NHS North West
Winter Plan 2011/12
Introductory Remarks
I am pleased to have been given the opportunity to make some introductory
remarks at the beginning of this important document.
Last winter the NHS in the North West faced considerable challenges including swine
flu and extended periods of severe weather. Despite this service providers managed
the challenges and continued to provide high quality services to patients.
There is little doubt that we will be faced with similar challenges this winter and
these challenges will coincide with the start of significant organisational change
across the whole of the NHS.
To support continued good performance the NHS North West has commissioned
work to build on the joint assurance process and develop a comprehensive Winter
Plan. In planning for next winter we need to learn from and share our successes. In
addition we need to understand where things did not go so well so as to prevent this
in future.
The plan has been constructed through work with NHS North West leads,
Commissioners and Providers during the early part of 2011 and is aimed at providing
guidance and shared learning so we can meet the challenges we face in a robust and
coordinated way.
I do hope you will find this helpful in your work locally.
Jane Cummings
Deputy Chief Executive and Chief Nurse
2
Contents
Page No
Section 1: Introductory remarks
2
Section 2: Background
4
Section 3: Roles and Responsibilities
5
Section 4: Commentary on experience from past winters
6
Section 5: Summary of recommendations on winter planning
16
Section 6: Key risks for winter 2011/12
18
Section 7: Winter plan assurance process
19
Section 8: Winter planning timetable
20
Section 9: Command, Control and Communications
21
Section 10: Appendices
24
3
Background
This plan sets out the learning points from winter 2010/11 and the actions needed
across the North West to ensure that high quality and responsive services are in
place for winter 2011/12.
The plan is predicated on NHS Foundation Trusts, NHS Trusts, NWAS, GP Consortia,
PCTs, Local Authority Social Services and other partner organisations joint planning
and preparation to ensure effective arrangements are in place to provide high
quality, responsive elective, urgent and unscheduled care during the winter period
2011/12.
- Roles and responsibilities
- Lessons learned from past winters
- Priorities and risks for Winter 2011
- The process and timetable for assurance of local winter plans
- The process of assurance
- Communication processes across the NHSNW
4
Roles and Responsibilities
The North West Strategic Health Authority is responsible for assuring that all
stakeholders in local health economies have robust, effective and efficient plans in
place for the management of winter.
The Chief Executive of PCT Clusters across the North West will be responsible for
coordinating a whole economy winter plan, drawing together plans from all
providers in their area and including arrangements agreed with local authorities and
other partners.
The winter plans are expected to demonstrate actions to address

Operational readiness (bed management, capacity, staffing and New Year
elective ‘re-start’ etc.)

Out of hours arrangements

Handover of patient care from ambulance to acute trust

NHS/Social Care joint arrangements including work with local authorities
Ambulance Service/Primary Care/A&E links

Critical care services

Preventative measures, including seasonal flu immunisation programme
and respiratory hygiene

Communications
In addition plans must clearly quantify escalation arrangements, specify
arrangements to provide additional capacity particularly in relation to critical care
surge plans, confirm communication arrangements within and between
communities and address risks identified from previous years.
A later section of this plan refers to the assurance process and a checklist is attached
at appendix 1 to support the development of these plans.
5
Responsibilities of the NHS North West
The role and responsibilities of the NHS North West for winter planning 2011/12 is
to:
 Hold to account health economies and partner organisations to ensure
that appropriate and robust arrangements are in place to manage winter
and that these plans build on learning from previous years.

Ensure proactive engagement with all organisations across the North
West to ensure proper arrangements are in place. This will include
oversight and monitoring of day-to-day performance through SITREPs,
exception reporting and ensuring clear escalation and communication
process through Gold Command arrangements.

Ensuring, through critical care networks, arrangements for critical care
are in place and that critical care surge planning arrangements are
operationally deliverable. This should include coordination arrangements
for the provision of ECMO.
Responsibilities of PCT Cluster Chief Executives – transitional arrangements
As part of the transitional arrangements Chief Executives of PCT Clusters are
responsible for:

Identifying leadership to coordinate and manage plans for local populations.
These arrangements should build on previous years wherever possible to
ensure learning and experience is not lost. As in previous years the emphasis
will be on the delivery of satisfactory performance and the monitoring of that
performance through SITREPs daily A&E performance and coordinated
communication systems.

Satisfying themselves that day-to-day management arrangements between
providers and partner organisations are in place to allow the system to cope
with any difficulties.

Ensure all local NHS organisations and partners have in place clear escalation
and communication arrangements. This will include assurance that daily
conference calls are arranged, if required.
Responsibilities of NHS Foundation Trusts and NHS Trusts

It is the responsibility of NHS Foundation Trusts and NHS Trusts to provide
services to patients and to deliver to the service standards agreed locally. To
achieve this appropriate management arrangements will need to be put in
place.
6

NHS Foundation Trusts and NHS Trusts should ensure they work closely with
commissioners and other providers to deliver comprehensive arrangements
across the local health economy. This will include ensuring effective
escalation arrangements are in place across the whole health community.

