The Scottish Government

Directorate for Health Performance

Dear Colleague National Unscheduled Care Programme: Preparing for Winter 2015/16 Summary This guidance supports Boards to ensure that they are fully prepared for this winter in order to minimise any potential disruption to NHS services, patients and carers. This guidance should be read in conjunction with the national report ‘Health & Social Care: Winter in Scotland in 2014/15’. Winter plans should provide safe and effective care for patients and have effective levels of capacity and funding to support service delivery and expected activity levels. Background Integrating health and social care and the £100m being invested to improve delayed discharge are priorities for the Scottish Government. The Scottish Government has also developed a fresh approach to improving unscheduled care across Scotland – in winter and all year round - which is based on six essential actions. This focus on integration, improving delayed discharge and the six essentials actions underpin the planning guidance for winter 2015/16 - with an additional focus on planning for the additional pressures and business continuity challenges that are faced in winter. Action NHS Boards are to lodge a draft winter plan and progress report on their local winter planning arrangements for this year by the end of August, and final plans by the end of October. These should be sent to winterplanningteam@scotland.gsi.gov.uk. Winter plans should also be signed of by the full board and published on the NHS Board’s website by the end of October. Yours sincerely

JOHN CONNAGHAN CBE NHSScotland Chief Operating Officer

DL (2015) 20 6 August 2015

Addresses

For action

NHS Board:

1. Chief Executives

2. Unscheduled Care Leads

3. Business Continuity Mgrs

4. Emergency Plan Officers

5. Infection Control Managers

6. Medical Directors

7. Nursing Directors

8. Human Resource Directors

10. Consultants in Dental PH

Other

1. Directors of Social Work

2. IJB Chief Officers

For information

1. Public Health Directors

2. Non Executive Directors

3. NHS Board Chairs

Enquiries to:

Stuart Low

NHSScotland Resilience &

Business Mgt Division

Tel: 0131 244 3458

E-mail:

stuart.low@scotland.gsi.gov.uk

National Unscheduled Care Programme: Preparing for Winter 2015/16

1. Introduction 1.1 Winter planning continues to play an integral role in the Scottish Government’s 6 Essential Actions Unscheduled Care Improvement Programme (Annex 1) and you should ensure that your NHS Board is fully prepared for this winter in order to minimise any potential disruption to NHS services, patients and carers. Boards must be satisfied that winter plans will provide safe and effective care for patients and that effective levels of capacity and funding are in place to support service delivery and expected activity levels. 1.2 This guidance should be read in conjunction with the national report ‘Health & Social Care: Winter in Scotland in 2014/15’. In winter 2014/15, the NHS in Scotland increased capacity and carried out more activity. There were increased and prolonged pressures from influenza and respiratory illness. Pressures from delayed discharge continued to increase through to the end of 2014 and eased in to 2015. These pressures will have contributed to the reduced key whole-system 4 hour A&E waiting times performance in December, January and February. Scotland saw significant A&E waiting times performance improvements in the spring and summer months. Integrating health and social care and the £100m being invested to improve delayed discharge are priorities for the Scottish Government. The Scottish Government has also developed a fresh approach to improving unscheduled care across Scotland – in winter and all year round - which is based on six essential actions. This focus on integration, improving delayed discharge and the six essential actions underpin the planning guidance for winter 2015/16 - with an additional focus on planning for the additional pressures and business continuity challenges that are faced in winter. 1.3 The continuing shift in patterns of disease to long term conditions, growing numbers of older people with multiple conditions and complex needs, and the financial environment present challenges to NHSScotland and its partners. That is why the Scottish Government is integrating health and social care. Joint working and resourcing will be crucial in putting outcomes for people at the centre of all our work, helping to avoid unnecessary admissions and ensuring that patients are discharged from acute settings as soon as they are ready. 1.4 Unscheduled and elective care performance in Scotland compares favourably with international comparators. Robust planning and analysis should facilitate NHS Boards to pursue further sustainable improvement through 95% performance towards the 98% 4 hour Emergency Access Standard. This should also help Boards to maintain the Treatment Time Guarantee (TTG) and to ensure delayed discharges are kept to an absolute minimum. New integration authorities are expected to increase the percentage of people who are discharged within 72 hours of being ready and reduce the bed days associated with delays. 1.5 Boards will need to take a balanced approach to the effective planning and scheduling of elective and unscheduled care, working closely with their Integration Joint Boards. This will be particularly important in light of predicted emergency activity over the festive period, when any surge in respiratory and circulatory admissions over the winter can increase pressures, particularly towards the end of December and into January. Support to understand the capacity and demand of each site is available through the unscheduled care 6 Essential Actions Improvement programme. Developing the Basic Buildings Blocks model (Essential Action 2) will provide a baseline of the whole system and enable robust planning. The focus of the whole system patient flow programme and Guided Patient Flow Assessment will also contribute to this overall picture.

