Post on 11-Aug-2020
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan
2016/17
Summary A&E Delivery and Winter Plan 2016/17
Prepared by BaNES Clinical Commissioning Group
in partnership with:
BaNES Council (LA)
Royal United Hospitals Bath NHS Foundation Trust (RUH)
Wiltshire Clinical Commissioning Group
Wiltshire Council
Sirona Care & Health (Sirona)
Wiltshire Health and Care
South Western Ambulance Service NHS Foundation Trust (SWASFT)
Avon and Wiltshire Mental Health Partnership NHS Trust (AWP)
Care UK (NHS 111 provider)
Bath and North East Somerset Doctors Urgent Care (BDUC)
Dorothy House Hospice, Care UK (DH)
Bath Emergency Medical Services (BEMS+)
Arriva Transport Solutions Ltd (non-emergency PTS provider)
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 2 of 25
Version Control
Version Date Changes Made by: Comments
0.1 05/10/2016 Dominic Morgan 1st Draft
0.2 28/10/2016 Dominic Morgan
2nd Draft – updated provider
winter plans and A&E RIG
assessment
0.3 02/11/2016 Dominic Morgan
3rd Draft updated with
further provider winter plans
and latest A&E
Improvement Plan
0.4 04/11/2016 Dominic Morgan
4th Draft provider updates
and updated to address
NHSE assurance
3
Contents
Executive Summary .................................................................................................. 4
1. A&E Delivery and Winter Plan Development ................................................... 6
1.1 Learning from 2015/16 .......................................................................................... 7
1.2 Allocation of ORCP Resilience Funding .................................................................. 7
2. A&E Delivery Board Four-Hour Performance .................................................. 9
2.1 Governance: How the RIG actions and Winter Plan will be monitored and
implemented ......................................................................................................... 9
3. Operational Performance Management Framework (OPMF) & Escalation . 10
3.1 Operational Performance Management Framework (OPMF) ................................ 10
3.2 Daily Operational Management of the UCS ........................................................... 10
3.3 Common Understanding of Escalation .................................................................. 11
3.4 Individual Provider & System Status Reporting Daily Status Report (DSR) ........ 11
4. Provider Winter Plans and Demand & Capacity Modelling .......................... 12
4.1 Royal United Hospitals NHS Foundation Trust (RUH) ........................................... 13
4.2 SWASFT ............................................................................................................... 14
4.3 CareUK (NHS 111) ................................................................................................ 14
4.4 Sirona (BaNES Health & Social Care.................................................................. 15
4.5 AWP (Liaison Mental Health) .............................................................................. 15
4.6 BDUC (GP Out of Hours) .................................................................................... 16
4.7 BaNES Primary Care .......................................................................................... 16
5. Communications .............................................................................................. 19
6. Flu Vaccination ................................................................................................. 20
6.1 Public Vaccination ................................................................................................. 20
6.2 Health organisations internal protection ................................................................ 20
6.3 Pandemic Flu......................................................................................................... 21
7. Infection Control ............................................................................................... 21
8. NHSE A&E Improvement and Winter Plan Guidance – Self-Assessment ... 22
9. Other CCG’s Winter Plans ............................................................................... 24
10. Conclusion ........................................................................................................ 25
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 4 of 25
Executive Summary
The purpose of the Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan
(referred to as ‘the Plan’ throughout the document) is to ensure that the BaNES health and social
care system is aligned in its delivery of the five main actions contained within the A&E Rapid
Improvement Guidance (RIG) and is also prepared and coordinated to respond to the anticipated
increased needs and service demands throughout the 2016/17 winter period (Q3 & Q4) and in
response to known periods of pressure across the health and care community.
2015/16 was very challenging both a local and national level resulting in the failure to deliver the
A&E standard. The BaNES Health and Care community did not experience recovery during quarter
1 or quarter 2 of 2016 as seen in previous years. High escalation at the Royal United Hospitals
Bath (RUH) has become the norm with increased demand, combined with increases in Delayed
Transfers of Care (DToC) impacting on limited capacity.
In response to the A&E pressure and associated poor performance NHSE has mandated System
Resilience Groups (SRG) to become A&E Delivery Boards (A&EDB) and provided a set of Rapid
Implementation Guidance (RIG) which sets out five main areas for action to be implemented ahead
of this winter. These areas are:
1. Streaming at the front door to ambulatory and primary care. This will reduce waits and
improve flow through emergency departments by allowing staff in the main department to
focus on patients with more complex conditions.
2. NHS 111 – Increasing the number of calls transferred for clinical advice. This will decrease
call transfers to ambulance services and reduce A&E attendances.
3. Ambulances – Dispatch on Disposition (DoD) and code review pilots; Health Education
England (HEE) increasing workforce. This will help the system move towards the best
model to enhance patient outcomes by ensuring all those who contact the ambulance
service receive an appropriate and timely clinician and transport response. The aim is for a
decrease in conveyance and an increase in ‘hear and treat’ and ‘see and treat’ to divert
patients away from the ED.
4. Improved flow – ‘must do’s that each Trust should implement to enhance patient flow. This
will reduce inpatient bed occupancy, reduce length of stay, and implementation of the
‘SAFER’ bundle will facilitate clinicians working collaboratively in the best interests of
patients.
5. Discharge – mandating ‘Discharge to Assess’ and ‘trusted assessor’ type models. All
systems moving to a ‘Discharge to Assess’ model will greatly reduce delays in discharging
and points to home as the first port of call if clinically appropriate. This will require close
working with local authorities on social care to ensure successful implementation for the
whole health and care system.
The A&EDB has undertaken a comprehensive assessment of the RIG and the conclusions and
actions are contained in the attached A&E Rapid Implementation Guidance (RIG) Detailed
Baseline Assessment and associated briefing.
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20160930 A&E RIG Detailed Baseline Assessment.pdf
20160930 A&E RIG Detailed Baseline Assessment Briefing.pdf
The Bath and North East Somerset (BaNES) draft A&E Delivery and Winter Plan 2016/17 was
submitted to NHSE on 5th October and the received NHSE feedback embedded below has been
include within this revised version for the 4th November submission deadline.
