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Editorial Wednesday 28 January 2015: Text of NHS England's major incidence guidance

Here follows the short version of the text of NHS England West Midlands local area team's major incident guidance, which has made the news today.

Urgent Care Checklist/On–Call guidance
The purpose of this checklist is primarily to assist both CCG and Area Team on-call managers and Directors when the system pressures across urgent care providers is significant.

* CCG On call
It should be used as a guide for CCG on call directors/managers to ensure (as the responsible on call local system leader) to manage the system operationally with providers and ensure all appropriate actions have been taken. The checklist can also be used to identify gaps in provision and should be used proactively i.e. before the point of escalation.

* Area Team (West Midlands Sub-Region) On call
For the On call manager (1st on call) the checklist should be used to assure themselves that CCG on call managers /directors have undertaken all appropriate actions (in accordance with the checklist) before discussing or requesting advice/more formal action. If the on call manager is assured all appropriate action is being taken then it would be for them to advise the Area Director on call (2nd on call) to discuss and support more formal measures. This would only occur in the most extreme of situations ie. Trust declaring internal major incidents/external major incident.

* Major incidents /formal actions
In terms of more formal action the advice about calling an Internal or External Major Incident is a significant step which must lead to the Trust putting in place a series of actions to change the nature of its response. It is not simply, and should not be used as, a means of declaring that the Trust is under pressure, however severe that pressure is.

If calling an External Major Incident, the Trust is invoking its Major Emergency Plan. The CCG /Area team should be discussing this action prior to the Trust decision .Although fine detail will differ by Trust, in essence, actions taken by any Trust doing this should include:
* Establishment of the Emergency Control /Incident Centre in the Trust. (Trust Gold on call on site).
* Cancellation of staff leave
* Closure of Outpatients clinics to divert clinical and admin staff to A&E, MAU and wards.
* Cancellation of elective care –inpatients and day cases apart from urgent elective /cancer cases
* Conversion of day case units to full wards
* Request Diversion of ambulances and A&E attenders to other hospitals ( in the current circumstances, this will not be agreed by other hospitals and WMAS as they do not have the capacity to take additional patients)
* Notification to the public not to attend the Trust for emergency and routine care.
* Involve other agencies such as police ,ambulance, fire

Any Trust considering this action should be aware it would need to be supported by their Local CCG on call and agreed with the On call Director for NHS England out of hours.( In hours it would be with the Director of Operations and Delivery for the Area Team)

The calling of a Major External Incident should be undertaken in accordance with the protocols in the Incident Response Plan agreed through the LHRP.

If a Trust is discussing calling an internal major Incident, this usually means the Trust is signalling to its own staff that it has pressures it is struggling to deal with and will then invoke some of the actions above, short of the full range involving calling an External Major Incident. This should be agreed/discussed with the CCG (on call) and by the Director on call for NHS England as well.

1. Has the CCG on call manager /Director visited the Trust and undertaken a review of the position in ED, MAU and on the wards?

2. Has the Trust established a command and control arrangement led by the executive director on call? Are they on site?

3. How many ambulances waiting to off load/what is the current position in the Trust?

4. Where is the Trust against ambulance and attendance predictions?

5. Are escalation protocols for 12 hour trolley waits in place and working effectively?

6. Do A&E and Medical Admissions staff have access to diagnostic support on 24/7 basis? Is there a system for notifying senior clinical decision makers of the outcome of the diagnostic test so that they can rapidly review the results (can diagnostics be accessed concurrently?)

7. Have all alternative bed spaces been opened and staffed?

8. Do patients who need to be admitted have an MDT team review to establish their complex or ongoing needs, and to prepare for discharge, within 14 hours of admission?

9. Does the Trust have senior clinical decision makers (Consultants) available in A&E and Medical admissions on an extended day basis or preferably 24/7 at times of high pressure?

10. Have criteria for community and step down services been flexed (on agreement with partner providers and CCG) to support early discharge?

11. Has all available community capacity been utilised?

12. Have criteria for social care assessment and placements been flexed with the Local Authority?

13. Have alternative options for treatment been communicated to the media and self-care messages shared with the public?

14. Are psychiatric patients provided with psychiatric assessment within an hour for emergency needs on a 24/7 basis?

15. Does the Trust have twice daily ward rounds operating every day to enable effective discharge?

16. Can a consultant refer a patient to an urgent GP appointment on the same day?

17. Has the Trust cancelled elective operations to redeploy resources to non-elective care (apart from Urgent elective /cancer operations)

This is not an exhaustive list but should be used as a guide to the level of information/action that the Trust/health economy should have in place before raising any further steps required.