1.6 NHS Boards should effectively forward plan to ensure that cancer patients who have a MDT, diagnostic or treatment target date occurring over the festive period are not delayed and that 31 day and 62 day cancer waiting times are not adversely impacted. In addition, NHS Boards should work through Regional Planning Groups to ensure that both local and regional cancer treatment dates are maintained through the winter period. 1.7 In preparing for this winter, NHS Boards are expected to consider the recommendations and actions from the ‘National Primary Care Out of Hours Review’ being led by Sir Lewis Ritchie, which is due to report in the Autumn. 1.8 NHS Boards should monitor any changes in the cohorts of admitted patients and their care requirements (including respiratory, circulatory and ICU) over the festive period. Primary care and community services should be engaged in minimising transfers of care through use of anticipatory care planning. A directory of services and alternatives to admissions should be available, covering primary and community services and also third and independent sector social care provision. Any additional capacity in these areas should be highlighted. 1.9 Robust analysis should be undertaken to plan capacity and demand levels for this winter. Data now available from ISD, via the Health and Social Care Data Integration and Intelligence Project (HSCDIIP), can help with such analysis. Recent years activity levels and improvements in flow should be taken into account as part of this process. Trends over three to five years should be considered. We also expect NHS Boards’ winter planning to address variation in demand. 1.10 This planning must be explicit on the additional capacity planned for winter, including capacity in staffed medical beds and intermediate care beds. Deliverable plans for workforce capacity over the winter period must be agreed by October and detailed in the winter plan – these are important milestones. Nursing rotas that are made up for the festive period should not include the use of agency staff and should conform to workload planning tool guidance. It is important that this capacity is in place before the risk of boarding medical patients in surgical wards increases and the appropriate indicators of potential surge are monitored on a daily basis. Analysis should include triggers for whole system escalation process to prevent access block. 1.11 Sustainably achieving safe and effective patient flow is critical to maintaining performance as a standard operating model across the winter period. Utilising the improved communication and leadership of the Capacity and Patient Flow Programme, Safety Huddles should focus on proactive discharge planning including, pre noon discharges, weekend discharges, utilisation of discharge lounge and criteria led discharge. Review of support services such as portering, cleaning, pharmacy and transport should be undertaken to ensure capacity is aligned to demand, not just within hours, but also across 7 days and out of hours periods. 1.12 The Chief Medical Officer would encourage NHS Boards to make sure all staff are vaccinated against seasonal flu, particularly front-line staff and those working in areas where patients might be at greater risk (paediatric, oncology, maternity, care of elderly, haematology, ICUs). Boards should aim for vaccinating 50% of front line staff and efforts should be made to make the vaccine available at times and places that are convenient for staff. Senior clinicians and NHS Managers should ensure staff understand the benefits of the vaccine to healthcare workers and to patients.

2. Critical Areas, Outcomes and Indicators 2.1 This guidance takes last winter’s performance into account. It highlights the critical areas that should be covered in this year’s local winter plans, as detailed below. It is expected that the local indicators, underpinning each critical area, are included in relevant local management processes to achieve the outcomes described. Indicators should also align with the unscheduled care 6 Essential Action Improvement Programme (summarised at annex 1). Winter plans should set out the geographies and frequency of the local indicators being monitored and provide further detail on how these indicators might be developed, where applicable. i) Safe & effective admission / discharge continues in the lead-up to and over the festive period and also in to January.

Outcome: Emergency and elective patients are safely and effectively admitted and discharged over the Christmas - New Year holiday period. Over this period the numbers of patients receiving elective treatment reduces. NHS Boards should minimise the risk of boarding medical patients in surgical wards. This will help ensure that patients do not have unnecessary stays in hospital; and hospitals are in a good position to deal with the surge in patients normally admitted in the first week back in January. Local indicator(s) : the daily and cumulative balance of admissions / discharges over the festive period; levels of boarding medical patients in surgical wards; delayed discharge; community hospital bed occupancy; number of Social Work assessments including variances from planned levels. ii) Workforce capacity plans & rotas for winter / festive period agreed by October. Outcome: NHS 24; GP OOH; Dental; SAS emergency / PTS; and Hospital (medical / nursing / diagnostics / pharmacy / phlebotomy / AHP/ IPCT / portering / cleaning / etc.) rotas as well as levels of community capacity (including community nursing / AHP / intermediate care / Social Work assessment / home care / care home) for the winter / festive period are agreed in October to underpin safe and effective admission and discharge of emergency and elective patients.

Local indicator(s): Workforce capacity plans & rotas for winter / festive period agreed by October; effective local escalation of any deviation from plan and actions to address these; extra capacity scheduled for the ‘return to work’ days after the four day festive break, factored into annual leave management arrangements. iii) Whole system activity plans for winter: post-festive surge / respiratory pathway. Outcome: The clinically focussed and empowered hospital management have a target operating model that sets out the expected range of daily emergency and elective admissions and discharges over the festive and winter period. The expected range takes account of the potential surge in emergency admissions in the first week of January and includes the potential surge in respiratory and circulatory admissions over the winter. The hospital models will include flows between front doors, receiving units, and downstream wards. Local indicator(s): daily number of cancelled elective procedures; daily number of elective and emergency admissions and discharges; number of respiratory admissions and variation from plan.

iv) Strategies for additional winter beds and surge capacity. Outcome: The risk of an increase in the levels of boarding medical patients in surgical wards in the first week of January is minimised. The staffing plans for additional staffed medical beds and additional intermediate bed capacity for winter is agreed in October. The planned dates for introduction of additional staffed medical beds and intermediate beds in the community are agreed and the capacity is operational before the expected surge in admissions. It is essential that Boards who plan additional beds should make appropriate arrangements to create a safe and person centred environment. Local indicator(s): planned number of additional staffed medical beds for winter by site and the planned date of introduction of these beds; planned number of additional intermediate beds in the community and the planned date of introduction of these beds; levels of boarding. v) The risk of patients being delayed on their pathway is minimised. Outcome: Patients receive timely assessments in A&E, Acute Assessment Units, Acute Receiving Units and downstream specialty wards. Delays between decision to transfer/discharge and actual transfer/discharge are minimised. The capacity in these units reflect the arrival patterns and potential waiting times for assessment and/or transfer/discharge. Patients in downstream wards are discharged earlier in the day to avoid unnecessary stays in hospital and to improve flow through the hospital. There is early engagement with SAS for ambulance discharge and transfer.