161011 BaNES
improvement winter assurance.pdf
To aid identification of the updated areas within the plan and the actions taken to address the
assurance criteria these have been highlighted in the table below
A&E Improvement Plan Criteria 2 - A&E Delivery and Winter Plan Section 4.5 - AWP (Liaison Mental Health) & 4.1 Royal United Hospitals NHS Foundation Trust (RUH) Criteria 3 - A&E Delivery and Winter Plan Section 4.3 - CareUK (NHS 111) (updated) and Demand & Capacity Modelling Section 4.12 - Combined Clinical Hub (added) Criteria 5 - A&E Delivery and Winter Plan Section 1 - A&E Delivery and Winter Plan Development (Updated) Criteria 6 - A&E Delivery and Winter Plan Section 1 - A&E Delivery and Winter Plan Development (Updated) & the DToC Sub Group updated ToRs Criteria 7 - A&E Delivery and Winter Plan Section 1 - A&E Delivery and Winter Plan Development (Updated)
Criteria 8 - A&E Delivery and Winter Plan Section 4 - Provider Winter Plans (updated) and Section 3.6 - Multi Agency Discharge Event (MADE), MFFD Action Plan and Mandated Pre-Christmas 85% Occupancy Levels (updated) A&E Winter Plan assurance framework
Criteria 2 - A&E Delivery and Winter Plan Section 1.3 - System Capacity and Demand Plans (added)
Criteria 4 - A &E Delivery and Winter Plan Section 4.6 - BDUC (GP Out of Hours) & Section 4.7 - BaNES Primary
Care
Criteria 5 - A&E Delivery and Winter Plan Section 4.2 - SWASFT Winter Assurance Event (updated)
Criteria 6 - A&E Delivery and Winter Plan Section 4 - Provider Winter Plans (updated) and Demand & Capacity
Modelling Section 4.12 - Combined Clinical Hub (added)
Criteria 8 - A&E Delivery and Winter Plan Section 4 - Provider Winter Plans (updated)
Criteria 12 - A&E Delivery and Winter Plan Section 4.5 - AWP (Liaison Mental Health)
Criteria 15 - A&E Delivery and Winter Plan Section 4 - Provider Winter Plans (updated)
Winter Plan Further Updates
A&E Delivery and Winter Plan Section 4.8 - ATSL (NEPTS) Further Business Continuity
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 6 of 25
1. A&E Delivery and Winter Plan Development
The BaNES A&E Delivery Board will oversee the delivery of the NHSE A&E Rapid Improvement
Guidance (RIG) 5 main actions and the resilience of the BaNES Health and Care system across
the winter months. The plan has been developed with consideration against NHSE’s Winter and
A&E Improvement Plan Guidance (Section 8 NHSE A&E Improvement and Winter Plan Guidance -
Self-Assessment).
The plan has been in development since April 2016 and in collaboration with key partners across
the Health and Care system surrounding the RUH catchment area and takes into account the
NHSE RIG. It incorporates:
BaNES System Improvement Plan (SIP)
BaNES CCG ORCP Investments
Urgent Care QIPP programme
BaNES Operational Performance Management Framework (OPMF)
BaNES Escalation Framework
Planning, analysis and preparation for 2016/17 including the winter period has been undertaken in
a number of key events including:
Urgent Care Summit 24/03/2016
Dom Care Summit 21/04/2016
SUECN Repatriation Event 12/09/2016
Hospital to Care Home event 20/09/2016
NHSE South Central Winter Escalation Workshop 28/09/16
The RUH have refreshed their internal plan and have updated their role within the SIP and revised
their ToR for their programme board to reflect the RIG action. In addition to the RUH’s internal
Improvement Board actions, there has been on-going emergency and urgent care planning
undertaken by various supporting groups and forum to develop both ORCP schemes and
additional capacity across the winter period within BaNES to support system delivery. These
include:
DToC Action Group (Now A&E Delivery Board Sub Group)
CCG Urgent Care QIPP Group
SRG Clinical Sub Group (Now A&E Delivery Board Sub Group)
Arriva Operational Group (AOG)
There are a number of agreed next steps now completed and to further support the final
development of the A&E Delivery and Winter Plan and include:
Final Provider Winter Plans by 24/10/2016
Review of providers Winter Demand and Capacity assumptions 03/11/2016
A&E Delivery Board review of BaNES A&E Delivery and Winter Plan 03/11/2016
Review of NHSE revised Escalation Guidance (now released by NHSE)
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BaNES Winter Workshop (24/11/2016)
Commissioned Discharge Demand and Capacity Modelling (03/11/2016)
Priority Actions for Next Month
Winter plan finalised and STP resilience workshop on 24th November
RUH multi-discharge event (MADE) arranged for 29th and 30th November with preparatory
workshop on 17th November
D2A workshop in November supported and facilitated by ECIP
Further output of demand & capacity modelling by SCWCSU
20161103 Four Hour Performance A&EDB Briefing.pdf
06. 20161031 4-Hour System Improvement Plan.pdf
1.1 Learning from 2015/16
To ensure a more robust approach in 2016/17 the CCG developed a number of key actions based
on the identified learning from 2015/16. The key lessons learnt have been set out below and this
plan has been designed to address each of the areas of concern.
Each provider has been required to develop robust demand and capacity modelling across the
winter period to include the latest demand intelligence to build strong planning.
Review of the whole system escalation policy and internal provider actions to support both
provider internal and whole system escalation.
All partners to take key action in advance of winter to reduce NEL demand and NEL
admissions with the RUH.
Increased action to reduce Ready for Transfer (RfT), DToC and stranded patients within the
RUH and Community capacity.
Early allocation of ORCP resilience funding and to support external acute capacity to
support flow.
