On-Call Handbook€¦ · On-Call Handbook Version 9.1 May 2017 NHS Mansfield and Ashfield Clinical Commissioning Group NHS Newark and Sherwood Clinical Commissioning Group

On-Call Handbook

Version 9.1

May 2017

NHS Mansfield and Ashfield Clinical Commissioning Group NHS Newark and Sherwood Clinical Commissioning Group NHS Nottingham City Clinical Commissioning Group NHS Nottingham North and East Clinical Commissioning Group NHS Nottingham West Clinical Commissioning Group NHS Rushcliffe Clinical Commissioning Group

8.5 Hazel Buchanan Oct 2016 Updated 12 hour protocol. Updated contact

details. Change in ICC location.

9.0 Hazel Buchanan April 2017 Removal of Comms details. Escalation Level

Framework included. Blue Light Protocol

included as action card. Death in a GP

practice action card. Transportation approval

action card included.

9.1 Hazel Buchanan May 2017 Change to Arriva on-call/escalation numbers

CCG on call handbook Version 9.1

Contents

CONTACT DETAILS ................................................................................................................................... 7

ACTION CARDS ...................................................................................................................................... 10

Emergency Department and System Pressures ................................................................................ 11

Patient Handover Delays Between EMAS and Acute Trust .............................................................. 15

Ambulance Divert ............................................................................................................................. 17

111 Service Pressures ....................................................................................................................... 19

Severe Weather ................................................................................................................................ 21

Systems Outage and Building Incidents ............................................................................................ 23

Out of Hours Cascade of Urgent Information ................................................................................... 25

High Cost Patient Transfers (Arriva).................................................................................................. 27

Approval of Additional Patient Transport Services ........................................................................... 29

Blue Light Protocol ............................................................................................................................ 33

Death in a GP Practice (south Nottinghamshire) .............................................................................. 35

FORMS ................................................................................................................................................... 37

REFERENCE PACK .................................................................................................................................. 39

1.0 Introduction .................................................................................................................................... 39

2.0 On Call Structure ............................................................................................................................. 39

2.1 Clinical Commissioning Groups ................................................................................................... 39

2.2 NHS England North Midlands (Derbyshire/Nottinghamshire) .................................................... 40

2.3 CCG Business Continuity Plans .................................................................................................... 41

2.4 Training ....................................................................................................................................... 41

3.0 On-Call Processes ............................................................................................................................ 41

3.1 General Processes ....................................................................................................................... 41

3.1.1 Communications Support .................................................................................................... 41

3.1.2 Legal Support ....................................................................................................................... 42

3.2 Service Pressures ........................................................................................................................ 42

3.3 Public Health ............................................................................................................................... 43

3.3.1 Communicable Diseases ...................................................................................................... 43

3.4 Weather Alerts ............................................................................................................................ 45

3.5 Blue Light Protocol ...................................................................................................................... 47


4.0 Incidents .......................................................................................................................................... 49

4.1 Incident Classifications ................................................................................................................ 49

4.2 Incident levels ............................................................................................................................. 50

4.3 Types of Incidents ...................................................................................................................... 50

4.4. Response Structure ................................................................................................................... 51

4.4.1 Tactical – CCG or NHS England ............................................................................................. 51

4.4.2 Strategic – NHS England ....................................................................................................... 51

4.4.3 Incident Command Centre (ICC) .............................................................................................. 52

4.4.4 Accessing Medicines in an Emergency ................................................................................. 53

4.4.5 Chemical, Biological, Radioactive, Nuclear Materials (CBRN) .............................................. 54

Appendix 1 – Ambulance Divert Checklist ............................................................................................ 55

Appendix 2 – National Stock Medications ............................................................................................ 57

Appendix 3 – Assessing Medicines in an Emergency ............................................................................ 59

Appendix 4 – Regional Winter Resilience Room ................................................................................... 61

Appendix 5 – NHS England 12 Hour Breach Report Form .................................................................... 66

Appendix 6 NHS Escalation and De-escalation ................................................................................ 67

Appendix 7 Blue Light Protocol - Proforma ...................................................................................... 68

Appendix 8 – Death in a GP Practice Checklist ................................................................................. 74


The handbook is divided into two sections. The first section includes the contact list, action cards and forms required whilst on call.