Local indicator(s) : distributions of attendances / admissions; distribution of time to assessment; distribution of time between decision to transfer/discharge and actual time; % of discharges before noon; % of discharges through discharge lounge; % of discharges that are criteria led; levels of boarding medical patients in surgical wards. vi) Discharges at weekend & bank holiday. Outcome: Patients are discharged at weekend and bank holidays to avoid unnecessary stays in hospital and to improve flow through the hospital. Local indicator(s): % of discharges that are criteria led on weekend and bank holidays; daily number of elective and emergency admissions and discharges. vii) Escalation plans tested with partners. Outcome: Access block is avoided at each ED where there is a target operating model managed effectively by an empowered site management team with clear parameters on whole system escalation processes. Local indicator(s): attendance profile by day of week and time of day managed against available capacity; locally identified indicators of pressure i.e.% occupancy of ED, utilisation of trolley/cubicle; % patients waiting for admission over 2, 4 hours – all indicators should be locally agreed and monitored

viii) Business continuity plans tested with partners. Outcome: The board has business continuity management arrangements in place to manage and mitigate all key disruptive risks including the impact of severe weather.

Local indicator(s): progress against any actions from the testing of business continuity plans. ix) Preparing effectively for norovirus. Outcome: The risk of norovirus outbreaks becoming widespread throughout a hospital is minimised. The HPS Norovirus Outbreak Guidance for 2015/16 is effectively implemented.

Local indicator(s): number of wards closed to norovirus; application of HPS norovirus guidance. x) Delivering seasonal flu vaccination to public and staff. Outcome: CMO uptake targets for seasonal flu vaccination for those aged 65 and above, at risk groups, and front line staff are delivered as early as possible in the season before flu viruses are circulating.

Local indicator(s) : % uptake for those aged 65+ and ‘at risk’ groups; % uptake of staff vaccine by site / speciality and variance from planned levels in line with CMO advice. xi) Communication plans Outcome: The public and patients are kept informed of winter pressures, their impact on services, and the actions being taken.

Local indicator(s) : daily record of communications activity; early and wide promotion of winter plan xii) Effective analysis to plan for and monitor winter capacity, activity, pressures and performance Outcome: NHS Boards have, and use, a range of analysis to effectively plan for and monitor winter capacity, activity, pressures and performance at board and site levels. Local indicator(s) : Agreed and resourced analytical plans for winter analysis.

3. Self-Assessment Checklists and Winter Plan Review 3.1 The self-assessment checklists (Appendix A) have been reviewed and provide further detail to support the development of local winter plans. These checklists should be used by governance groups to assess the quality of your Board’s winter preparations and to ascertain where further action might be required. There is no requirement for these checklists to be submitted to the Scottish Government, however, local Executive Leads for unscheduled care should regularly review progress. 3.2 NHS Boards are to submit a progress report on their local winter planning arrangements for this year to winterplanningteam@scotland.gsi.gov.uk, by the end of August at the latest. This should cover the actions being taken around the critical areas highlighted

to achieve the outcomes described above. At the same time NHS Boards should also lodge their draft local plan with Scottish Government, who will continue to engage with NHS Boards throughout the autumn and winter period. This is a shadow year for IJBs, which provides opportunities for building on the whole system planning approach of recent years. IJBs and Chief Officers should be fully involved in the winter planning process, including development of business continuity responses, and ensuring that effective joint communication processes are in place. Data sets and information around capacity planning should be aligned to support a common understanding of capacity requirements across an integrated system. The Scottish Government will share local plans with partners to help support this planning process. 3.3 A National Unscheduled Care Event will be held on 17th September, venue (tbc) and will include sessions on a range of initiatives designed to support NHS Boards to effectively prepare for winter.

4. Winter Plan Sign-Off 4.1 Chief Executives must ensure that winter plans have been scrutinised by the full board, formally signed-off and published on their Board’s website by the end of October 2015. At this point the plan should also be lodged with the Scottish Government. Planned actions should ensure safe and effective care for patients and support sustained performance, at the required standard, over the winter period. 4.2 I recognise the tremendous commitment made by the workforce in meeting the challenges of winter and I would be grateful if you could pass on my appreciation of their dedication and valued contribution.

Annex 1

6 Essential Actions to Improving Unscheduled Care Performance

Safe, person centred, effective

care delivered to

every patient,

every time without

unnecessary waits, delays

and duplication

Capacity and Patient Flow Realignment

Medical and Surgical Processes arranged to Pull Patients from ED

7 day services

Ensuring Patients are cared for in their own

homes

Clinically Focused and Empowered Hospital

Management

Patient and Staff

Experience

Patient rather than Bed Management -

Operational Performance

1

To achieve: Improve: By managing: Do these well: Triumvirate Management Clinical Leadership Escalation

Safety, Flow Huddles

Basic Building Blocks

Bed Planning Toolkit Workforce Capacity Toolkit Guided Patient Flow Analysis

Patient tracking through System Admission/ discharge prediction

Balance capacity & demand

Proactive Discharge Management

Triage to appropriate assessment Flow through ED: minors/majors

Access to Senior Decision Maker Access to Assessment/Diagnostics

Smooth admission/ discharge profile

Surgical Emergency & Elective Services Integrated SAS Services/ decision support GP/OOH services

Living & dying well at home

Shift Emergency to Urgent Redirection / Know Who To Turn To Short stay assessment / Avoid admission

Appendix A:

National Unscheduled Care Programme: Preparing for Winter 2015/16

Winter Preparedness: NHS Board Self-Assessment

These checklists should be read in conjunction with the:

National Unscheduled Care Programme: Preparing for Winter

2015/16 Guidance.

Health & Social Care: Winter in Scotland 2014/15 Report.

NHS Territorial Boards, Integrated Joint Boards (IJBs) and other

partners should consider all of these actions, in detail, as part of

their winter planning preparations.

NHS Special Boards, should review all of these actions to

identify those most applicable to their own area of operations.

Special Boards should also consider how they can best support

Territorial Boards across the full complement of actions and

initiate supportive partnership working where required.