1.2 Allocation of ORCP Resilience Funding
The CCG has agreed ORCP schemes worth £1.136m into 2016/17. The funding includes
£300,000 of ring-fenced funding to existing schemes within BaNES to reduce NEL and support
NEL activity within the RUH, with £836,000 to support agreed ORCP resilience schemes in
2016/17 to further reduce impact on the RUH and improve patient flow. These schemes have been
centred on external support to the RUH to cover the agreed priority areas of:
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 8 of 25
Continuation of 2015/16 ORCP resilience schemes into April 2016 (NHSE Requirement)
Sirona expansion of Discharge to Assess (D2A)
Dorothy House Additional EOL support capacity
Supporting 7 day Discharge Liaison from Sirona within the RUH
Supporting Earlier Presentation model within BaNES to reduce NEL admissions
Further funding has been held for potential further winter capacity in BaNES following the
outcome of the SCWCSU’s Discharge Demand and Capacity Modelling
The table below summarises the ORCP resilience spend and funding decisions in 2016/17
20160630 BaNES ORCP Allocation 2016-17 Briefing Note v1.pdf
1.3 System Capacity and Demand Plans
BaNES A&EDB has commissioned additional CSU capacity to support the creation of a new
Discharge Demand and Capacity Planning tool. The initial headline findings have been shared
within the November A&EDB. The planning tool has shown the purchase of the 17 additional beds
into the BaNES UCS in 2015/2016 made no material difference to the UCS and to the RUH 4 Hour
Standard performance.
The Planning tool has shown the main areas that need where capacity needs to be flexed to
support whole system flow. BaNES CCG and LA are working through the capacity and flow
recommendations. The Planning Tool will allow the UCS to test the effectiveness of demand and
capacity interventions.
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2. A&E Delivery Board Four-Hour Performance
The BaNES A&EDB was established on 1st September in shadow form following NHS England
and NHS Improvement’s letter of 28th July 2016 which set out a clear expectation to get four hour
performance back on track.
As a result of the continued poor four-hour performance, the RUH agreed to an offer of intensive
ECIP support. ECIP visited the RUH on 7th September 2016 to review emergency flow across the
internal acute pathway. The areas identified for improvement included:
SAFER bundle benefits realisation through collaboration with medical specialties
Increasing non-elective ambulatory medical activity and % of medical take through
ambulatory care
Medical outlier management
The consistency of offer around discharge to assess (D2A) at home pathway, a whole
system priority
20160930 Four Hour Performance A&EDB Briefing.pdf
2.1 Governance: How the RIG actions and Winter Plan will be monitored and
implemented
The Chief Officer of BaNES CCG has been confirmed as the Chair of the A&EDB. Revised terms
of reference and executive level representation along with a revised governance structure to
oversee the A&E Improvement Plan have been circulated and are expected to be signed off at the
A&EDB on 6th October.
The main purpose of the Board is to drive improvement in performance by managing the delivery
of the A&E Improvement Plan, holding to account the local urgent and emergency system to
ensure effective working and to identify and respond to risks that would prevent the system
meeting its core responsibilities.
An Urgent & Emergency Care STP Programme Board is overseeing delivery of the identified
priorities across the STP footprint. This Programme Board meets on a monthly basis with
fortnightly telephone conference calls between the three CCGs in between to ensure momentum is
maintained.
The current work stream priorities, identified through a series of workshops earlier this year,
incorporate and focus on the delivery of the key “must dos” that feature within existing and the
recently published 2017-19 Operational Planning and Contracting Guidance. Work within the STP
for Urgent and Emergency Care is and will continue to add value to the existing work currently
targeting the delivery of these “must do’s” (in particular implementation of the five A&E rapid
improvement initiatives) and continuous effort is being made to ensure that duplication of reporting
is minimised as a collaborative and information sharing approach across the Footprint is
established.
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 10 of 25
Figure 1. Draft AE Delivery Board Governance Structure
05. AE Delivery Board ToR Draft V4.pdf
3. Operational Performance Management Framework (OPMF) & Escalation
The primary responsibilities of the A&EDB is to ensure patients within BaNES Local Health & Care
Economy (LHE) receive safe and effective care, while maintaining financial stability of all partners.
These requirements do not change during times of increased pressure created by demand
throughout the year, but should be integral to normal system planning. To ensure this approach is
maintained, all service providers are required to complete National Health Service England (NHSE)
directed Operational Resilience and Capacity Planning (ORCP), based on robust demand
predictors, to ensure the correct levels of demand throughout the planning cycle and incorporating
appropriate service level provision at all times.
3.1 Operational Performance Management Framework (OPMF)
To ensure the delivery of safe services across the LHE, an OPMF is in place.
3.2 Daily Operational Management of the UCS
To measure and assist in forecasting the ‘heat’ within the system on a daily basis the OPMF
establishes the management of the daily operational performance supported by a daily Urgent
Care Dashboard (UCD).
11
The UCD has been designed to be information rich and not data rich to allow an increased focus
and oversight of the LHE measures that support better real-time operational pro-active decision
making.
3.3 Common Understanding of Escalation
To help create a more uniformed approach there is a common language and common
understanding of escalation used within the LHE below. This has helped to remove some
confusion and decreased the conversations around interpretation, to allow partners to further
concentrate on finding solutions.
Planned Escalation – provider demand and capacity planning has identified a degree of
flexible capacity which is used as part of managing flexible demand.
Unplanned Escalation – provider demand and capacity planning has been exceeded due
to significant unforeseen additional demand pressure (Major incident, rising tide event etc.)
3.4 Individual Provider & System Status Reporting Daily Status Report (DSR)
To enhance this approach the OPMF has established the daily operational status declaration
processes for both all providers by 10.00am and across the whole UCS, set by the CCG by
11.00am. These processes have been established to provide daily operational leadership of the
whole UCS and recorded within the shared Daily Status Report (DSR). All providers are required to
determine their daily status when measured against the agreed matrix set out within the BaNES
A&E Delivery Board – Operational Performance Management Framework (OPMF) and Escalation
Policy
2016 BaNES A&E Delivery Board – Operational Performance Management Framework (OPMF) & Escalation Policy v1.pdf
3.5 NHSE South Central
NHSE South Central is putting in place the following support:
The NHSE SC Escalation Standard Operating Procedure and supporting Action Cards will
be refreshed to reflect this new guidance before distribution locally across SC;
A new NHS England-SC web page will be set up to store information relevant to winter,
escalation and urgent & emergency care. The webpage is in development and the link will
be shared in due course
All the presentations from the recent winter workshops will be saved here alongside key
information including relevant articles, papers, guidance and other related documents.