The second section titled Reference Pack provides further information and links to relevant documents. It also includes relevant information in relation to major incidents, which are led by Category 1 responders.

CCG on call handbook 7

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CONTACT DETAILS

Organisation Name or Function

In hours Emergency Planning arrangements

OOHS Emergency Planning arrangements

Arriva (Patient Transport Service)

Monday- Friday Business hours

Lee Beighton (Control Manager)

07880 007 606

Darren Clarke (Quality Manager)

07880 007 003

Wendy Tomlin (Quality Manger)

07880 007 002

Monday – Friday 1730-1900,

Saturday 0800-1600

Nottingham Control 0117 943 9927

Monday- Friday 1900-2300,

Saturday 1600-2300 and Sunday

0700-2300

Leicester Control 0117 943 9990

Monday – Sunday 2300-0700

Bristol Control 0117 943 9910/

0117 943 9911

Browne Jacobson

Legal Advice

07795284653 OR

07979536998

City Care

07768 145113

This is the On Call Manager mobile number

07768 145113


Communications Support (media)

Contact CCG Comms person Contact relevant on call person for provider, in order to liaise with their comms person

Doncaster and Bassetlaw Hospitals Foundation Trust

01302 366 666

On Call Director

or email -

[email protected]

01302 366 666

On Call Director

or email -

[email protected]

EMAS 0115 967 5099 0115 967 5099

Legal Advice

Browne Jacobson

07795284653 OR

07979536998

Mid Notts - Mid Nottinghamshire Clinical Commissioning Groups (Mansfield & Ashfield/ Newark &

0300 456 4957

Ask for the Nottinghamshire North

0300 456 4957

Ask for the Nottinghamshire North


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Sherwood CCGs) CCG On Call Manager CCG On Call Manager

NHIS 01623 410310

NHS England North Midlands (Derbyshire & Nottinghamshire)

07623 503853 (pager)

1st point of contact 24 hours a day,

7 days a week

07623 503853 (pager)


7 days a week

NHS England North Midlands (Staffordshire & Shropshire)

07623 503852


7 days a week

07623 503852


7 days a week

NHS England (Leicestershire & Lincolnshire)

07623 929 239 – via Page One

Director On-Call

07623 929 252 – via Page One

Senior Manager On-Call

07623 929 239 – via Page One

Director On-Call

07623 929 252 – via Page One


NHS England (Yorkshire & Humber)

0333 012 4589

Director On-Call

0333 012 4267


0333 012 4589

Director On-Call

0333 012 4267


NHS Property Services 03003 038590 and ask for the NHS Property Services on call manager

If the local manager is not available, contact the NHS Property Services regional manager: Dial: 0844 736 8578 a call handler will put you through sort to the correct region

03003 038590 and ask for the NHS Property Services on call manager

If the local manager is not available, contact the NHS Property Services regional manager: Dial: 0844 736 8578 a call handler will put you through t to the correct region

Nottingham CityCare Partnerships

07768 145113


07768 145113


Nottingham City Council 0115 876 2987 0115 915 1640

Nottinghamshire County Council 0115 977 3471

0115 977 3674

0300 456 4546

Emergency Duty Team – (M-F 5PM to 8:30 AM F-M 4:30PM to 8:30AM)

Nottingham University Hospitals

0115 924 9924

Ask for the Silver On Call

0115 924 9924

Ask for the Silver On Call

Nottinghamshire Health Care Trust (including County Health Partnership)

0115 969 1300

Ask for the On Call Gold Director

0115 969 1300

Ask for the On Call Gold Director


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NHS Bassetlaw CCG

01777 274 400 Contacted through The Rotherham NHS Foundation Trust switchboard on 01709 820000 and ask for the “South Yorkshire & Bassetlaw CCG On Call Officer”.