Priorities 1. Resilience

2. Unscheduled / Elective Care

3. Out of Hours

4. Norovirus

5. Seasonal Flu

6. Respiratory Pathway

7. Management Information

8. Sign-Off

9. Integration of Key Partners / Services

Winter Preparedness: Self-Assessment Guidance

Local governance groups should use the attached checklists to self-assess the quality of their Boards overall winter preparations and to

ascertain where further action is required to ensure that winter preparedness priorities are met.

There is no requirement for these checklists to be submitted to the Scottish Government.

Boards will be expected to lodge their draft winter plans and a progress report on local winter planning arrangements with the Scottish

Government by the end of August 2015 and their final winter plans by the end of October 2015. Plans and reports should be sent to

winterplanningteam@scotland.gsi.gov.uk.

Winter Plans should consider the critical areas highlighted in the National Unscheduled Care Programme: Preparing for Winter 2015/16

Guidance and demonstrate effective integration of key partners and services.

The following RAG status definition table is offered as a guide to help you evaluate the status of your Board’s overall winter preparedness

against each action.

RAG Status Definition Action Required Green Systems / Processes fully in place & tested where appropriate.

Routine Monitoring

Amber Systems / Processes are in development and will be fully in place by the end of October. Active Monitoring & Review

Red Systems/Processes are not in place and there is no development plan.

Urgent Action Required

1 Board Overview: Resilience Preparedness (Assessment of the Boards overall winter preparations and further actions required)

RAG Further Action/Comments

1 The Board has robust business continuity management arrangements in place to manage and mitigate all key disruptive risks including the impact of severe weather. These arrangements have built on the lessons learned from previous periods of severe weather, and are regularly tested to ensure they remain relevant and fit for purpose. Resilience officers are fully involved in all aspects of winter planning to ensure that business continuity management principles are embedded in winter plans. The Preparing For Emergencies: Guidance For Health Boards in Scotland (2013) sets out the expectations in relation to BCM and the training and exercising of incident plans – see Sections 4 and 5, and Appendix 2 of Preparing for Emergencies for details.

2 The Board’s business continuity (BC) plans take into account the organisations critical activities, analysis of the effects of disruption and the actual risks of disruption and develop plans based on risk-assessed worst case scenarios. Risk assessments take into account staff absences and a business impact analysis so that essential staffing requirements are available to maintain key services. The critical activities and how they are being addressed are included on the corporate risk register and are regularly monitored by the risk owner. The Board has negotiated arrangements in place for mutual aid with local partners, which cover all potential requirements in respect of various risk scenarios.

3 The Board has HR policies in place that cover:

what staff should do in the event of severe weather hindering access to work, and

how the appropriate travel advice will be communicated to staff and patients Resilience officers and HR departments will need to develop a staff travel advice and communications protocol to ensure that travel advice and messages to the public are consistent with those issued by Local /Regional Resilience Partnerships to avoid confusion. This should be communicated to all staff.

4 The Board’s website will be used to advise on travel to hospital appointments during severe weather and prospective cancellation of clinics.

5 The Board works with local authorities to create a capacity plan to manage any potential increase in demand for mortuary services over the winter period; this process involves funeral directors.

6 The Board will test the effectiveness of its winter plan by 30 Oct with stakeholders. The final version of the Board’s plan has been jointly approved with the H&SC Partnership’s Integrated Joint Board.

2 Board Overview: Unscheduled / Elective Care Preparedness (Assessment of the Boards overall winter preparations and further actions required)

RAG Further Action/Comments

1 Clinically Focussed and Empowered Hospital Management

1.1 Clear site management process is in place with operational overview of all emergency and elective activity. Ideally this should be a triumvirate approach of operational, medical and nursing Directors/leads with autonomy to make decisions to manage the site

1.2 Effective communication protocols are in place between clinical departments and senior managers to ensure that potential system pressures are identified as they emerge and as soon as they occur escalation procedures are invoked.

1.3 Effective communication protocols are in place between key partners, particularly across local authority housing, equipment and adaptation services, Mental Health Services, and the independent sector.

Shared information should include key contacts and levels of service cover over weekends and festive holiday periods, bed states and any decisions which have been taken outside of agreed arrangements.

1.4 A Target Operating Model should be communicated to all staff. Escalation policies are well defined, clearly understood, and well tested. Clear thresholds and authorities for triggering, and standing down, escalation plans should be established and clearly communicated.

1.5 Escalation policies are in place and consider the likely impact of emergency admissions on elective work and vice versa, including respiratory, circulatory, orthopaedics, cancer patients, ICU/PICU.

This should be based on detailed modelling, pre-emptive scheduling of electives throughout the autumn, and early spring, and clear strategies regarding which lists may be subject to short-notice cancellation with a minimum impact.

1.6 Escalation policies are focused around in-patient capacity across the whole system.

Pressures are often due to an inability to discharge patients timeously. Systems should be in place for the early identification of patients who no longer require acute care and discharged without further delay

1.7 Escalation procedures are linked to a sustainable resourcing plan, which encompasses the full use of step-down community facilities, such as community hospitals and care homes.

All escalation plans should have clearly identified points of contact and should be comprehensively tested and adjusted to ensure their effectiveness.

2 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 has specifically taken into account the surge in activity in the first week of January.

2.1 Demand, capacity, and activity plans across emergency and elective provision are fully integrated. Weekly projections for scheduled and unscheduled demand and the capacity required to meet this demand should be in place. Plans for scheduled services should include a specific ‘buffering range’ for scheduled queue size, such that the scheduled queue size for any speciality/sub-speciality can fluctuate to take account of any increases in unscheduled demand without resulting in scheduled waiting times being exceeded. This requires scheduled queue size for specific specialities to be comparatively low at the beginning of the winter period. Boards should be able to evidence that for critical specialities scheduled queue size and shape are such that a winter surge in unscheduled demand can be managed without materially disadvantaging scheduled waiting times, whilst at all times ensuring patient safety and clinical effectiveness.