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 12 of 25
3.6 Multi Agency Discharge Event (MADE), MFFD Action Plan and Mandated Pre-
Christmas 85% Occupancy Levels
To further prepare for winter a Multi Agency Discharge Event (MADE) has been arranged for 29th
and 30th November with preparatory workshop on 17th November. This event will follow the NHSI
Rapid Improvement Guide (RIG) and will bring together the local health system to:
Support improved patient flow across the system
Recognise and unblock delays
Challenge, improve and simplify complex discharge processes
The UCS will be monitored to consider further MADE weeks if required.
The A&EDB is working with all system partners to produce a revised bespoke Multi Agency
Discharge Event (MADE) action plan including 2015/2016 lessons learnt to conduct a reduction of
delays in downstream delays and to achieve the mandated Pre-Christmas 85% occupancy level.
The A&EDB has further requested the A&EDB DToC Sub Group to formulate the updated MFFD
Action Plan.
Rapid Improvement Guide to Multi Agency Discharge Event - FINAL.pdf
4. Provider Winter Plans and Demand & Capacity Modelling
To further aid the preparation for this winter and provide some mitigating actions for January’s
performance the STP Urgent Group has agreed to hold an STP Winter Workshop. All partners
want to be sure they are in as good a position as possible and provide the A&EDBs with confident
in the system’s ability to improve and sustain delivery over the winter months and this event will be
an opportunity to further test system resilience. The event will cover:
Systemwide, what we know – demand and surges across the period (Dec16 to April 17)
and the role of Leadership
Escalation Review - Operational Pressure Escalation Framework (OPEF)
MADE Events - what’s needed to achieve these?
Winter Plans - including risks and mitigations
Presentations from RUH, SFT, GWH, SWASFT, CareUK, AWP, WC&H, SEQUEL/GWH,
Sirona and Medvivo. Please use the attached presentation template to aid timings.
BSW STP Systemwide Communication Plan
Next Steps
This STP event will support the delivery of the overall system KPIs in additional to the good
progress made with demand & capacity modelling work which will provide further focus for the
A&EDB.
13
20161027 STP Winter
Workshop Provider Presentations Draft v1.pptx
4.1 Royal United Hospitals NHS Foundation Trust (RUH)
The Royal United Hospitals NHS Foundation Trust (RUH) has provided their internal board paper
which provides an overview of their Operational Resilience and Capacity Plan (ORCP) for Urgent
Care which has been developed in parallel to planned care. The overall aim of the plan is to
provide assurance that there is system resilience and robust planning to achieve and sustain the
key acute trust performance targets;
4 Hour emergency access
RTT
Cancer Waiting Times
The plan details Trust operational resilience planning including;
Assessment and admission
Clinical site management
Transfer and discharge
Patient and carer involvement
Severe weather procedures
Pandemic flu planning
Infection control
Business continuity
The plan provides assurance that there is a robust Urgent Care Programme in place for 2016/167
at the RUH with a clear governance structure reporting into both the transformation Board and
Management Board, and can demonstrate core membership of the three A&EDB’s and urgent care
operational delivery groups. Programme performance monitoring is monthly against both project
and trust wide KPI’s and metrics as part of the agreed 2016/17 Urgent Care Programme. The
2016/17 programme also provides assurance of the 2016/17 programme delivery, sustainability of
benefits and current risks to delivery.
The plan details the capacity modelling undertaken to determine the capacity required to
deliver non-elective care including planned and unplanned escalation requirements
RUH - Winter Plan Paper.pdf
The RUH has provided further assurance within the A&E Improvement Update and to A&EDB on
the RUH target of 30% use of Ambulatory Care and have predicted achieving this by the end of
January 2017.
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 14 of 25
4.2 SWASFT
The purpose of the SWASFT Winter Plan is to provide an overview of South Western Ambulance
Service NHS Foundation Trust’s (SWASFT) arrangements for the sustainable delivery of Urgent
and Emergency Care Services within its operational area from 1st November 2016 to 1st March
2017.
The plan details arrangements for the provision and delivery of the following core services:
999 Accident & Emergency Services including Clinical Hubs
NHS 111 Services within Cornwall and Dorset
Out of Hours (OOHs) services within Dorset and Gloucestershire
Tiverton Urgent Care Centre (UCC) Service
The SWASFT Winter Plan reflects the live and continuous nature of the Trust’s planning for the
winter period and as a result this plan will be updated regularly to ensure that it provides an
accurate reflection of the Trust’s preparedness at any given time.
The plan also sets out how the Trust will contribute to NHS England’s requirements on A&E
Delivery Boards to accurately forecast activity for the winter period.
Since the submission of the first draft commissioners have held a South West SWASFT Winter
Assurance Event, while assure overall, the North Division (Old GWAS area) have requested further
assurance on the mix of Double Crew Ambulances (DCA) virus Rapid Response Vehicles (RRV)
following the introduction of the Ambulance Response Programme (ARP). SWASFT is providing
this the North Division commissioners as separate assurance action.
Winter Plan 2017 1 19 Trust Format 241016.pdf
4.3 CareUK (NHS 111)
The CareUK Winter Plan describes the detailed understanding of the historic volumes, service
level achievement, external influences and technical changes that will have impacted on historic
volumes, or have the potential to impact on future volumes.