NHS Foundation Trusts and NHS Trusts should agree arrangements to
participate in Community wide conference calls and may wish to coordinate
these on a daily basis.
Responsibilities of Social Services

Social Services and their partner organisations will work closely with local
health providers and commissioners to ensure that performance is
monitored and proper contributions are made to local capacity planning and
management of activity.
7
Commentary on experience from past winters – including
recommendations
Influenza
Last year saw an increase in the incidence of influenza in both the general public and
in staff.
Whilst there was widespread communication with the public and staff on the need
to take up vaccination, significant numbers of people came forward late in the
season as the effects of the virus became better known.
Uptake in people over 65 demonstrates a steady state year on year but with a slight
fall during 09/10 as demonstrated below
North West
% uptake
06/07
75.00%
% uptake
07/08
74.10%
% uptake
08/09
75.00%
% uptake
09/10
73.4%
% uptake
10/11
74.6%
% uptake of influenza vaccine in people aged 65 and over
Uptake in people under 65 but at risk shows a marked improvement over recent
years as demonstrated below
North West
% uptake
06/07
43.00%
% uptake
07/08
45.80%
% uptake
08/09
49.00%
% uptake
09/10
52.7%
% uptake
10/11
53.2%
% uptake of influenza vaccine in people under 65 but at risk
There is a slight increase in the over 65 uptake to 74.6% and an increase to 53.2% in
the under 65 but at risk group. Uptake has been fairly static in recent years for the
over 65 age group at or around the government target of 75% whilst the under 65
age group has shown a moderate increase.
Note:(98.4% of practices responded in the North West)
Figures for staff uptake of influenza vaccine need to be reviewed following high
levels of absence in some areas over the winter and in particular the holiday period
last Christmas. Commissioners may wish to discuss with local providers the
development of staff immunisation targets. It is recognised that there are complex
legal and employment issues in requiring staff to be immunised but with variation in
rates between organisations ranging from 10% to 90% and an average this year of
51%, it is clear there is room for improvement. (see graph below)
8
Seasonal Flu Vaccine Uptake (Frontline Healthcare Workers) – All Trusts 2010/11
Many lessons can be learned from those organisations that achieved high levels of
immunization in staff the most important being that taking vaccine to staff appears
to be more effective than requiring staff to make appointments at occupational
health departments.
Recommendation 1: A high profile is given to all local publicity/communication
with the public about the importance of immunization against seasonal flu.
Recommendation 2: Internal vaccination arrangements are developed to facilitate
vaccine being taken to staff in their workplace rather than being offered through
an appointment system and explicit arrangements are made to ensure staff
working in high risk areas (i.e. Neonatal Care) are vaccinated.
9
North West Ambulance Service
Call volume and type
The NHS North West Emergency Care Review identified links between NWAS cat A
call volume and future capacity problems within the secondary care sector. Whilst
no positive conclusions were drawn in 2009 it is interesting to note that a similar
pattern occurred this year.
Category A calls started to increase during weeks 43 and 44 (w/c 5 th and 12th
December 2010) and whilst this had an immediate effect on NWAS performance the
real effect on providers came some days later in the form of respiratory illness which
led to longer than average inpatient care spells.
The table below shows the step increase in category A calls, a pattern which is
becoming more predictable and should be used in escalation planning in the future.
The predictable nature of urgent and unscheduled care was highlighted in the NHS
North West Emergency Care Review. The conclusions reached still stand and it is
essential local activity patterns are understood and used in planning for both routine
activity and during peak periods.
Recommendation 3: Early warning arrangements are agreed with NWAS around
increases in call volume and local planning reflects simultaneous escalation
arrangements.
10
Diverts
The ability of NWAS to manage diversions between hospitals is crucial in ensuring
both continuity of ambulance provision and avoiding congestion in A&E
departments.
Whilst CMS is not yet fully developed it is opportune to agree central monitoring of
resource by NWAS and through judicious use of diversions benefits can be achieved
in avoiding ambulance queues and easing surges in activity in A&E. In the majority of
cases diverts will only need to provide a breathing space of an hour or less and the
benefits will be evident to both the Ambulance and Hospital Trusts.
Innovation in the way resources are directed between hospitals will benefit all and
it is suggested that the current Hospital Diverts Policy is applied more rigorously.
Recommendation 4: NWAS monitor pressure points and manage diversion
arrangements through coordination of resource distribution in control centres
using CMS
Smoothing spikes in activity
It is well known that both acute units and NWAS struggle to manage spikes in
activity. Whilst some of these are beyond our control, the fact that the vast majority
of patients admitted via their GP are booked with NWAS after midday and arrive at
hospital during the afternoon and early evening is currently not.
Efficiency and resilience in acute health provision is predicated on managing smooth
flows of patients but this is not supported by the way GP direct patients are
managed. Urgent action is required in primary care to address this and specific local
actions should be included in this year’s winter planning discussions.
Recommendation 5: GP Consortia and PCTs develop local arrangements to reduce
afternoon spikes in activity by spreading GP direct admissions over the working
day (8am to 6pm)
Ambulance Turnaround
The efficiency of patient handover at provider units is now a major performance
issue across the North West. Site visits are being conducted by NWAS senior
managers to agree actions to address handover at the 12 most challenged providers.