2.2 NHS Boards should implement the range of analysis and management tools that are being promoted to enable effective and related planning and management of scheduled and unscheduled services e.g. Statistical Process Control, Queuing Theory, Discreet Event Simulation, Variation Methodology, etc.

2.2 Pre-planning has optimised the use of capacity for the delivery of emergency and elective treatment, including identification of winter surge beds for emergency admissions. This will be best achieved through the use of structured analysis and tools to understand and manage all aspects of variation that impact on services, by developing metrics and escalation plans around flexing or cancelling electives, and by covering longer term contingencies around frontloading activity for autumn and spring.

2.3 Pre-planning and modelling has been undertaken around elective activity to plan responses, escalation and recovery to minimise the impact of winter peaks in demand on the delivery of routine elective work.

A set of clear actions should be developed based on a firm understanding of demand and capacity, prediction and management of variation.

In the event of severe weather impacting significantly on elective activity, NHS Boards, should contact SGHSCD Access Support Team to advise of any service disruption

2.4 Planning and analysis will facilitate the Board to consistently deliver the 4 Hour Emergency Access target (95%) and work towards the (98% Standard), eliminate 12 hour breaches whilst avoiding 8 hour breaches, and maintain the delivery of all elective care. Boards are expected to maintain performance against all LDP standards, while recognising that clinical decision making in the interests of all patients is paramount. This includes TTG (legal requirement), 18 weeks, Diagnostics, Outpatients and Cancer. Monitoring of these measure is required to support escalation policies and achieve sustainable flow through the system.

2.5 NHS Boards should review and take stock of their performance against the British Association of Day Surgery (BADS) Directory version 4 to ensure that they have achieved optimum performance against the surgical procedures identified as being suitable for day case surgery” Achieving optimal performance against BADS version 4 will support NHS Boards to manage bed occupancy, admission and discharge of elective patients.

3 Agree staff rotas in October for the fortnight in which the two festive holiday periods occur to match planned activities such as MDTs, and projected peaks in demand. These rotas should include services that support the management of inpatient pathways, (e.g.) diagnostics, pharmacy, phlebotomy, AHPs, IPCT, portering, cleaning etc.

3.1 Consultant (Medical and Surgical) cover along with multi-professional support teams, including IPCT cover, will be planned to effectively manage predicted activity and discharge over the festive holiday periods, by no later than the end of October.

This should take into account predicted peaks in demand, including impact of significant events (e.g.). Hogmanay Street parties on services, and match the available staff resource accordingly. Any plans to reduce the number of hospitals accepting emergency admissions for particular specialties over the festive

period, due to low demand and elective activity, need to be clearly communicated to partner organisations.

3.2 Extra capacity should be scheduled for the ‘return to work’ days after the four day festive break and this should be factored into annual leave management arrangements.

3.3 Additional festive services are planned in collaboration with partner organisations e.g. Police Scotland, SAS, Voluntary Sector etc. Boards are aware of externally provided festive services such as minor injuries bus in city centre, paramedic outreach services and mitigate for any change in service provision from partner organisations

3.4 Out of Hours services, GP, Dental and Pharmacy provision over festive period should be communicated to clinician/manager on call to ensure alternatives to attendance are considered.

4 Optimise patient flow by proactively managing Discharge Process utilising Estimated Date of Discharge as soon as patients are admitted or scheduled for admission with supporting processes (e.g.) multi-disciplinary ward rounds. This will support the proactive management of discharge, ensuring there are no delays in patient pathways.

4.1 Discharge planning will commence at the point of admission or at pre-admission assessment

using, where available, protocols and pathways for common conditions to avoid delays during the discharge process.

Patients, their families and carers should be involved in discharge planning as early as possible to allow them to prepare and put in place the necessary arrangements to support discharge.

4.2 There will be on-going engagement with the SAS to effectively plan patient transport when it is known, or anticipated, that patients will require transport home or to another care setting. Where transport service limited or higher demand Boards should consider alternative arrangements as part of the escalation process

4.3 Multi-disciplinary Ward Rounds will be embedded to proactively manage the patient journey and prepare for discharge detailing the estimated date of discharge.

This should be displayed visually for the care team to see and should be the focus of all daily ward rounds and bed meetings and inform daily safety flow huddles

4.4 Regular daily ward rounds and bed meetings will be conducted to ensure a proactive approach to discharge. Discharges should be made early in the day, including over weekends, and should involve key members of the multidisciplinary team, including social work.

Test scheduling and the availability of results, discharge medication, transport requirements and availability of medical and nursing staff to undertake discharge should all be considered during this process to optimise discharge pre-noon on the estimated date of discharge.

4.5 Predictive data will be used to assess the hourly demand for beds allowing for discharges to be scheduled to optimise flow.

Boards should consider evaluating the accuracy of EDD to help improve the discharge process.

4.6 Discharge lounges should be fully utilised to facilitate pre-noon capacity. Processes should be in place to support morning discharge at all times. This should be monitored for uptake and discharge compliance

5 Ensure that senior clinical decision making capacity is available for assessment, care planning, MDTs and discharge 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.

5.1 There is adequate medical, nursing and AHP cover across both, the festive holiday period, and

over weekends to conduct assessments, plan effective care programmes and perform dedicated discharge rounds. Criteria-led discharges, should be put in place wherever possible to improve discharge process across 7 day.

5.2 Key partners such as: pharmacy, transport and social care services will have determined capacity and demand for services and be able to provide adequate capacity to support the discharge process. These services should be aware of any initiatives that impact on increased provision being required and communication processes are in place to support this. There should be a monitoring and communication process in place to avoid delays, remove bottlenecks and smooth patient discharge processes

6 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.

6.1 There is close partnership working with local authorities and the third and independent sector to

ensure that adequate care packages are in place in the community to meet predicted discharge levels.

This will be particularly important over the festive holiday periods.