CareUK rolling forecast has been developed to replace the Supply versus Demand model originally
produced at the start of the service and replaced the original model in September 2014. The
rolling forecast is based on the volumes seen from September 2013, with allowances for additional
contracts and seasonal variation. Bank Holiday Modelling is contained within the Rolling Forecast,
but allows for planning on a day by day rather than weekly volume basis, with
validation/commentary as adjustments made based on volumes seen closer to actual dates. This
rolling forecast is updated on a daily basis, to ensure prompt reaction to trends seen.
As a seasonal trend is now visible in terms of volume data now being available for more than 12
months, showing the variation between the winter and summer months on a day by day and week
15
by week basis). This pattern is used as the baseline for all forecasting processes (to include the
full impact of the winter 2014/5 and Winter 2015/2016) As the historical 2015 volumes and the
2016 volumes to date will reflect the expected uplift between Summer and Winter, a further 7.5%
has been added to the volumes from Winter 2015/2016 to provide additional resilience.
For winter and Christmas 2016/2017, actual call volumes from the same period last year were
used as a guide for planning. Detailed planning for Christmas and New Year 2016/7 has been
undertaken on a day by day basis.
Care UK 111 2016-2017 Winter Plan.pdf
4.4 Sirona (BaNES Health & Social Care
Current plans for the winter of Nov 2016-March 2017 do not include any investment for additional
resource or services. In addition there is a level of uncertainty within the existing teams due to
change of provider in April 2017 which is increasing vacancy levels within the community teams.
There is a risk that it is not possible to provide continuity of service as a result of emerging winter
pressures during mobilisation. Risk assessments are being carried out for each service to
understand any capacity/staffing issues. Appropriate risk-mitigation plans agreed with
commissioners to be put in place on a case-by-case basis. This risk has been included within the
A&EDB Risk Register.
BANES Winter Plan 16 17.pdf
4.5 AWP (Liaison Mental Health)
AWP’s Winter Plan has been developed in order to ensure minimum disruption to mental health
service delivery throughout the winter, and specifically, across Christmas and the New Year 2016 -
2017. This plan will link in with the Winter Plans of partner organisations, including the CCGs,
Acute Trusts, Local Authorities and Ambulance Trusts.
The AWP Winter Plan is shared externally with NHS England Area Teams and is available through
the Local Health Resilience Partnership to group members. Internally, the Plan is developed by
relevant teams, shared through relevant Operations meetings and the Trust Resilience Group.
The LDU Management Teams are responsible for ensuring that all staff within their LDU
understands the content of the Plan, their roles and responsibilities and the implications of the
Plan.
The A&EDB agreed not to pursue 24/7 liaison mental health services at this time as to meet this
standard would not be cost effective and would require significant investment.
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 16 of 25
AWP Winter Plan V7 8 Final.pdf
4.6 BDUC (GP Out of Hours)
The BDUC Winter Plan has been developed in collaboration with all members of the Bath
Operational Team and aims to demonstrate how plans will ensure the delivery of safe and high
quality services during potential periods of pressure. The Winter Plan:
Reflects a whole system approach to the delivery of services over the forthcoming winter
period
Builds upon lessons learnt over the previous year
Identifies the potential risks and sets out options and solutions to mitigate against them
BDUC have taken a pragmatic review of the anticipated winter pressures expected and drawn
information from all available sources to provide the best possible assumptions across the South
West. It should be noted that any remedial changes identified will be implemented prior to
December 2016 as it is vital that the standard of care, quality of services and legal requirements
are maintained even during the most challenging of situations. The potential impact on the patient
experience is considerable and during the winter period we will aim to ensure:
No unnecessary waiting or delays
No inequality of access to our services
BaNES is leading with other STP CCGs on the reprocurement of NHS 111 and OOHs working with
the other CCGs across the STP footprint to transform services towards the combined clinical hub
model.
Bath Doctors Urgent Care Winter Plan 2016-17_V1 3.pdf
4.7 BaNES Primary Care
Out of hours services are currently provided by BDUC. However, for core hours GP Practice PMS
contractual obligations note arrangements for access to ‘essential services’ – i.e. the management
of its registered patients or temporary residents that are ill (or believe themselves to be) within core
hours and to have in place arrangements for access to such services in core hours in case of
emergency.
The majority of practices also offer ‘Extended Hours’ providing appointments at times outside of
core hours in the evening and weekends in line with the NHSE specification. As part of the CQC
inspection process, key lines of enquiry include a review of how risks are anticipated and planned
17
for in advance by the practice (e.g. seasonal fluctuations in demand, the impact of adverse
weather, or disruption to staffing).
For registered patients aged over 75 there should be an accountable GP to ensure the essential
services are provided under the main GP contract, and to ‘work co-operatively with other health
and social care professionals who may become involved in the care and treatment of the Patient to
ensure the delivery of a multi-disciplinary care package’. In addition all BaNES practices are
expected to be offering additional appointments during 28th December – 31st March 2017 (approx.
10,000 expected in total) as part of the Urgent Care Escalation scheme.
The majority of practices also participate in the NHSE commissioned the Avoiding Unplanned
Admissions Directed Enhanced Service (AUA DES), which funds proactive case finding and review
for vulnerable people at risk of hospital admission. This describes a care coordination role for the
2% at risk registered population covered by this scheme. The AUA DES outlines the creation of a
register, and (where applicable) the development of personalised care plans, or, for all patients on
the register, undertaking at least one care review in the previous 12 months. The development or
review of care plans will be undertaken with the patient and (where applicable), their carer.
Alongside this, the CCG has funded three Early Home Visiting Service (EHVS) pilot schemes
running from October 2016 – March 2017. All three have now been mobilised. The aim of the
service is focussed on Primary Care patients who might otherwise be at risk of an unnecessary
overnight admission to Hospital, should they present later in the day.
BaNES has agreed to extend and fund the BaNES HCP Transfer third party vehicle through to 31st
March 2017 to provide further availability to GPs to maximise the use of Amb Care at the RUH and
to further reduce late presentations and reduce NEL admissions within the RUH.
4.8 ATSL (NEPTS)
Commissioners continue to work with Arriva Transport Solutions Limited (ASTL) to formulate their
Demand and Capacity their approach to winter. The A&EDB has requested further business
continuity planning to minimise the impact of the NEPTS performance on the wider system.