It would only when the position has been assured by CCG on call that any further actions would be agreed with the Area team On Call Director.

Sugested Winter key messages - Communicating about NHS winter pressures and resilience
Seasonal pressures are nothing new to the NHS, and for some time the three national bodies responsible for the oversight of commissioners and providers have been working closely together to help local organisations ensure their services are maintained throughout the year.

These working arrangements are continually evolving and this note from NHS England, NHS Trust Development Authority and Monitor responds to requests from NHS communicators for advice, and reflects the local operational landscape whereby the whole health and care community works together, led by System Resilience Groups. Our aim is to help patients use NHS services as effectively as possible.

As such it makes sense to ensure that we are as joined up as possible at a local level before issuing any communications about individual NHS services.

In practice this must mean ensuring a conversation takes place beforehand which includes as a minimum your SRG chair, and your respective regional/area TDA, Monitor and NHS England team.

But good practice requires you also give prior notice to all local partners, such as:

* Clinical commissioning groups

* Neighbouring acute and other relevant trusts

* Ambulance services

* TDA or Monitor

* Local NHS England area team

* 111 providers

* Local authorities

And in addition briefing, as appropriate:

* Pharmacy networks

* Dentistry networks

Co-ordinating local communications in this way will mean that patients receive the most up-to-date information about local services available to them - such as extended opening by GPs, or OOH dentistry and pharmacy options.

All NHS organisations should feel confident to discuss their pressures within the SRG so that alternative services are as prepared as possible for any increased workload coming their way.

Informing NHS staff, patients and the public, stakeholders and the media
Communications about the NHS are most useful when they are as clear as possible about what is happening with local services and keep patients, the public and others informed. We can help patients use NHS services as effectively as possible by describing what is going on in simple language and providing constructive advice and avoiding internal jargon that could confuse or alarm people.

As well as explaining to patients where they can access services, communications work best when they are clear on what the local health system is doing to manage the situation. This could set out a number of things, such as:

* the context, supported by facts and figures
* a clear explanation of the action being taken, in plain non-technical language –explaining what is available to patients as well as what is not

* what action is being taken by the other parts of the local health system, for example in primary and social care.

In the rest of this document we offer the national facts, figures, messages and lines that might help you in devising your local communications. These are based on best practice as developed and refined by NHS communicators, but they don’t cover every single eventuality, and if you want to make use of them you will no doubt want to tailor them to fit your local circumstances.

Every week NHS England will publish figures on its website about the current level of demand. If people would like the latest facts, they can be circulated. Below are some generic messages and facts that we will use throughout the winter.

The most recent available data shows:

* Nearly 22 million people visit A&E every year, that’s 59, 558 every day.

* Compared to five years ago, the NHS in England handles 3,500 extra attendances every day as attendance has risen from 17.8m visits.

* Last year, 21.7 million attendances at A&E departments, minor injury units and urgent care centres.

* The NHS responds to more than 100 million urgent calls or visits every year.

* 5.2 million emergency admissions to England’s hospitals last year, rising by around 4-5 per cent this year

* An estimated 340 million GP consultations in 2012.

* Approximately 24 million calls to NHS urgent and emergency care telephone services.

* 9.1 million calls to emergency 999 services in 2012.

* In January 2013 there were 899,027 calls to the NHS 111 service, with 97.7% answered within 60 seconds. Scaled up this would represent 10.5 million calls per year to the service. This compared to 2.7 million calls to NHS 111 in 2012.

* 7 million emergency ambulance journeys in 2012.

* Spending on major A&E services in England is thought to be between £760m and£1.5bn per year, with the average cost of an attendance thought to be about £68.

* Compared to four years ago, every day the NHS is seeing 16,000 more hospital outpatients, performing 10,000 more diagnostic tests and carrying out 2,000 more operations and 2000 extra ambulance journeys a day.

Facts used in our national communications
* The NHS has pulled out all the stops to prepare for this winter. We are determined to protect the good standards of service that patients deserve, despite the very considerable pressures we anticipate over the winter months.

* Planning started earlier than ever before [June] with hospitals, GPs, social services and other health professionals coming together to identify local pressures and respond in every area of the country.

* A&E and 999 services are for life-threatening and serious conditions. Your local high-street pharmacy can help you deal with minor illnesses and complaints such as coughs, colds, flu, stomach upsets, aches and sprains.
* If you feel it’s not a 999 emergency, but you need medical help fast, dial 111. NHS 111 is a fast and easy way to get the right help, and is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile phones.

