours service and NHS24 A range of information from the acute service;- o daily performance in four hour targets o available beds o delayed discharges o numbers of patients in A&E o predicted admissions o closed beds that could be opened o staffing issues o inpatient outbreak information o adverse weather information The information will be disseminated in a number of ways: By e-mail and/or faxed summary sheet By daily conference call By text to appropriate individuals on the rota for that day using the traffic light system 4.7. Communication Plan A communication plan is in preparation which will be directed at both the staff and the public. It is acknowledged that some components of the plan require to start earlier this year for example the leaflet distribution. In view of current financial pressures, the Core Group has suggested that the National Leaflet be distributed across Lanarkshire with no requirement to develop a local one. Information for the public on early preparedness for winter will be available and displayed in A&E Departments, as well as wider circulation to the general public in the form of the information leaflet. There are close links to the National H1N1 communications plans. 5. Cost Profile The preparations for Winter and the development of staffing capacity in the period from late December to 31 st March 2010 are achieved through a mix of embedded recurrent budgets within the operating divisions and additional non-recurrent resources held by the Board centrally. The estimated cost of the plans contained within this paper are an additional 577k as outlined in the attached action plan (Appendix 3). This sum is already accounted for within the Board financial plan for 2009/10. Where there are proposals in the plan to increase capacity these are based on a 3 month period January March, with the exception of the Out of Hours Service where capacity requires to be increased over the festive period. It is intended that usage will Page 9 of 10

be monitored on a weekly basis with an assessment in month of the additional capacity required for the next month. As previously stated both local authorities and the SAS have expressed concerns due to funding pressures this year and any additional requests over and above normal services will require to be funded, these are shown within the work plan. The nature and extent of spend will be influenced by the actions that will be taken in line with the escalation plan and the introduction of additional capacity into the system. 6. Summary The NHS Board is asked to endorse the detail of the winter plan, the actions that it is proposed to take in conjunction with partner agencies to address pressures during the winter period, the cost implications associated with implementation of the plan and the monitoring and reporting mechanisms through the ERC together with the adoption of the escalation plan where this is considered necessary. The NHS Lanarkshire Board is asked to approve the Winter Plan and Action Plan for 2009/10, and the allocation of up to 577k in non-recurring costs. Page 10 of 10