Whilst action to address spikes in activity will undoubtedly help it should be
recognized that NWAS staff are part of the whole NHS team providing emergency
care to the population of the North West. Their early inclusion in all issues relating to
the provision of care and in particular changes to A&E functionality on a local basis is
essential.
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Provider units must acknowledge that it is not acceptable to leave a patient waiting
with an NWAS crew in any part of the hospital. Handover must occur on arrival to
allow the crew to be released without delay.
To achieve this it may be that increased provision will need to be made by receiving
units to accept responsibility for patients on arrival. This may include the availability
of additional trolleys in some departments and/or the acceptance of rapid handover
of minor patients in accordance with NWAS procedures.
Recommendation 6: As part of the NWAS site visits principles on patient handover
are agreed and shared with staff at each receiving unit and within the Ambulance
Service.
Recommendation 7: The issue of patient handover at each receiving unit is
reviewed prior to next winter to ensure efficient processes and procedures
(including rapid handover) are in place. This may include provision of additional
trolleys/space in A&E departments.
Discharge Transport
Provider units’ ability to manage A&E performance and patient flow through the
hospital is highly dependent on the efficiency and timeliness of patient discharges.
Equally from an NWAS perspective maximizing the use of the discharge transport
service is dependent on early notification of patient and transport details and on the
patient being ready.
Planned early day discharge is essential for both hospital and ambulance service
efficiency (and is usually better for patients) and must be a priority in local planning
and operational delivery.
Recommendation 8: Patient discharges should be as early in the day as possible.
Planning for and managing H1-N1 (swine flu) pandemic
The discipline generated in joint planning for a possible flu pandemic generated
significant benefits in overall winter preparedness in many local health economies.
The clear and strong message in this must not be lost and our focus should always be
on joined up working.
It is noted that weaknesses in preparedness and resilience are evident in the
nursing/care home sector and this should be addressed. Increased support to
nursing homes in the area of infection control would be particularly helpful in the
future.
12
Managing swine flu cases was challenging particularly to critical care and the
considerable input of the Critical Care Network must be recognised. Perhaps the
most challenging issue was establishing Extracorporeal Membrane Oxygenation
(ECMO) beds and the associated support services including staff. It is noted that the
involvement of Gold command in coordinating ECMO services had a significant effect
and should continue in the future if required.
Recommendation 8: Continued joint working on flu planning is important and has
benefits for general winter planning in local health economies.
Recommendation 9: Resilience of Nursing Home arrangements for winter and in
particular their ability to manage infection control should be monitored and
actions taken where appropriate.
Recommendation 10: Early involvement of the NHS North West in coordinating
ECMO arrangements if required.
SITREPS
SITREP completion will continue to be required to coordinate NHS North West
returns to the Department of Health.
There is an important issue in relation to the way SITREP data is collected and
communicated. Whilst weekly and monthly data is collected for the period midnight
to midnight the winter daily SITREP is based on the period 8am to 8am.
Data on the number of flu patients that ICBIS collected was often from a different
time period. This caused confusion and frustration, as Gold Command conversations
were often more about the accuracy of data rather than actions. This needs
recognising and it is suggested that all data is supplied electronically, including ITU
data.
Recommendation 11: All data should be collected electronically through a process
distinct from health economy teleconferences. Data should be submitted in a pre
agreed format and at a pre agreed time.
Managing elective surgery
It is widely accepted that when providers are under increasing pressure one of the
first issues to be considered is the postponement of elective surgery. A strong
argument could be made for the whole of the NHS to start to treat the period
between mid December and mid January differently. To try to continue with
‘normal’ service provision whilst managing winter pressures may no longer be
achievable.
13
Last winter decisions were taken to cancel some routine elective surgery across the
region to enhance critical care beds, in future we may need to accept higher
numbers of cancellations or we must start to profile the amount of elective work,
particularly day case work, which can be done during this period.
A “one decision fits all” approach to cancelled surgery is not appropriate particularly
where dedicated ‘elective only’ facilities exist so expediency suggests these decisions
should be taken on a local basis with the SHA providing review if required.
Furthermore the decision to cancel elective surgery must be followed with
agreement about making up lost activity at a point early in the new year. This is an
area which the SHA can provide guidance on.
Recommendation 13: Profiling of surgical work to increase day case/less complex
activity during known busy periods should help with managing flow. (Cancer work
excluded)
Recommendation 14: Decisions taken at a regional level to agree postponement of
elective activity should be communicated as early in the day as possible
Recommendation 15: Where elective activity is postponed plans should be agreed
as soon as practicable with local commissioners on future activity levels to make
good the shortfall particularly if the recovery period spans two financial years
Primary care provision during busy periods/holidays
Communication across health economies over bank holidays/extended holidays in
some areas is well developed in others it is not. The practice of holding a conference