* Alternatively, to find out where your local NHS services are, go to www.nhs.uk and use the service finder.

The national ‘feeling under the weather’ campaign:

We are advising elderly people:
* If you’re feeling under the weather, get help as soon as possible. See your local pharmacist or get advice from www.nhs.uk/asap. The earlier, the better.
* Speak to your friends, family or carer if you are feeling under the weather. They can help you to get advice from your local pharmacist or from www.nhs.uk/asap. The earlier, the better.
* If you have a bad cough, trouble breathing, a cold or sore throat, tell your friends, family or carer before it gets worse. The earlier, the better. * Getting advice from your local pharmacist or by visiting www.nhs.uk/asap early may help prevent your bad cough, trouble breathing, cold, or sore throat from getting worse. The earlier, the better.
* Local pharmacists provide expert advice to help you manage your long-term condition or can even help you if you have a bad cough, trouble breathing, a cold or sore throat. They have longer opening hours than GP practices, and most have a private consultation area. They’ll also tell you if they think you should see a doctor.

We are advising their friends, families and carers:
* If you are visiting or caring for an elderly relative or friend who is unwell, get advice from www.nhs.uk/asap or see your local pharmacist to help manage their care. The earlier, the better.

* If you know of an elderly relative or friend who has a bad cough, trouble breathing, a cold or sore throat, get advice from www.nhs.uk/asap or see your local pharmacist before it gets worse. The earlier, the better.

* If you’re feeling under the weather, get help as soon as possible. Get advice from www.nhs.uk/asap or see your local pharmacist. The earlier, the better.

* Local pharmacists provide expert advice to help you manage your long-term condition or can even help you if you have a bad cough, trouble breathing, a cold or sore throat. They have longer opening hours than GP practices, and most have a private consultation area. They’ll also tell you if they think you should see a doctor.

What trusts might say in particular operational situations
Issue: Delays to ambulance services/queuing ambulances
“We are aware that [insert Ambulance Service] colleagues are under a great deal of pressure. Plans are in place to ensure that ambulance, nursing and medical colleagues can continue to provide a safe service. We are working to minimise delays that have been caused by high levels of demand.”

Issue: Hospital wards or A&E departments closed
“We are aware that [name of organisation and department] has had to temporarily stop accepting non-urgent patients. This is standard procedure to make it possible for NHS staff to to [deal with issue, eg ‘deal with a rise in seriously ill patients’ or ‘deal quickly with an outbreak of Norovirus’] and every effort is being made to return services to normal as soon as possible.

“We would like to remind people not to visit hospitals if they have had a sore throat, cough, cold, sickness and/or diarrhoea, or flu until they have been free of symptoms for 48 hours. Otherwise there is a risk that you could spread the virus, which could cause a major disruption to NHS services.”

Issue: NHS services are under pressure
“The NHS is experiencing unprecedented demand this winter. We want to ensure that services are readily available for those that most need them. We are putting plans in place, to ensure that patient safety is maintained. This is something that happens every time there is an increase in demand for NHS services, but particularly over the winter months, when there can be an increase in people becoming unwell. This may mean that some patients may experience a slight delay to some services, or that services are delivered in a slightly different way. Our main priority is to maintain patient safety.”

Issue: Delayed discharges
“At the moment both NHS and social care staff are experiencing high levels of demand. We are working closely with our social care colleagues, to ensure that patients are discharged as quickly as possible, but also to ensure that any support services that are needed are in place.”

Issue: routine Elective procedures postponed
“As part of our plans to manage high demands on NHS services, clinical teams may take the decision to postpone some operations to ensure they can deal with acute and emergency care such as accidents, medical and surgical emergencies. This is standard procedure. Clinicians will not take this decision lightly, and every effort will be made to reschedule their treatment as soon as we can. We would ask for people to be patient as NHS staff work hard to ensure that NHS services are maintained as much as possible.”

Issue: beds in hospital
“We know that winter might look difficult this year, with the cold weather conditions, a seasonal flu outbreak, and particular services coming under significant pressure. The NHS is facing a difficult year, but is well prepared.

“Plans are in place to ensure that people who need critical care get access to treatment. Patients are moved out of critical care beds as soon as it is safe to do so, so that although it may appear that beds are full, this does not mean that patients are not being admitted; patients will get treatment and if necessary extra beds will be made available.”

If transfers are needed
“Our primary concern is the safety of patients. A system is in place that allows the transfer of patients between hospitals, to ensure that people who need hospital and emergency care can get treatment quickly. These plans are developed to make sure that the NHS is flexible enough to manage increases in demand.”