6.2 Ongoing and detailed engagement between local partners around the capacity of social care services to accommodate predicted discharge levels will start no later than October.

6.3 The Board and their respective local authorities have put in place a joint escalation plan resolve issues that might arise.

Consideration should be given to developing local agreements on the direct purchase of homecare by ward staff.

6.4 Intermediate care options, such as enhanced supported discharge, reablement and rehabilitation will be utilised, where possible.

Rapid Response teams should have the ability to directly purchase appropriate homecare packages, following the period of Intermediate care.

6.5 Host NHS Boards and local authorities are taking the discharge requirements of patients who are receiving treatment at the Golden Jubilee National Hospital into account.

6.6 Patients identified as being at high risk of admission from, both the SPARRA register and local intelligence, and who have a care manager allocated to them, will be identifiable on contact with OOH and acute services to help prevent admissions and facilitate appropriate early discharge.

6.7 All plans for Anticipatory Care Planning will be implemented, in advance of the winter period, to ensure continuity of care and avoid unnecessary emergency admissions / attendances. If attendances or admissions occur Anticipatory Care Plans and key information summaries should be used as part of discharge hospital to inform home circumstances and fit for discharge

7 Ensure that communications between key partners, staff, patients and the public are effective and that key messages are consistent.

7.1 Effective communication protocols are in place between clinical departments and senior managers to ensure that potential system pressures are identified as soon as they occur, and that escalation procedures are invoked at the earliest opportunity.

7.2 Demand, capacity, and activity plans across emergency and elective provision are fully integrated.

Collaboration between partners, including NHS 24, Locality Partnerships, Scottish Ambulance Service, SNBTS through to A&E departments, OOH services, hospital wards and critical care, is vital in ensuring that winter plans are developed as part of a whole systems approach.

7.3 Effective communication protocols are in place between key partners, particularly across local authority housing, equipment and adaptation services, Mental Health Services, and the independent sector.

Shared information should include key contacts and levels of service cover over weekends and festive holiday periods, bed states and any decisions which have been taken outside of agreed arrangements.

7.4 Communications with the public, patients and staff will make use of all available mediums, including social media, and that key messages will be accurate and consistent.

NHS 24 are leading on the 2015/16 ‘Be Healthwise This Winter’ media campaign, and SG Health Performance Directorate is working with partners and policy colleagues to ensure that key winter messages, around repeat prescriptions’, respiratory hygiene, and norovirus are effectively communicated to the public. In late October the SG will launch its Resilience Campaign, in partnership with the British Red Cross, and other organisations to highlight the risks and consequences of all kinds of severe weather and the simple practical ways people can reduce these risks. Messages will continue to be targeted at more vulnerable and harder to reach people in our communities. The public facing website http://www.readyscotland.org/ will continue to provide a one stop shop for information and advice on how to prepare for and mitigate against the consequences from a range of risks and emergencies. This information can also be accessed via a smartphone app accessible through Google play or iTunes. The Met Office National Severe Weather Warning System provides information on the localised impact of severe weather events.

3 Board Overview: Out of Hours Preparedness (Assessment of the Boards overall winter preparations and further actions required)

RAG Further Action/Comments

1 The OOH plan covers the full winter period and pays particular attention to the festive period. This should include an agreed escalation process. Have you considered/discussed local processes with NHS 24 on providing pre-prioritised calls during the OOH period?

2 The plan clearly demonstrates how the Board will manage both predicted and unpredicted demand from NHS 24 and includes measures to ensure that pressures during weekends, public holidays are operating effectively. The plan demonstrates that resource planning and demand management are prioritised over the festive period.

3 There is evidence of attempts at enabling and effecting innovation around how the Board will predict and manage pressures on public holidays/Saturday mornings and over the festive period.

The plan sets out options, mitigations and solutions considered and employed.

4 There is reference to direct referrals between services. For example, are direct contact arrangements in place, for example between Primary Care Emergency Centres (PCECs)/Accident & Emergency (A&E) Departments/Minor Injuries Units (MIUs) and other relevant services? Are efforts being made to encourage greater use of special notes, where appropriate?

5 The plan encourages good record management practices relevant to maintaining good management information including presentations, dispositions and referrals; as well as good patient records.

6 There is reference to provision of pharmacy services, including details of the professional line, where pharmacists can contact the out of hours centres directly with patient/prescription queries and vice versa

7 Clear arrangements are in place to enable access to mental health crisis teams/services, particularly during the festive period.

8 There is reference to provision of dental services, to ensure that services are in place either via general dental practices or out of hours centres This should include an agreed escalation process for emergency dental cases; i.e. trauma, uncontrolled bleeding and increasing swelling.

9 The plan displays a confidence that staff will be available to work the planned rotas. While it is unlikely that all shifts will be filled at the moment, the plan should reflect a confidence that shifts will be filled nearer the time. If Boards believe that there may be a problem for example, in relation to a particular profession, this should be highlighted.

10 There is evidence of what the Board is doing to communicate to the public how their out of hours services will work over the winter period and how that complements the national communications being led by NHS 24. This should include reference to a public communications strategy covering surgery hours, access arrangements, location and hours of PCECs, MIUs, pharmacy opening, etc.

11 There is evidence of joint working between NHS Territorial Boards and the SAS in how this plan will be delivered through joint mechanisms, particularly in relation to discharge planning, along with examples of innovation involving the use of ambulance services.

12 There is evidence of joint working between NHS Territorial Boards and NHS 24 in preparing this plan. This should confirm agreement about the call demand analysis being used.

13 There is evidence of joint working with the acute sector and primary care Out-of-Hours planners in preparing this plan. This should cover possible impact on A&E Departments, MIUs and any other acute receiving units (and vice versa), including covering the contact arrangements.

14 There is evidence of working with social work services in preparing this plan. This should be include referral systems, social work on-call availability, support for primary care health services in the community and support to social services to support patients / clients in their own homes etc.