call between Acute, OOH/Primary and Community Care Providers (and Social Care if
possible) is commended and should be seriously considered by all health economies.
The patterns of unscheduled care presenting at acute trusts is predictable and
elective care activity is known. Whilst metrics are not yet well developed in
community services there are some indicators available (i.e. NHSD Syndromic
surveillance). Mapping known data onto the current local position at (say) 10am
each day should help avoid situations where escalation occurs too late.
Recommendation 16: A conference call including all key providers and
commissioners in the local health economy is held on a daily basis at a time to
allow a plan for the day to be developed.
Recommendation 17: Metrics are developed to support performance monitoring in
Community services
Primary Care resilience and escalation arrangements need to be more robust.
14
Local health economy winter plans must explore the possibility of general practice
having standby arrangements at peak times to provide additional surgeries at short
notice. Some health economies are providing extended hours through ‘Darzi’
practices but there is little evidence of any robust resilience arrangements in general
practices.
Equally, there are differing approaches to escalation in Primary Care and methods of
escalation vary mainly between bringing extra GPs in to provide care in centres or
home visits and extra support ‘on line’ to triage calls.
Any lengthening of the time from an initial call from a patient to a call back will
increase the likelihood of the patient defaulting to an alternative, usually A&E and
therefore the key to successful escalation is speed. By far the quickest way of flexing
staff numbers up and down is by using GPs ‘on line’ to triage calls and from
conversations this appears to be the most efficient method.
Access to GP practices for self presenters, without the need for an appointment in
the lead up to Bank Holidays (the day before) can also help in managing
inappropriate attendances/calls during holidays.
Recommendation 18: Primary Care resilience and escalation arrangements should
be reviewed to ensure robust plans are in place to manage pre and post bank
holiday activity and that OOH provision is appropriate and can quickly respond to
surges in activity.
All but one Primary Care Trust used the Choose Well scheme during winter 10/11 to
advise the public of alternatives to A&E. In most areas the Choose Well
arrangements have traditionally been supplemented by media campaigns in the lead
up to Winter/Christmas. The effectiveness of media campaigns has been enhanced
in some PCTs through the involvement of acute sector clinicians giving clear
messages about use of A&E.
Recommendation 19: Senior Clinicians from Acute Trusts are involved media
campaigns around services available over the winter period.
15
Summary of Recommendations
Recommendation 1: A high profile is given to all local publicity/communication
with the public about the importance of immunization against seasonal flu.
Recommendation 2: Internal vaccination arrangements are developed to facilitate
vaccine being taken to staff in their workplace rather than being offered through
an appointment system in Occupational Health.
Recommendation 3: Early warning arrangements are agreed with NWAS around
increases in call volume and local planning reflects simultaneous escalation
arrangements.
Recommendation 4: NWAS monitor pressure points and manage diversion
arrangements through coordination of resource distribution in control centres
using CMS
Recommendation 5: GP Consortia and PCTs develop local arrangements to reduce
afternoon spikes in activity by spreading GP direct admissions over the working
day (8am to 6pm)
Recommendation 6: As part of the NWAS site visits principles on patient handover
are agreed and shared with staff at each receiving unit and within the Ambulance
Service.
Recommendation 7: The issue of patient handover at each receiving unit is
reviewed prior to next winter to ensure efficient processes and procedures
(including rapid handover) are in place. This may include provision of additional
trolleys/space in A&E departments
Recommendation 8: Patient discharges should be as early in the day as possible.
Recommendation 9: Continued joint working on flu planning is important and has
benefits for general winter planning in local health economies.
Recommendation 10: Resilience of Nursing Home arrangements for winter and in
particular their ability to manage infection control should be monitored and
actions taken where appropriate.
Recommendation 11: Early involvement of the NHS North West in coordinating
ECMO arrangements should be the norm.
Recommendation 12: All data should be collected electronically through a process
distinct from health economy teleconferences. Data should be submitted in a pre
agreed format and at a pre agreed time.
16
Recommendation 13: Profiling of surgical work to increase day case/less complex
activity during known busy periods should help with managing flow. (Cancer work
excluded)
Recommendation 14: Decisions taken at a regional level to agree cancellation of
elective activity should be communicated as early in the day as possible
Recommendation 15: Where elective activity is cancelled plans should be agreed as
soon as practicable with local commissioners on future activity levels to make good
the shortfall particularly if the recovery period spans two financial years
Recommendation 16: A conference call including all key providers and
commissioners in the local health economy is held on a daily basis at a time to
allow a plan for the day to be developed.
Recommendation 17: Metrics are developed to support performance monitoring in
Community services
Recommendation 18: Primary Care resilience and escalation arrangements should
be reviewed to ensure robust plans are in place to manage pre and post bank
holiday activity and that OOH provision is appropriate and can quickly respond to
surges in activity.
Recommendation 19: Senior Clinicians from Acute Trusts are involved media
campaigns around services available over the winter period.
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Key risks for winter 2011/12
Four key risks have been identified for winter 2011/12. These are:

Implementation of planned reductions to local authority budgets which could
lead to an increase in delayed transfers of care from acute providers. It is
important that local plans recognise the potential for delays and ensure plans
are in place to mitigate against the potential impact on NHS services.
Local plans will be tested as part of the SHA assurance process

Reduced acute bed capacity leading to an increasing reliance on community
capacity and out of hospital services which may not be as resilient as acute
providers during periods of increased pressure or severe weather.
A lack of resilience in community/out of hospital services has a direct effect
on acute providers. As such the robustness of alternative, community and
home based models of care should be tested as part of the assurance
process.

The reduction in the A&E 4 hour operational standard from 98% to 95%
which may lead to a loss of focus in A&E departments. The NHS North West
will continue to work closely with Trusts where performance is below the
95% operational target going into winter 2011/12.

The impact of potential public sector industrial action. If action is to be taken
the exact nature will not be known until much nearer the time. Local
arrangements will need to be agreed for minimum levels of cover in both
hospital and out of hospital services. It is essential that local arrangements
are adequate and senior HR advice must be available.
Other local issues will need to be addressed in winter plans. This will include issues
such as redecoration programmes and the direct effect these have on bed
availability.
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NHS North West: Winter Planning Assurance Process
As in previous years the NHS North West will be required to assure all winter plans.
This year the main assurance process will be carried out at cluster level with the SHA
team undertaking a monitoring and coordinating role.
To ensure consistency of approach the check list attached at appendix 1 has been
prepared. This years checklist has been developed to support joint planning and
working at locality and cluster level and is aimed at ensuring we do not loose
learning and experience from previous winters during this period of organisational
change.
Cluster Chief Executives will have an important role to play in ensuring
comprehensive plans are developed and that the areas identified in the checklist can
be evidenced to a sufficient extent to provide assurance.
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Winter Planning: Command, Control and Communications
(C3)
The NHS must plan for all eventualities and risks, some are known, some are not,
winter is a known risk but the consequences are often unknown. In the NHS in
England we experience many different affects from the period of October to March.
For example:





Extreme weather (snow, gales, rain, floods, very low/sub-zero
temperatures, etc.)
Infectious diseases such as Norovirus, flu, etc.
Staff sickness
Long bank holiday periods
Increase in demand for urgent/emergency care.
These events are managed throughout the NHS with various levels of impact.
Individually they are managed and effects on patients are mitigated through winter
plans. (the winter check list is included at appendix 1 below) However, when taken
collectively and for long periods, the effects can be more serious with operations
postponed and inpatient capacity being stretched. Primary Care can also be affected
with long bank holidays and seasonal influences; this is often made worse by poor
weather and travel disruption leading to more access issues for the NHS.
The impact of winter may require special management arrangements to ensure that
the NHS can meet its commitment and/or minimise the effect on patients.
It is good practice to have the performance of organisations monitored going into
winter so that early intervention can be taken locally as required. It also serves as an
‘early warning system’ for over viewing the system. Monitoring of winter disease is
useful to anticipate peaks of some activity such as flu, etc.
Often performance teams and Emergency Planning, Resilience and Response (EPRR)
teams are not co-located in organisations and therefore may not be familiar with
working together. A number of small exercises and training events should be carried
out to enable joint working, including working in a control room.
For ease of reference the term Lead PCT is for EPRR functions and Cluster PCT is used
for the commissioning and local management, in most cases will be the same
organisation. However the current commissioning arrangements need to be
considered.
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Command and Control
The NHS has tried and tested methods of Command and Control for Major Incidents.
These are used very effectively in short duration incidents that require the system to
surge over a short period. In a winter period this could last for weeks or even
months. Therefore the NHS must have winter plans that provide for a sustained
period and provide the leadership to reduce impact and enable recovery as soon as
possible. To this end the system needs to have ‘trigger’ mechanisms that can bring
on the most appropriate level of management which is proportionate to meet the
needs at that time. These ‘triggers’ are set out below in appendix 2.
It should be noted that the C3 arrangements for winter are designed to escalate and
de-escalate according to the circumstances prevailing at the time and thus minimise
the requirement to ‘over manage’ the system. Some areas of England will have
specific geographical challenges which may affect how they consider their
escalation. i.e. if there is no other hospitals close by to divert patients to they will
need early intervention by the local health economy or assistance form the wider
health family.
As set out in appendix 2, the requirement of each level of command is to ensure it
has in place systems that can provide the Executive Leadership and support that it
will need. It is not possible to be prescriptive about the number or grade of staff
required but the outcomes required should enable the responsible officer to shape
his/her team.
Outcomes
The outcomes required are:
 Monitoring of e-mails / communications from below or above
their own level.
 A named Executive level ‘on call’ throughout the period.
Preferably the same person(s) but if not, a rota will be required.
 Ability to make decisions at that level without referring to others.
 Access to telephone conference call facilities.
 Ability to provide data collection and distribution.
 A control room set up for an extended period.
 Embedded professional communications support in the team.
 Following teleconferences, minutes should be sent out as soon as
possible to ensure that decisions or actions are understood.
 Correct number of staff for up to 7day working may be required.
As set out in appendix a, escalation is expected to happen after Providers have used
their winter plan (some winter plans are specific i.e. 15% above normal) this will
provide a degree of internal escalation and surge. After this trigger, the C3
arrangements will come in to effect at each level. It is vital that as much intelligence
as possible is gathered to support decision making.
21
Communications
Communications are at the heart of all management systems and in time of extremis
they are more vital than ever. The communications between the structures below is
fairly simple but must be both ways and timely. Communications with partners,
public and patients is vital if we are to maintain the confidence of the public we
serve. All of the structures should embed communications staff in their teams. Their
role is not only to advise managers of issues that are likely to have media interest
but to provide advice on how to inform the public, patients and our staff of the
emerging situation to ensure there is the fullest engagement by all. This will assist in
managing demand and expectations. They should be present at the telephone
conference calls to hear the issues first hand. Communications leads may have their
own calls to develop strategies that the management team can sign off this will
ensure consistency and clarity of message.
22
Appendix 1
Assurance Checklist
Area/Service
Reference
in plan
1.0 Acute hospital capacity
1.1 Has the health and social care economy reviewed
performance from last winter and included lessons learned in
this years plans - evidence
1.2 Have urgent and routine elective, and emergency care
services been planned and profiled (against historical activity
data) appropriately across the Trust to meet elective and likely
emergency demand allowing for winter pressures
1.3 What real time systems does the Trust have access to, to help
predict periods of peak pressure and what are the agreed
trigger levels for escalation measures?
1.4 What measures are in place across the health economy to
support the urgent care system to manage an increase in
demand of 15% over 4-6 weeks?
1.5 What systems are in place to resume electives earlier if
emergency demand does not increase as expected?
1.6 What are the plans for a smooth but staggered restart of full in
patient activity after any winter pressures? Have
arrangements been agreed with commissioners to make up
lost elective activity?
1.7 What contingency arrangements have been made (including
with the private sector) to allow additional capacity to be
introduced at short notice? e.g. if emergency demand exceeds
anticipated winter pressures.
23
1.8
Is acute bed capacity the equivalent level to last year? Please
explain any difference and likely impact on service.
1.9 What are your plans to flex capacity to meet peaks and
troughs of unscheduled demand?
1.10 What systems in place to ensure patient discharge is
coordinated with partners in the Local Resilience Forum
Critical Care
1.11 What agreements have been reached with the critical care
network to ensure capacity is maintained or increased to deal
with increased demand on the basis of the scenario modelling.
1.12 Have there been discussions between the critical care
networks around mutual support during increased pressure?
What arrangements have been made?
1.13 Please supply a plan that sets out the specific arrangements
to meet critical care demand.
Staffing
1.14 Have hospital staff been trained to enable flexible deployment
and roistering across disciplines (and where appropriate from
the community to acute sector) to support times of peak
pressure? How will this be activated and managed?
1.15 What plans are in place to increase staffing levels in care
areas experiencing increased demand for services?
24
1.16 What plans do the Trust have to provide the flu vaccine to
prioritised staff groups - front line staff?
Diagnostic services
1.17 What plans are in place to cover any increased demand for
diagnostic tests as a result of winter pressures?
1.18 What plans are in place for access to urgent diagnostic tests
and reporting during the winter period?
2.0 Delayed Transfer of Care
2.1 Has a standard definition of a DTOC been put in place and
agreed by PCT and provider?
What is the definition?
2.2 What performance standards been agreed for each part of the
discharge pathway?
2.3 What reporting arrangements in place against each standard?
2.4 What escalation measures are in place where delays occur
and how are these activated
3.0 Social Care (including housing & wider Local
Government