Public Health Nottingham 0115 977 2819 / 2561 (Barbara Brady)

Public Health England 0344 225 4524 0115 967 5099 (ask for HPA)

Public Health On Call Rota 0115 967 5099 (ask for HPA)

Leave a message and the 1st, 2

nd or

3rd

On Call Manager will call you back

0115 967 5099 (ask for HPA)

Leave a message and the 1st, 2

nd or

3rd

On Call Manager will call you back

Public Health England Centre for Radiation Chemical and Environmental Hazards (CRCE)

24hr National Chemical Incident Hotline Number: 0344 8920555 This telephone number should not be issued to members of the public

24hr National Chemical Incident Hotline Number: 0344 8920555 This telephone number should not be issued to members of the public

Sherwood Forest Hospitals Foundation Trust

01623 622515

Ask for the On Call Director

01623 622515

Ask for the On Call Director

South Notts - Nottinghamshire South Clinical Commissioning Groups (Nottingham City/ Rushcliffe/Nottingham West/Nottingham North & East)

0300 456 4957

Ask for the South Notts CCG On Call Manager

0300 456 4957

Ask for the South Notts CCG On Call Manager

South Notts Urgent Care Lead 07850 213015 07850 213015

UK National Poisons Information Service (NPIS)

0344 892 0111

This telephone number should not be issued to members of the public

0344 892 0111

This telephone number should not be issued to members of the public


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ACTION CARDS


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Action Card 1

Emergency Department and System Pressures

Description

Escalation levels have been set nationally and include:

OPEL 1 – the system is maintaining flow OPEL 2 – there are signs of pressure OPEL 3 – the system is experiencing major pressures that continue to increase OPEL 4 – pressure has increased to a degree that organisations are unable to deliver comprehensive care The CCG on-call director is not expected to attend Black Alert meetings and will be informed of any actions to be undertaken.

4 hour target

Patients are expected to be transferred to a ward, an alternative care setting or discharged within 4 hours of the clinical decision to admit (DTA). This is to ensure patients receive clinically safe care in the most appropriate setting. Any pressures impacting on the 4 hour target will be managed internally by the Trust and during working hours, will be reported through to the Urgent Care Escalation process. Therefore DTA +4 and <8 will be managed through the internal acute trust alerting and intervention arrangements.

Where patients have been waiting more than eight hours confirmation of the current demand/capability within ED and the wider Trust is to be established.

12 hour target

All patient waits in the Emergency Department of over 12 hours, following DTA, are regarded as adverse incidents. The CCG on call person will be notified prior to an actual breach of 12 hours and kept abreast of the situation. Providers should notify the on-call manager at 8 hours following DTA. If at +10 hours the CCG on call manager feels that the overall position of the Trust is expected to get worse or 12 hour breaches are expected to occur or support/co-ordination is anticipated across the wider health economy then the NHS England on-call manager should be contact.

OPEL 3 & OPEL 4 – Black Alert

OPEL 3 and OPEL4 is when the local health and social care system is experiencing major pressures compromising patient flow. Actions taken in OPEL 2 have not succeeded in returning the system to OPEL 1.

NHS England North Midlands will notify the Regional Team where the On Call Manager believes pressures will require a multi-area coordinated response; or media interest is expected locally or possible nationally

All on call staff in Greater Nottingham are part of a wider circulation list for daily email communication (subject: 10AM system report [date]) on the status of ED. This email includes the escalation status of all providers in the system, trigger point for an increase in escalation status, system-wide action and outcome for each provider with respect to escalation levels. An overall system status is included in the email.


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And:

Confirmation of current demand/capability within A&E and the wider Trust (including active clinical triage process in place and documented plus any staffing issues).