15 There is evidence of clear links to the pandemic plan including provision for an escalation plan. The should reference plans to deal with a higher level of demand than is predicted and confirm that the trigger points for moving to the escalation arrangements have been agreed with NHS 24.

4 Prepare for & Implement Norovirus Outbreak Control Measures RAG Further Action/Comments 1 Infection Prevention and Control Teams (IPCTs) should read the HPS Norovirus Outbreak

Guidance 2015, due to be published around 17 Aug 2015, to ensure that the Board is optimally prepared.

2 IPCTs will be supported in the execution of a Norovirus Preparedness Plan before the season starts. Boards should ensure that their Health Protection Teams (HPTs) support the advance planning which care homes are undertaking to help keep people out of hospital this winter and provide advice and guidance to ensure that norovirus patients are well looked after in care homes.

3 HPS Norovirus Control Measures (or locally amended control measures) are easily accessible to all staff, e.g. available on ward computer desk tops, or in A4 folders on the wards. Staff should be reminded of the need to remain absent for 48 hours post last symptom of Diarrhoea and vomiting. Where staff are prevented from returning to work NHS Boards should refer to the guidance note issued in 2010 relating to staff absence and infection control.

4 Board communications regarding bed pressures and norovirus ward closures are optimal and everyone will be kept up to date in real time. Boards should consider how their communications Directorate can help inform the public about any visiting restrictions which might be recommended as a result of a norovirus outbreak.

5 Debriefs will be provided following individual outbreaks or end of season outbreaks to ensure system modifications to reduce the risk of future outbreaks. Multiple ward outbreaks at one point in time at a single hospital might also merit an evaluation.

6 IPCTs will ensure that the Board is kept up to date regarding the national norovirus situation.

7 Before the norovirus season has begun, staff in emergency medical receiving areas will confirm with the IPCTs the appropriateness of procedures to prevent outbreaks when individual patients have norovirus symptoms, e.g. patient placement, patient admission and environmental decontamination post discharge. The SG HAI team has contacted the HOAG to request that they liaise with the SMVN to reach consensus around testing procedures for patients that have been in the vicinity of norovirus outbreaks.

8 Boards must ensure arrangements are in place to provide adequate IPCT cover across the whole of the festive holiday period. While there is no national requirement to have 7 day IPCT cover, outwith the festive holiday period, Boards might wish to consider their local IPC arrangements.

9 The Board is prepared for rapidly changing norovirus situations, e.g. the closure of multiple wards over a couple of days. As part of their surge capacity plan, Boards should consider how wards will maintain capacity in the event that wards are closed due to norovirus.

10 There will be effective liaison between the IPCTs and the HPTs to optimise resources and response to the rapidly changing norovirus situation. This should include the notification of ‘tweets’ to help spread key message information.

11

The Board is aware of norovirus publicity materials and is prepared to deploy information internally and locally as appropriate, to spread key messages around norovirus and support the ‘Stay at Home Campaign’ message. This should include the notification of ‘tweets’ to help spread key message information.

5 Seasonal Flu, Staff Protection & Outbreak Resourcing RAG Further Action/Comments 1 At least 50% of all staff working in areas with high risk patients such as paediatric, oncology,

maternity, care of the elderly, haematology, ICUs, etc., have been vaccinated to prevent the

potential spread of infection to patients, as recommended in the CMO(2015)12. This will be evidenced through end of season vaccine uptake submitted to HPS by each NHS board. Local trajectories have been agreed and put in place to support and track progress. Uptake of vaccine in 2014/15 was still significantly below target, at 36.3%.

2 All of our staff have easy and convenient access to the seasonal flu vaccine. In line with

recommendations in CMO Letter (2014)12 clinics are available at the place of work and include clinics during early, late and night shifts, at convenient locations. Drop-in clinics are also available for staff unable to make their designated appointment and peer vaccination is facilitated to bring vaccine as close to the place of work for staff as possible.

It is the responsibility of health care staff to get vaccinated to protect themselves from seasonal flu and in turn protect their vulnerable patients, but NHS Boards have responsibility for ensuring vaccine is easily and conveniently available; that sufficient vaccine is available for staff vaccination programmes; and that senior management and clinical leaders with NHS Boards fully support vaccine delivery and uptake.

3 The winter plan takes into account the predicted surge of flu activity that can happen between October and March and we have adequate resources in place to deal with potential flu outbreaks across this period.

If there are reported flu outbreaks during the season, where evidence shows that vaccination uptake rates are not particularly high, Health Boards may undertake targeted immunisation. In addition, the centralised contingency stock of influenza vaccine, purchased by the Scottish Government can be utilised if required and an agreed protocol is in place with Health Boards on the use of the contingency stock. Antiviral prescribing for seasonal influenza may also be undertaken when influenza rates circulating in the community reach a trigger level (advice on this is generated by a CMO letter to health professionals)

4 HPS weekly updates, showing the current epidemiological picture on influenza infections across Scotland, will be routinely monitored over the winter period to help us detect early warning of imminent surges in activity.

Health Protection Scotland and the Health Protection Team within the Scottish Government monitor influenza rates during the season and take action where necessary, The Health Protection Team brief Ministers of outbreak/peaks in influenza activity where necessary. HPS produce a weekly influenza bulletin and a distillate of this is included in the HPS Winter Pressures Bulletin.

5 Adequate resources are in place to manage potential outbreaks of seasonal flu that might coincide with norovirus, severe weather and festive holiday periods.

NHS board contingency plans have a specific entry on plans to mitigate the potential impact of potential outbreaks of seasonal influenza to include infection control, staff vaccination and antiviral treatment and prophylaxis. Contingency planning to also address patient management, bed management, staff redeployment and use of reserve bank staff and include plans for deferral of elective admissions and plans for alternative use of existing estate or opening of reserve capacity to offset the pressures.