BaNES has agreed to extend and fund the BaNES HCP Transfer third party vehicle through to 31st
March 2017 to provide some additional on day transfer support to the RUH. NEPTS are continuing
to work with ATSL to deliver further system wide contingency. ATSL South West updated Winter
Plan to follow.
The A&EDB have requested that ATSL provide further assurance at the STP Winter Workshop on
24th November 2016.
4.9 Medvivo
The aim of Medvivo’s Operational Resilience and Capacity Plan (ORCP) is to describe Medvivo
Group’s approach to capacity planning in establishing and maintaining sustainable year-round
service delivery. The ORCP replaces the traditional winter plan in recognition that, whilst winter is
clearly a period of increased pressure, health and social care systems are experiencing year round
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 18 of 25
sustained and increasing pressure. A proactive, rather than reactive, approach is required in order
to build on lessons learned and to deliver robust, consistent operational resilience.
Medvivo Operational Resilience and Capacity Plan 2016.pdf
4.10 Wiltshire Health and Care
The Wiltshire Health and Care Winter Plan sets out the preparations and priorities for the operation
of adult community services over the winter of 2016/17. In doing so, it draws upon lessons learnt
from previous winters and summarises the main service developments that will have an impact on
the resilience and responsiveness of the services.
Wiltshire Health and Care Winter Plan 2016-17.pdf
4.11 Dorothy House Hospice Care (DHHC)
Continued demand on the Hospice at Home (H@H) service, which is partly funded by the 3 CCGs,
runs up to and beyond the SLA capacity being topped up by charitable monies. This year, as in the
rest of the NHS, we have not seen the quiet period so often seen in previous years over the
summer period. Our forecast is that at the end of this financial year DHHC will have provided over
24,000 hours of Hospice at Home care across our region (compared to the 17,000 hours paid for
by the SLA).
Coordination of our H@H care is now delivered 7 days a week 8am-7pm as standard, and the
RUH and community nursing and primary care teams have direct access to a registered nurse
during this time.
20160930 Dorothy House Hospice Care BaNES Winter Resilience Update.pdf
4.12 Combined Clinical Hub & Pharmacist Trial
The Severn Urgent and Emergency Care Network (UECN) is supporting a network trial to meet the
Commissioning Standards for Integrated Urgent Care by implementing a three month trial of an
Integrated Clinical Hub model Wiltshire are commencing on 3rd October 2016.
Providing a single point of access, the ICH will support and facilitate patient access to a clinical
advice and treatment services. Services will include NHS 111 providers, ambulance services, and
potentially expand to include emergency departments, social care, community services and GP out
of hours services, depending on early evaluation during the trial.
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Pharmacist trial in the Virtual Clinical Hub (VCH). Following the national requirement to develop
clinical hubs to support earlier clinical review in patient pathways from NHS111, BaNES is leading
the use of pharmacists in the NHS 111 CareUK call centre as a means to enhance clinical review
for medicines issues. The preferred model is to leverage existing resources in the community via
the Directory of Services. Date to be confirmed.
5. Communications
Locally we will continue to support NHSE’s ‘Stay Well This Winter’ national campaign, and is part
of locally targeted activity through the CCG’s winter communications planning.
Stay Well This Winter is designed to ensure that people who are most at risk of preventable
emergency admission to hospital are aware of and, wherever possible, motivated to take actions
that may avoid admission over winter.
The campaign this year focuses on self-care, taking action to prevent getting ill (including taking up
flu vaccinations where offered) and getting advice from pharmacists when the first signs of illness
appear.
Specific communications activity includes:
Monthly press releases throughout winter period focusing on the four main
stages of the national campaign. Releases shared with local stakeholders,
partners and media and include local stories such as 2-year old receiving nasal
flu vaccine. Published on CCG website (approx. 550+ hits per week), shared on
social media (approx. minimum reach of 11,000 accounts per week).
Social media scheduled weekly, using national and local materials where
possible, and linking with local groups/prominent accounts to reach target
audiences (i.e. Age UK B&NES, Carers’ Centre, Bath Mums, B&NES Council,
Sirona, RUH).
News articles published in Bath Mums newsletters and website (online forum
with 6K members).
Council ‘Connect’ residents’ magazine double page spread (delivered early
December to 76K households).
Internal communications to CCG/provider/partner staff to gain support for the
campaign as well as take up of flu vaccination.
Paid advertising scheduled for end of November and early January in regional
press and on social media with ‘first signs’ messaging as well as being
prepared for Christmas/stocking up on medication.
Printed resources sent to local organisations including dentists and opticians,
children’s centres, health visitors, Viv Hollis learning disability nurses, leisure
centres, care homes.
Training/talks (specifically about flu) given to practice managers, practice
nurses, health visitors, district nurses, midwives, reablement team.
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 20 of 25
Communications activity for Stay Well This Winter will be evaluated where
possible including website and social media analytics, and questions testing
public awareness in B&NES Council’s annual Voicebox survey.
6. Flu Vaccination
Preparations for the impact of flu this winter covers three main areas, Public vaccination, Health
organisations internal protection and Pandemic Flu, each response being undertaken to ensure the
system is prepared is set out below:
6.1 Public Vaccination
Last year across Bath & North East Somerset, Gloucestershire, Swindon & Wiltshire (BGSW)
uptake of the seasonal flu vaccination amongst all of the eligible groups e.g. pregnant women, over
65’s, under 65’s at risk and eligible children were above the England average. However uptake of
the seasonal flu vaccination amongst health care workers’ across BGSW was 44.9%, lower than
the England average of 49.5%.
6.2 Health organisations internal protection
There is a National CQUIN that sits under the heading of NHS Staff Health and Wellbeing and has
been incorporated into 2016/17 contracts with SWASFT, AWP, RUH, Sirona, Dorothy House, BMI,
Circle. BDUC were strongly encouraged to take up this CQUIN however continued to decline but
they would actively promote flu vaccination to their staff.