Request updates every subsequent hour UNTIL resolution. UNLESS: The decision to remain in A&E is based solely on clinical need for the patient (i.e. to move them would not be acceptable), authorised by the Senior Clinical Decision Maker; or The patient is expected to die, and they or their next of kin have requested they not be moved elsewhere

3. If the call is DTA + 10 hours and is for a number of patients contact NHS England on call if you believe (only contact NHS England within working hours and before 10:00AM the next working day)

The overall position of the Acute Trust(s) is expected to get worse; or

12 hour breaches are expected to occur; or

Support/coordination is anticipated across the wider economy area; or

The patient dies before transfer to the appropriate setting is completed; or

Increased risk of clinical harm.

4. If the call is due to 12 hour breaches complete the incident report sheet and the notification brief form as per the algorithm and notify NHS England on-call (see appendix 5):including

Location, number and length of each 12 hour breach including specialty, time of arrival, time of decision to admit, time of transfer

Actions and activity undertaken – including brief trust sitrep, immediate actions taken by the Trust and Commissioner

Any other relevant observations – include patient condition on arrival and at time of transfer

A Root Cause Analysis (RCA) should be completed within agreed timeframes. An initial RCA must be completed by the Trust within 24hrs and this is shared through the quality team.

If a 12hr breach has occurred out of hours (i.e. 5pm – 9am Monday to Friday, Weekends and Public Holidays) record the information as per above (see form in appendix 5).

NHS England are to be called before 10:00 the next day if the notification of the 12 hour breach is out of hours. If it occurs on a weekend, the CCG on-call director is to notify NHS England prior to 10:00 on Monday.

OPEL 3 and OPEL 4

The A&E Delivery Board will have liaised with NHS England in hours. The CCG on call person will be notified out of the Black Alert meeting if they are to communicate with NHS England out of hours and /or if required to attend any meetings.


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*Key √ = Yes X = no ? = Information awaited N/A = Not applicable


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Action Card 2

Patient Handover Delays Between EMAS and Acute Trust

Description

Patients arriving via ambulance to an Acute Trust A&E are required to be handed over into the care of Acute Trust Clinicians within 15 minutes of arrival. This is a maximum handover time placed on Ambulance & Acute Trusts to ensure patient safety and quality of care, and is expected to be achieved on all occasions.

It is the responsibility of the Acute Trust to ensure clinical handover takes place within 15 minutes of each patient arriving.

Additionally, the Ambulance Trust must ensure their crews are ready to respond to their next call within a further 15 minutes (i.e. a total maximum turnaround time of 30 minutes). Again, this is a maximum expected time to help ensure all patients receive clinically safe and appropriate care.

It is the responsibility of the Ambulance Trust to ensure crews and resources are available to respond to calls within the overall turnaround time.

It is recognised that there will be occasions when clinical handover and turnaround cannot be completed within the contracted times, however, all Trusts must work together to minimise delays and prevent them reaching clinically unsafe levels.

Handover is considered complete when full clinical responsibility for the patient has been transferred to the receiving hospital and the patient transferred from the Ambulance Trust equipment to the appropriate Hospital equipment.

The reporting procedure is as follows: 30 minute clinical handover delay - Ambulance Trust Silver Commander alerts Hospital Manager On-Call of handover delays. Hospital Manager On-Call to take actions to immediately enable release of ambulance crews 45 minute clinical handover delay - Ambulance Trust Gold Commander to alert Acute Trust Director On-Call to delay(s) if no plan(s) in place. 1 hour 15 minute clinical handover delay - If no plan has been agreed or resolution achieved, Ambulance Trust Gold Commander to contact CCG Director On-Call. CCG Director On-Call to manage resolution between Trusts


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Action Card 3

Ambulance Divert

Description

Full Divert

A Full divert is defined as movement of ambulance borne activity away from a site under pressure to the next nearest/appropriate ED – with their agreement (not hospitals that are part of the same Trust)

There are occasions when due to service failure certain groups of patients require diverting (i.e. failure of a CT scanner etc.) – the process for requesting a Full Divert should followed.

ED departments will not close other than in extremis (e.g. fire) and therefore requests for Full Divert will be by exception only and require approval by the CCG On-Call Manager prior to implementation. NHS England North Midlands (Derbyshire/Nottinghamshire) 1st On Call should be contacted to notify of the decision or outcome.