6 Respiratory Pathway RAG Further Action/Comments 1 There is an effective, co-ordinated respiratory service provided by the NHS board.

1.1 Clinicians (GP’s, Out of Hours services, A/E departments and hospital units) are familiar with their local pathway for patients with different levels of severity of exacerbation in their area.

1.2 Plans are in place to extend and enhance home support respiratory services over a 7 day period where appropriate.

1.3 Anticipatory Care/ Palliative care plans for such patients are available to all staff at all times. Consider use of an effective pre admission assessment/checklist i.e. appropriate medication prescribed, correct inhaler technique, appropriate O2 prescription, referred to the right hospital/right department, referred directly to acute respiratory assessment service where in place.. Consider use of self-management tools including anticipatory care plans/asthma care plans and that patients have advice information on action to take/who to contact in the event of an exacerbation. Patients should have their regular and emergency medication to hand, their care needs are supported and additional care needs identified (should they have an exacerbation).

1.4 Simple messages around keeping warm etc. are well displayed at points of contact, and are covered as part of any clinical review. This is an important part of ‘preparing for winter for HCPs and patients.

Simple measures are important in winter for patients with chronic disease/COPD. For example, keeping warm during cold weather and avoiding where possible family and friends with current illness can reduce the risk of exacerbation and hospitalisation.

2 There is effective discharge planning in place for people with chronic respiratory disease including COPD

2.1 Discharge planning includes medication review, ensuring correct usage/dosage (including O2), checking received appropriate immunisation, good inhaler technique, advice on support available from community pharmacy, general advice on keeping well e.g. keeping warm, eating well, smoking cessation. Local arrangements should be made to ensure that the actions described are done in the case of all admissions, either in hospital, before discharge, or in Primary Care soon after discharge, by a clinician with sufficient knowledge and skills to perform the review and make necessary clinical decisions (specifically including teaching or correcting inhaler technique).

2.2 All necessary medications and how to use them will be supplied on hospital discharge and patients will have their planned review arranged with the appropriate primary, secondary or intermediate care team.

3 People with chronic respiratory disease including COPD are managed with anticipatory and palliative care approaches and have access to specialist palliative care if clinically indicated.

3.1 Anticipatory Care Plan's (ACPs) will be completed for people with significant COPD and Palliative Care plans for those with end stage disease. Spread the use of ACPs and share with Out of Hours services. Consider use of SPARRA/Risk Prediction Models to identify those are risk of emergency admission over winter period. SPARRA Online: Monthly release of SPARRA data, http://www.bi.nhsnss.scot.nhs.uk/ . This release estimates an individual’s risk of emergency admission in the period 1st August 2014 to 31st July 2015. Consider proactive case/care management approach targeting people with heart failure, COPD and frail older people.

4 There is an effective and co-ordinated domiciliary oxygen therapy service provided by the NHS board

4.1 Staff are aware of the procedures for obtaining/organising home oxygen services. Staff have reviewed and are satisfied that they have adequate local access to oxygen concentrators and that they know how to deploy these where required. If following review, it is deemed that additional equipment is needed to be held locally for immediate access, please contact Health Facilities Scotland for assistance (0131 275 6860) Appropriate emergency plans/contacts are in place to enable patients to receive timely referral to home oxygen service over winter/festive period. Contingency arrangements exist, particularly in remote and rural areas, and arrangements are in place to enable clinical staff in these communities to access short term oxygen for hypoxaemic patients in cases where hospital admission or long term oxygen therapy is not clinically indicated.

Take steps to remind primary care of the correct pathway for accessing oxygen, and its clinical indications.

5 People with an exacerbation of chronic respiratory disease/COPD have access to oxygen therapy and supportive ventilation where clinically indicated.

5.1 Emergency care contact points have access to pulse oximetry.

Take steps to ensure that all points of first contact with such patients can assess for hypoxaemia, and are aware of those patients in their area who are at risk of CO2 retention. Such patients should be known to Ambulance services, Out of Hours Emergency centres and A/E departments, either through electronic notifications such as eKIS, or by patient help cards, message in a bottle etc.

7 Management Information RAG Further Action/Comments 1 Admissions data will be input to the System Watch predictive modelling system as close to real

time as possible. Local quality assurance of the site and board level data is in place.

2 Effective reporting lines are in place to provide the Scottish Government with routine weekly management information and any additional information that might be required on an exception / daily basis. Over the winter period we will be augmenting the weekly management information collected on an all-year-round basis and will share this information across NHSScotland to help Boards compare and benchmark performance.

3 Effective reporting lines are in place to provide the SG Directorate for Health Workforce & Performance with immediate notification of significant service pressures that will disrupt services to patients as soon as they arise. Any exception reporting should be set within the context of planned / actual capacity and demand activity.

8 Sign Off RAG Further Action/Comments 1 The Chief Executive will discuss the winter plan at board meetings and personally sign off and

publish the plan on the Boards website by the end of October at the latest.

2 A summary of the winter plan will be published on the Board website by the end of October.

3 Arrangements are in place to include governance of winter planning within local Unscheduled Care Management Groups or other relevant management groups as appropriate. Membership of these groups should include national and local Unscheduled Care Teams where applicable.

9 Key Roles / Services Integrated into Planning Process RAG Further Action/Comments Heads of Service

Nursing / Medical Consultants

Consultants in Dental Public Health

AHP Leads

Infection Control Managers

Managers Responsible for Capacity & Flow

Pharmacy Leads

Mental Health Leads

Business Continuity / Emergency Planning Managers

OOH Service Managers

GP’s

NHS 24

SAS

Territorial NHS Boards

Independent Sector

Local Authorities

Integration Joint Board Chief Officers and Interim Chief Officers

Strategic Co-ordination Group

Third Sector

SG Health & Social Care Directorate