The rationale for the CQUIN is Frontline healthcare workers are more likely to be exposed to the
influenza virus, particularly during winter months when some of their patients will be infected. It has
been estimated that up to one in four healthcare workers may become infected with influenza
during a mild influenza season- a much higher incidence than expected in the general population.
Influenza is also a highly transmissible infection. The patient population found in hospital is much
more vulnerable to severe effects. Healthcare workers may transmit illness to patients even if they
are mildly infected. The green book recommends that healthcare workers directly involved in
patient care are vaccinated annually. It is also encouraged by the General Medical Council and by
the British Medical Association.
There is a contraction expectation that they will be a 75% uptake of the flu vaccination and the
CQUIN will be paid in Quarter 4 because of the natural of the vaccine availability and roll out.
There is a lot of staff engagement involved in this CQUIN because last year we saw a national
drop in staff vaccination. There are rules within the CQUIN for partial payment but anything under
64% will receive no money.
RUH Occupational Health is very committed to achieving this target. They have engaged with
public health and asked for assistance in reviewing their CQUINS plans to ensure that they are
doing everything possible to promote the flu vaccination in an innovative and positive way.
Public Health had a Flu Myth Busting Seminar in September. Target audience were any provider
that had a Flu Staff Vaccination CQUIN attached including in this group were Care Home staff.
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Those that attended found the session very useful. The RUH, Sirona, Dorothy house, BMI and
care home staff attended. BaNES LA are leading on the Care Homes on encouraging their staff
vaccinated to protect their patients.
6.3 Pandemic Flu
Significant arrangements are in place through the Avon and Somerset Local Health Resilience
Partnership, Influenza Pandemic Framework. The framework builds upon existing arrangements
for escalation and winter planning and should be read in conjunction with:
Avon and Somerset LHRP Communicable Disease Framework
Avon and Somerset LHRP Health Community Response Plan
Individual Organisations Business Continuity and / or Operational Influenza Pandemic
Plans
Avon and Somerset Local Resilience Forum (LRF) Excess Deaths Plan
Avon and Somerset LRF Pandemic Influenza Plan
This framework has been produced on behalf of Avon and Somerset Local Health Resilience
Partnership (LHRP) to support the delivery of an effective response in the event of an Influenza
Pandemic.
Avon and Somerset LHRP Influenza Pandemic Framework V1 0_1st Issue 29 September 2015.pdf
7. Infection Control
Each provider is responsible and has in place individual plans around the management,
containment and avoidance of infectious diseases such as norovirus and gastroenteritis and the
impact of infectious diseases closing beds are monitored as part of daily UCD. Further impact on
the community beds or care provision is also recorded and significant outbreaks are managed in
conjunction with the daily system calls. Routine system monitoring of any community outbreaks for
the Avon, Gloucestershire and Wiltshire areas is provided on a weekly basis by Public Health
England.
A new Outbreaks Information Pack for care homes is being prepared with Public Health which will
be highlighted in the Care Homes Forum newsletter. The CCG is also considering the possibility of
training on how to use this pack with care homes. The Care Homes Forum has had a presentation
on Infection and the Care Homes Information Pack.
Infection Control is a standing agenda item with sharing of information on outbreaks between
providers, council and CCG and avoidance support. The CCG’s Quality dashboard will capture
infection outbreak information so that we have up to date information at all times and can monitor
impact.
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 22 of 25
8. NHSE A&E Improvement and Winter Plan Guidance – Self-Assessment
BaNES A&EDB has undertaken a review against the NSHE best practice guidance and applied a
RAG status for each area. While 9 areas are assessed as green, there remain 8 areas assessed
as amber and this reflects the evolving nature of the A&E Delivery and Winter Plan for 2016/17.
Further updates will be provided as the plan develops.
23
BaNES A&EDB Self-Assessment - Winter Plan
Winter Plan RAG A&EDB Position
No. Criteria
1
Plans contain evidence that a review has taken place into the
management of winter 2015/16 and lessons are reflected in this year's
plan
GAssured, a number of system wide Demand & Capacity review events have
taken place.
2
Plans contain evidence for flexing capacity in the event of surge, across
the acute, community, residential/home care sectors and packages of
care. This should include the agreed multi agency triggers for extending
and withdrawing this extra capacity in a consistent cohesive manner YES
A
Partly Assured, individual provider and ongoing CSU commissioned system
wide Demand and Capacity modelling being undertaken, due at November
A&EDB
3
Plans contain clear 24/7 leadership arrangements for all organisations
and the mechanism to escalate issues in and out of office hours. These
should include CCG, Provider and Local Authority on-call arrangements
at an executive level. YES
GAssured, both tried and tested shared CCG and LA on call and Operational
Performance Management Framework (OPMF) in place.
4
Plans contain evidence of how Primary Care will work with the rest of
the system to support the management of flow, particularly on Bank
Holidays and out of hours YES
GAssured, additional primary care capacity funding now in place and
additional capacity agreed acroos the winter months.
5Evidence of robust plans for ambulance services providers to deal with
known activity peaks in demand across the winter period YESG
Assured, SWAFST have a Demand and Capacity plan incorporating the
latest Ambulance Response Programme (ARP) impact. ARP 2.2 new codign
set in place.
6Evidence of robust plans for NHS 111 providers to deal with known
activity peaks in demand across the winter period YESA
Partly Assured, robust Demand and Capacity evidenced from CareUK.
(Subject to workforce issues).
7
Plans contain evidence of a comprehensive local flu strategy with a
mechanism to monitor and performance manage provider and
community uptake of vaccination on a regular basis.
GAssured, public programme in place, provider and CQUIN’s to support
uptake in place and Pandemic Planning in place.
8
Plans contain actions for adverse weather which includes the clinical
impact of cold weather and snow as well as the impact on business
continuity. YES
A
Partly Assured, Adverse Weather resil ience remains the primary
responsibil ity of all partners. Further testing planned as part of STP Winter
Workshop (24/11/2016).