Peripheral/Border Divert

A peripheral divert is a request for patients in border areas i.e. those equidistant between acute Trusts, to be taken to the acute trust under less pressure. These are often used to ease acute peaks and are usually short term with a defined number of ambulances over an hour period rather than a full divert of ambulances.

In certain areas, local agreements are in place to enable peripheral diverts to happen. In these circumstances there is no requirement for additional approval, only notification.

Peripheral Diverts or Deflects should only require authorisation by the CCG Director On-Call where Ambulance and Acute Trust Directors On-Call cannot reach agreement locally

Deflect

A deflect is the movement of ambulance borne activity to another site within the same acute hospital group.

Procedural Considerations

It is expected that the protocol will only be used when Trusts have exhausted both internal systems and escalation plans as well as local health and social care plans to meet demand. NHS England North Midlands (Derbyshire/Nottinghamshire) 1st On Call retains authority to stop any local divert agreement where they consider not to do so would put patients at unacceptable clinical risk

All actions on the Escalation Actions Checklist must have been taken, as far as reasonably practicable, before a Trust contacts the Ambulance Trust to request a Full/Peripheral Divert or Deflect. The Requesting Acute Director On-Call must confirm the actions in Escalation Checklist are in place; the Ambulance Gold Commander should complete a supporting Checklist. Peripheral Diverts or Deflects should only require authorisation by the CCG Director On-Call where Ambulance and Acute Trust Directors On-Call cannot reach agreement locally.


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Action Card 4

111 Service Pressures

Description

111 have their own internal mechanisms and contingencies for handling heavy call volumes. However, if there is an incident which significantly increases their call volumes then they are required to contact the CCG on call manager.


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Action Card 5

Severe Weather

Description

CCG response will be relevant to a surge in demand and therefore the activation of action cards for system pressures may be more relevant than anything specific to severe weather. It will be important to understand the type of impact including across multi-agencies in order to ascertain the level of support required during on-call. During normal working hours weather alerts are received which provides the opportunity for forward planning. The alerts are included in the weekly email to the on call manager (see handbook for further information). Level 2 indicates that severe weather is forecast and the on call person will be notified through the weekly email. The response to severe weather is activated during level 3 or level 4 for hot, cold or extreme weather situations. (Please see section 3.4 of handbook for detail of level 2) Level 3 Response to heatwave or severe winter weather currently occurring.

Winter - mean temperature of 2°C or less and/or widespread ice and heavy snow Heatwave – threshold is 30°C during the day and 15°C at night

Be aware of a possible surge in demand during and following cold spell. Ensure staff are aware of risks.

• continue to communicate public health media messages • communicate alerts to staff and make sure that winter plans are in operation • ensure key partners are undertaking action in response to alerts • support local community organisations to mobilise community emergency plans • ensure continuity arrangements are working with provider organisations • work with partner agencies (e.g. transport) to ensure road and pavement gritting

arrangements are in effect to allow access to critical services and pedestrian hotspots

Level 4 Major incident – Emergency response - Central Government will declare a Level 4 alert in the event of severe or prolonged cold weather or heatwave affecting sectors other than health NATIONAL EMERGENCY Continue actions as per Level 3 unless advised to the contrary Implementation of national emergency response arrangements by central govt Central government will declare a Level 4 alert in the event of severe weather affecting sectors other than health and if requiring coordinated multi-agency

Where a major incident is declared, instructions will be provided to the CCG on call manager by the NHS England North Midlands (Derbyshire/Nottinghamshire) 1st On Call and/or from the Strategic or Tactical Co-ordinating Groups. (In a situation where CCG staff are unable to access their offices, they are required to re-locate to other premises, as per business continuity plan.)


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Action Card 6

Systems Outage and Building Incidents

Description

The CCG on call manager may be contacted to help with an unexpected systems outage or building incident.