3.1 How have you established assurance across the health
economy that social services have ensured through contracts,
line management and inspection that all the residential and
nursing homes have effective protocols with primary care to
avoid unnecessary admissions to hospital and facilitate timely
return after an admission?
25
3.2 How have you established assurance that Social services
have ensured that all residential and nursing homes have
provided appropriate training and support to their staff to
enable them to care for flu cases and avoid admission to
hospital?
3.3 Is the bed capacity in social care system at an equivalent to
last year? what arrangements have been made to ensure no
detrimental effect to service?
3.4 What is the procedure in place that alerts the PCT when
capacity is full?
3.5 What arrangements are in place between social services and
the local NHS to allow appropriate and timely discharge of
patients from hospital care?
3.6 What contingency plans in place should a private sector home
become unable, at short notice, to provide ongoing care for
residents?
3.7 What plans do Social Services have in place to include
provision for enhanced out of hours cover during the winter
period?
3.8 What provision has been made to identify and support
vulnerable people in the community at times of staff absence
due to leave/illness?
3.9 What liaison and support systems have been established with
local nursing/residential homeowners during the winter
period?
3.10 What mechanisms exist between health and social care for
the quick resolution of any issues arising from agreeing care
packages?
26
4.0 Ambulance Service
4.1 What contingency plans are in place to maintain agreed levels
of response time performance during periods of significantly
increased demand and low staffing levels?
4.2 What Contingency Plans are in place for extreme weather,
including snow and ice.
4.3 What protocols in place between Ambulance
services/hospitals and A&E to ensure rapid turn around of
vehicles?
4.4 What discharge transport arrangements both in and out of
hours have been agreed with each hospital.
4.5 Has the ambulance service agreed to provide patient transfers
at short notice? If not please comment on contingency plan.
4.6 What plans do the trust have to provide flu vaccine to
prioritised staff groups - front line staff?
4.7 What plans do the Trust have for Business Continuity during
periods of Industrial Action.
5.0 Primary and Community Services
Out of Hours Services
5.1 How have PCTs established confidence that OOH
arrangements are robust, and will be able to manage surges
in demand?
27
5.2 What real time systems does the Trust have in place, with
adequate monitoring, to help predict periods of peak pressure
with agreed trigger levels for escalation measures?
5.3 What arrangements are in place to ensure adequate primary
care services are available during an epidemic/ high flu rate
period?
5.4 How have PCTs ensured that all practices have business
continuity plans?
Continuity of Care
5.5 What systems are in place for GPs, in liaison with other
primary care and social service colleagues, to ensure the
identification of high risk community based patients?
5.6 What arrangements are in place to support nursing and
residential homes to avoid unnecessary hospital admissions?
What are these?
5.7 What arrangements do PCTs have in place to support single
handed GPs who may not have the infrastructure required to
meet surges in demand?
5.8 What arrangements are in place to support patients requiring
home oxygen services?
5.9a What plans are in place to make sure that all staff (in
secondary and primary care settings) have access to up-todate information about the Choose Well campaign and in
particular about local services, including pharmacies, urgent
care centres, walk in centres and so on, so that they are able
to signpost patients and the public to appropriate local
services?
28
Staffing
5.9b Have staff been trained to enable flexible deployment and
rostering across disciplines (and where appropriate from the
community to acute sector) to support times of peak
pressure?
How will plans be actioned?
5.10 What plans are in place to increase staffing levels in care
areas experiencing increased demand for services?
5.11 What plans has the trust developed to provide the flu vaccine
to prioritised staff groups - front line staff?
Flu campaign
5.12 Have PCTs begun to develop plans for delivery of flu vaccine
to identified staff groups and to identified high risk patient
groups?
5.13 What arrangements do PCTs have in place to offer flu vaccine
to all staff involved in the delivery and/or support to patients?
5.14 What are your plans to target information to COPD patients
about preparing for winter, winter illnesses, medicines review,
self-care, flu vaccination and so on?
5.15 How do you plan to work with your LPC to ensure local
pharmacies are actively involved in promoting the Choose
Well and flu vaccination messages to the public?
5.16 How do you plan to identify at risk patients who were not
vaccinated against the seasonal flu virus last year, and how
are you going to engage with them about vaccination this
year?
5.17 What plans are in place to follow up patients who do not
respond to initial invitations to be vaccinated this year?
29
5.18 How do you plan to make staff seasonal flu vaccination
sessions more accessible, to support an increase in
vaccination rates?
Intermediate Care
5.19 How has the health economy established assurance that
planned levels of capacity within intermediate care schemes
sufficient to meet forecast demand for an epidemic/ high flu
rate /high flu rate?
5.20 What is the procedure to alert the PCT when capacity is full?
5.21 What are the contingency plans to increase the level of
provision if demand is higher than planned?
5.22 Is there a single point of access for the full range of
intermediate care services to ensure simplicity and clarity for
users?
5.23 Are services organised on a 24/7 basis?
5.24 What is the communication plan to ensure that all potential
users of intermediate care are fully aware of the availability of
services and how to access them?
5.25 What are the multi-agency arrangements for planning, coordination and review of services before the winter period?
30
5.26 Have staff been trained to enable flexible deployment and
rostering across disciplines (and where appropriate from the
community to acute sector) to support times of peak
pressure?
5.27 What are the plans to increase staffing levels in care areas
experiencing increased demand for services?
5.28 What plans do PCTs have in place to offer flu vaccine to all
staff involved in the delivery and/or support to patients?
6.0 Mental Health and Learning Disabilities
6.1 What plans are in place for the care of inpatients who develop
flu in all sectors of mental health inpatient care - open, low
secure, medium secure and high secure units?
6.2 What are the arrangements to ensure access to services and
primary care cover over an epidemic/ high flu rate flu period
and to identify and maintain vulnerable people in the
community?
6.3 What arrangements are in place for 24/7 rapid response
support for mental health assessment of patients in A&E
during an epidemic/ high flu rate flu period?
6.4 What arrangements are in place to provide adolescent mental
health cover during an epidemic/ high flu rate flu and
Christmas and New Year period ?
6.5 Have hospital staff been trained to enable flexible deployment
and rostering across disciplines (and where appropriate from
the community to inpatients sector) to support times of peak
pressure?
6.6 What plans are in place to increase staffing levels in care
areas experiencing increased demand for services?
31
6.7 What plans do the trust have to provide the vaccine to
prioritised staff groups - front line staff?
7.0 Escalation and Communication
7.1 How will your communications and engagement team work
with others at a health economy and cluster level (including
commissioners and providers and other public sector
organisations), to plan, co-ordinate and implement your winter
communications and engagement plan?
7.2 Are key clinical and managerial staff within the health
economy clear on the triggers, actions and responsibilities
within the business continuity plans of their trust?
7.3 What is the plan for communicating information to the public,
publicising the services that are available?
7.4 Does the health economy have internal communications plans
for keeping staff fully informed about preparations for winter?
7.4 What plans are in place for commissioners and providers to
use communications and engagement to reduce:

the number of "inappropriate" attenders i.e. those who
attend A&E with low HRG (v06,v07,v08 and 9) and an
attendance disposal of 'Discharged NFA',' Left dept.
before being treated', 'left dept. having refused
treatment';

the number of “frequent fliers” i.e. those people with
four or more attendances in a 12 month period
8.0 Command and Control
8.1 Are there Trigger points in place to agree escalation?
32
8.2 Are there agreed Command, Communication and Control
systems in place to manage the different levels of escalation?
8.3 Does the escalation plan provide for 7 day working by
managers if required
8.4 Does the escalation plan identify who will lead the
organisation at each level of the Trigger points
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Appendix 2
Winter Triggers for Command and Control
(Transition)
Level One (Within Trust)
Description - Trusts manage their own pressures within normal parameters. Liaison
between providers and commissioners should be the norm and this will ensure that
all local stakeholders are aware of current pressures and ready to respond
appropriately to any peaks and troughs in demand. This level may typically be + 15%
of urgent activity, this could be across the organisation or just one key area.
Escalation Trigger Point – If individual Trust resources cannot / are consistently
struggling to meet demand (+ 15%) then the affected trust should liaise with its
commissioners to implement a Health Tactical Coordinating Group (HTCG) at Health
*Economy level. This group may be chaired by the affected Acute Trust but must
contain an executive level input from the lead commissioning organisation and
partner agencies such as Social Care.
*The Health economy should consist of all the local health providers, including Social
Care partners this group should be the same one who met and produced the winter
plan. (Planning Group) At Level 2 it becomes the Health Tactical Coordinating Group
for the purposes of Command and Control
Level Two ( Local Health Economy)
Description – Health economies manage their own pressures within their agreed
planning frameworks. Joint working between providers and commissioners is
expected on a daily basis – led by the Commissioner Executive Director (Cluster
PCT/GPC). Liaison with the Lead PCT / Local Health Emergency Preparedness
Communities (LHEPC) is expected to ensure that all stakeholders are sharing the
same information and preparation can be made to facilitate escalation to level three
if required.
Escalation Trigger Point – If health economy resources cannot meet the demand
AND all the appropriate steps have been taken such as deployment of additional
resources, accelerated hospital discharge and cancellation of elective workload then the lead commissioning organisation (Cluster PCT/GPC) should liaise with the
Lead PCT/LHEPC to implement a Health Strategic Coordinating Group (HSCG) at the
agreed geographical level. This group should be chaired by the Lead PCT/On Call
Strategic Commander (Health) but must contain an Executive Level delegate from
each commissioner/organisation. The commissioning bodies shall be responsible for
liaison across their health economy in respect of any outputs from the Strategic
Meetings through the respective Health Tactical Coordinating Groups.
34
Level Three ( Cluster wide Health Economy)
Description – The Lead PCT / LHEPC will coordinate the agreed geographical health
economy through the Health Strategic Coordinating Group having regard to mutual
aid and agreeing generic decisions across the conurbation. Commissioners manage
the pressures within their health economy through their Tactical Coordinating
Groups and feed into the Lead PCT/LHEPC on a daily basis. If part of a multi-agency
response, then the Lead PCT/LHEPC will also attend the Local Resilience Forums SCG
and feed into that process.
Escalation Trigger point – If Lead PCT/LHEPC NHS resources and joint working
cannot meet the demand OR the NHS SHA/CB declare a Level Four response - then
the Lead PCT / LHEPC will liaise with the NHS SHA/CB to implement a Sector Health
(Regional) Coordinating Group. This group will be chaired by a Director of the NHS
SHA/CB but must contain the Chair(s) from the Health Strategic Coordinating
Group(s) (HSCG)
Level Four (Sector (Regional) Health Economy)
Description – The NHS SHA/CB manage the pressures within their (Region) Sector
through the Sector Health (Regional) Coordinating Group. The SHCG will coordinate
the Sector health economies through the Lead PCTs/LHEPCs having regard to
(Regional) Sector decisions across the affected geographic area. If part of a multiagency response then the Lead PCT/LHEPC will also attend the Local SCG and feed
into that process with (Regional) Sector NHS SHA/CB attending any requisite wider
geographical groups if established.
Escalation Trigger point – If over the geographical area managed NHS resources
cannot meet the demand then the (Regional) Sector NHS SHA/CB will liaise with the
National NHS/NHS CB to request national / international input / resources. The NHS/
NHS CB input will be fed back to the (Regional) Sector by an Executive Director of the
NHS/NHS CB.
Level Five (National Health Service)
Description – The demand is such that only a nationally coordinated response is
appropriate, this may be concluded following escalation through the various stages
above OR fed down the chain as in Swine Flu. In either scenario the top-down input
will be managed within Cluster PCTs via the Lead PCT/LHEPC and Sector Health
Strategic Coordinating Group(s).
35
Dept. of
Health/NHS CB
Level 5
Strategic Health Authority/ NHS
CB Sectors (Times X)
Level 4
Lead PCT/ LHEPC
Level 3
Lead PCT/ LHEPC
Level 3
Lead PCT/LHEPC
Level 3
Lead PCT/LHEPC
Level 3
Lead PCT/LHEPC
Level 3
PCT Cluster L 2
PCT Cluster L 2
PCT Cluster L 2
PCT Cluster L 2
PCT Cluster L 2
Providers L 1& 2
Acute/MHT/AMB/
Primary care
Providers L 1&2
Acute/MHT/AMB/
Primary care
Providers L 1&2
Acute/MHT/AMB/
Primary care
Providers L 1&2
Acute/MHT/AMB/
Primary care
Providers L 1&2
Acute/MHT/AMB/
Primary care
36