9
Plans contain a clear focus on high risk groups and admissions
avoidance best practice including evidence for externally cascading
advance warnings and briefings YES
G
Assured, strong CCGs Comms plans in place. Avoiding Unplanned
Admissions Directed Enhanced Service (AUA DES), this enables care
coordination role for the 2% at risk registered population.
10
Clear evidence of system wide escalation plans in l ine with the new
national framework with agreed consistent local multi agency triggers.
These triggers should include both escalation and de-escalation YES
G
Assured, system wide Escalation Policy in place. This will be subject to
review following any new NHSE guidance and further subject to testing as
part of BaNES Winter Workshop.
11Plans to contain processes for system-wide operational
sitrep/dashboard for daily review and escalation reporting YESG
Assured, tried and tested OPMF in place supported by daily Urgent Care
Dashboard (UCD).
12Plans contain clear evidence of collaborative operational planning with
social services and mental health services YESG
Assured, all partners completing Winter Plans to include robust Demand
and Capacity planning.
13Plans contain processes to manage infectious disease outbreaks to
avoid (and contain) any D&V/norovirus impact YESG
Assured, all partners have robust infection control processes in place.
BaNES Infection Control Collaborative in place.
14
Plans contain clear and consistent multi-agency proactive and reactive
communications actions to promote appropriate use of local services.
YES
G Assured, robust CCG Comms Plans in place.
15Evidence that systems have mechanisms to test, or have tested, these
arrangements ahead of the winter period. YESA
Partly Assured, Full system monitoring in place, further testing being
undertaken as part of STP Winter Workshop (24/11/2016).
16The system has a strong track record of responding well together in a
swift and reactive manner YESG
Assured, long history of working together to resolve issues with OPMF in
place since 2013.
Bath and North East Somerset (BaNES) A&E Delivery and Winter Plan 2016/17 Page 24 of 25
BaNES A&EDB Self-Assessment A&E Improvement Plan
9. Other CCG’s Winter Plans
Wiltshire - Due to the impact of the West Wiltshire demand volumes on the RUH, the Wiltshire
Clinical Commissioning Group’s Winter Plan 2016-17 has been included as support to this plan.
Both CCGs have agreed to capture their individual actions and ORCP investments within each
Winter Plan and for the ongoing monitoring and governance to be completed with the A&EDB.
Wiltshire CCG Winter Plans 1617 v0 4 latest.pdf
Somerset – The Somerset Winter Plan sets out the Somerset Urgent Care System planning and
delivery arrangements for 2016/17. The plan has been developed in collaboration with members
of the Somerset Urgent Care Programme Board to ensure the delivery of safe and high quality
services to the population during potential periods of pressure.
The Somerset Winter Plan:
Reflects a whole system approach to the delivery of services over the forthcoming winter
period
Builds upon lessons learnt within Somerset over recent years and in particular from Winter
2015/16
Winter Plan RAG A&EDB Position
No Criteria
1Plans demonstrate the new governance arrangements and clearly
outlines roles and responsibilities.G
Assured, A&E Delivery Board in place, Revised ToR to be agreed in
November A&EDB. Executive level representation agreed.
2Plans have evidence for delivering ED streaming (against criteria set out
in RIG) by November 2016G
Assured, Front Door ED streaming in place provided by BDUC being co-
located at the RUH ED.
3Plans demonstrate delivery of an increase in NHS 111 calls being
handled by clinicians (against criteria set out in RIG) By November 2016 A
Partly Assured, Robust Demand and Capacity planning in place, however
they remains questions about the workforce and recruitment cover
predicted resources.
4Plans demonstrate delivery of ambulance response programme
initiative (against criteria set out in RIG) ahead of winter 2016/17G
Assured, SWAFST are the national trial leaders for the Ambulance Response
Programme (ARP). ARP 2.2 New coding now in place.
5Plans contain evidence to implement measures to improve flow through
the system (against criteria set out in RIG) by November 2016A
Partly Assured, While some strong action has been achieved a number of
schemes remain as trials or require mobilisation.
6
Plans contain evidence of implementing best practice measures to
improve discharge processes (against criteria set out in RIG) by
November 2016
A
Partly Assured, While some strong action has been achieved a number of
schemes remain to be fully mobilised and are subject to further
development
7
Evidence of delivery of other improvement actions being taken to get
back to delivery of trajectory (if off track) and timescales for when these
will be achieved
A
Partly Assured, SIP in place across the system , it remains early days in the
delivery of the full impact of the multiple projects. This is subject to the
tripartite monitoring process. Recent performance has shown strong
improvement.
8The system has a strong track record of working well together to deliver
multi agency actionsG
Assured, there is a long history of cross system working, however the
effectiveness of collaborative working remains difficult to evidence
sustaining improvement.
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Illustrates the approaches to infection control and the seasonal flu campaign
Outlines the communications being used over the winter period
Identifies the challenges, risks and mitigating actions required
Somerset Winter Plan 2016-17 final.pdf
Swindon - Swindon’s Winter Resilience Plan 2016-2017 has been developed to address expected
demand over Q3 & Q4 and outline sufficient resilience management across the organisation and
expected planning across partnership provision to cope with this demand and includes:
Identify profile demand across Q3 and Q4 1016 / 2017 and gap from expected normal
system demand
Define additional schemes and actions which contribute to increased capacity management
Quantify contribution to understand demand management and KPI /capacity expectation
Incorporate lessons learnt from Winter 2015/2016
Define clear expected contingency actions across Silver and Gold levels routinely which will
be considered within periods of pressure to regain system control
SWINDON WINTER RESILIENCE PLAN 16-17.pdf
10. Conclusion
The A&EDB recognises the requirement to deliver a robust and comprehensive Winter Plan to
ensure that patient safety is maintained throughout the Winter period and that as a system we are
able to deliver the agreed 4 hour Improvement Trajectory for Quarters 3 and 4.
The A&EDB will continue to plan and challenge all partners to ensure both objectives are
delivered.
The A&E DB has formally reviewed and sign off the plan on the 3rd November 2016.