In all cases, staff in local providers should consult their business continuity plans which will include building specific security and facilities management and telephony and IT contact numbers.

NHS Property Services cover on call for Community Health Partnerships (not to be confused with CHP – County Health Partnerships) and lift buildings.


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Action Card 7

Out of Hours Cascade of Urgent Information

Description

There may be situations where NHS England require urgent information to be cascaded out of hours. In these situations NHS England North Midlands (Derbyshire/Nottinghamshire) 1st on call manager will be contacted by the national or regional on call manager. They will in turn contact the CCG on call manager to support the process.


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Action Card 8

High Cost Patient Transfers (Arriva)

Description

Arriva have a financial limit of £250 for high cost journeys. Any journeys above this amount must receive authorisation from a CCG. During working hours authorisation will be provided by NHS Mansfield and Ashfield or NHS Nottingham City CCG. Out of hours authorisation will be provided through the on-call rota in order to ensure that transfers are not delayed.


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Action Card 9

Approval of Additional Patient Transport Services

Description

To date NUH have been using Ambicorp to provide additional capacity for ambulance patient transport services when Arriva is unable to meet demand. Although Arriva is contracted to provide the services, NUH have been defaulting to Ambicorp resulting in commissioners paying twice and incurring additional costs. In order to manage the costs and ensure that services are being used efficiently and as contracted, commissioners are no longer paying for Ambicorp. Also, there is an obligation for Arriva to cover Ambicorp costs where they are asking NUH to book additional resource. Out of hours authorisation may be requested and it is important that all factors have been taken into consideration by the providers including NUH and Arriva. The action card includes relevant questions to ask prior to approval of any additional resource. This is different to high cost journeys which is covered in Action Card 8. Although relevant to NUH, this action card can be used if SFHFT is asking for additional patient transport services.


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Monday- Friday 1900-2300, Saturday 1600-2300 and Sunday 0700-2300

Leicester Control 0117 943 9990

Monday – Sunday 2300-0700

Bristol Control 0117 943 9910/ 0117 943 9911

*Key √ = Yes X = no ? = Information awaited N/A = Not applicable


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PAGE LEFT INTENTIONALLY BLANK


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Action Card 10

Blue Light Protocol

Description

The Nottinghamshire Healthcare NHS Foundation Trust Bronze On-Call will chair the process out of hours and report to the CCG on call manager. (Further detail is in section 3.5 of the handbook and appendix 7)

This protocol relates to people of all ages with learning disabilities and/or autism who are at risk of admission to a specialist learning disability or mental health inpatient service who display challenging behaviour.

The Nottinghamshire Healthcare NHS Foundation Trust, as Chair of the process (and commissioner of the bed) are required to have an admission gateway process so that where a planned or unplanned admission to hospital is considered for someone with a learning disability and/ or autism, a challenge process is in place to check and provide evidence that there is no available alternative for the individual.

The aim of the ‘Blue Light’ Protocol is to provide the Trust with a set of prompts and questions to prevent people being admitted unnecessarily into inpatient learning disability and mental health hospital beds.

The Nottinghamshire Healthcare NHS Foundation Trust Bronze on-call manager will speak to the relevant stakeholders (as detailed in the protocol) to establish the following:

What is the reason for considering admission?

Have alternatives to admission been explored?

Does the person require admission to hospital or are there other alternatives that might meet the patient’s needs?

Is there anything preventing appropriate support being implemented in the community?

Is there a clear aim for the treatment required in hospital/what are the expected outcomes?

If the person requires admission, have people thought about discharge planning?

The Chair will arrange a conference call, including with the CCG on-call. The call will cover:

The chair is made known to everyone on the conference call and they summarise the current situation.

Understanding the person. The needs & wishes of the person are identified by the family and the individual, relevant carers, or clinicians.

All current risks are identified.

Care and treatment needs. Options considered (see preference list below).

Current resources and potential resources available are identified.

The best course of action is decided on; a support plan agreed with responsible people to follow up identified.

The role of the on-call CCG manager is to:

Identify any barriers of a commissioning nature that are preventing the patient being

cared for in the community.

Satisfy themselves that the outcome of the review will result in the patient being

cared for in the least restrictive environment.

Ensure that any recommendations are communicated appropriately to colleagues within the CCG (details are included in the protocol).


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Action Card 11

Death in a GP Practice (south Nottinghamshire)

Description

In the event that a patient dies in a GP practice, a checklist has been developed for the practice to work through. The steps are as follows:

1. Contact the police Using 101, non-emergency number.

2. Inform the CCG In hours contact a member of the CCG’s Quality Team via the PA to the Quality Team on

0115 8831752

Out of hours contact the CCG’s ‘on call’ Director via: 03004564957

3. Informing the coroner Nottinghamshire Police are the coroner’s agents for reporting and investigating deaths -

Ensure that they have informed the coroner of the death.

4. Inform the CQC A ‘Death of a person using the service’ Statutory Notification must be completed via:

http://www.cqc.org.uk/content/notifications-gp-providers#hide2 This must be submitted ‘as

quickly as possible after the death’. The CQC will review and decide on whether any follow

up (eg. a telephone call / visit to the practice) is necessary. In addition to describing the

incident and what actions were taken, the practice should reference how they have

supported their staff after the incident, and how they plan to review / share the Significant

Event findings and actions.

5. Complete Significant Event paperwork Complete a Significant Event report identifying actions taken during the event

6. Electronic Palliative Care Coordination Systems (EPaCCS) Update EPaCCS if appropriate.

7. Inform NHS England Via email, to the Responsible Officer at: [email protected]

8. Debrief practice staff Ensure staff are debriefed / supported appropriately.

9. Check lease If in rented premises check lease and any requirements to report a death on site.

10. Present Significant Event Present the SE at a practice meeting to share learning and feedback to staff.

11. Significant Event Learning Consider whether there is any learning to share with other colleagues and practices.

.


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FORMS


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REFERENCE PACK

1.0 Introduction

The purpose of this document is as a reference document for CCG senior managers who cover the on call procedures for the south and mid Nottinghamshire Clinical Commissioning Groups (CCGs). The handbook will be utilised by NHS Bassetlaw CCG as relevant.

CCGs are designated as Category 2 responders under the Civil Contingencies Act, and in doing so become ‘co-operating bodies’. Responsibilities are defined as co-operating and sharing relevant information with Category 1 responders i.e. Police, Fire & Rescue Service, Local Authorities and NHS England.

On a day to day basis the on call rota provides an escalation procedure relevant to the health economy and CCG responsibilities. As such, CCGs must have a robust escalation procedure so that should a commissioned NHS-funded provider have a problem (rather than an immediate major incident), the locally-agreed route for escalation would be via the CCGs. Escalation would either be directly as per the handbook or through other dedicated escalation plans, integrating with emergency planning and response.

The handbook provides an overview of the emergency response structure and procedures. Action cards are included in the handbook in relation to category 2 responses. These are separate cards that can be used as reference documents by on-call managers.

The handbook covers all responsibilities of CCGs but may not cover all calls due to the complexity of the health economy. A directory is provided and on call managers are recommended to follow the most similar action card where a scenario is not directly covered.

As a category 2 responder, the CCGs provide the commissioned providers with a route of escalation 24/7 such that business as usual pressures and minor incidents can be managed so that they do not become significant incidents or emergencies.

Appendix 6 covers the escalation and de-escalation for the NHS.

2.0 On Call Structure

2.1 Clinical Commissioning Groups

CCGs are category 2 responders. The on call managers and responsibilities are covered based on south Nottinghamshire, including NHS Nottingham University Hospitals NHS Trust and mid Nottinghamshire, including Sherwood Forest Hospitals Foundation NHS Trust. The on call arrangements apply 24 hours a day and will integrate with other plans and processes, as relevant, in order that efficiencies are assured. As such, it is important that processes during normal working hours include handovers to the on call rota.

The types of calls that the CCG on call would be expected to deal with are as follows:

111 service pressures

Emergency Department pressures

Ambulance divert requests

Patient handover delays


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Requests for additional resources by an NHS funded provider as a result of a local incident

Business continuity issues impacting commissioned services A description and the action cards for each of the above events are provided in the go to Action Cards at the front of the Reference Pack. The contact details and action cards can be printed separately in order to have the action cards to hand when on call.

Other areas where category 2 responders could be directly involved include:

Single agency critical incident

NHS England North Midlands (Derbyshire/Nottinghamshire) initiated major incident

Health protection incidents and outbreaks

The on call rotas run for the full week from Monday 09:00 to the following Monday at 09:00. The on call rota includes a CCG manager for the south and for Mid Notts Any individual requiring the CCG on call manager will contact NEMS, via their single point of access service on 0300 456 4957, requesting the manager relevant to the provider or location, depending on whether south or Mid Notts.

2.2 NHS England North Midlands (Derbyshire/Nottinghamshire)

The NHS England North Midlands (Derbyshire/Nottinghamshire) is a category 1 responder. This responsibility means that there are a number of specific duties which need to be carried out in planning for and the response phase to an emergency.

The key responsibilities are:

ACCOUNTABLE for the assurance of the resilience of the local NHS and its commissioned healthcare services

COORDINATION of the health response to Major Incidents in Derbyshire and Nottinghamshire

RECEIVE major incident activations and information from EMAS and other Category 1 and 2 responders

CASCADE information relating to incidents relevant to all Derbyshire and/or Nottinghamshire NHS organisations plus all relevant healthcare providers

Although the final two responsibilities will on the whole be discharged by the EPRR Team for NHS England North Midlands (Derbyshire/Nottinghamshire), during the out of hours periods, weekends and bank holidays this will become the responsibility of NHS England North Midlands (Derbyshire/Nottinghamshire) On Call Director in the first instance but may require support from the CCG On Call Manager. See section 4 for incidents.


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2.3 CCG Business Continuity Plans

CCGs are required to have Business Continuity Plans which are separate to the detail in the handbook and responses may link into the on call structure depending on the nature of the incident. The CCG business continuity plans are used to assist in the continuity and recovery of an individual CCG in the event of an unplanned disruption. A disruption could be any event, which threatens personnel, buildings or operational capacity and requires special measures to be taken to restore normal service. The aim of the plans is to set out the roles, responsibilities and actions to be taken by the CCG to enable continuity and recovery of the key parts of the service following a significant disruption.

2.4 Training

An induction is available for all new staff listed on the on call rota. Training will be provided as required. To access what training is available please contact the operations lead for your CCG via: South Nottinghamshire – Sam Marlow – [email protected] Mid Nottinghamshire – Gina Holmes – [email protected]

3.0 On-Call Processes

3.1 General Processes

Both in normal working hours and out of hours it is assumed that most incidents will be managed remotely by telephone and that it should only be necessary for the on call manager to attend the incident scene in exceptional circumstances. Calls will go to NEMS who will establish the appropriate on call manager at the request of the caller. NEMS will provide the on call manager with the name and contact details. In deciding on how to manage an incident, the on call manager will initiate and authorise any urgent action required working with the provider and most senior available members of staff. This may mean escalating to NHS England North Midlands (Derbyshire/Nottinghamshire) which is outlined in the action cards. An on call incident report sheet must be completed in all instances. A copy is provided in forms. Also, the incident report sheet is always attached to the email confirming your on call duties, along with the on call numbers. Completed forms should be emailed as soon as possible to the contact who circulates the weekly on call details. South Nottinghamshire – Sam Marlow – [email protected] Mid Nottinghamshire – Gina Holmes – [email protected]

3.1.1 Communications Support

The on call process is supported by 24/7 communications support. These individuals may be contacted where an incident has potential immediate media interest that cannot wait to be


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addressed on the next working day. Please see CONTACT DETAILS for contact information. Communications support will be able to provide advice over the phone, co-ordinate communications with the media directly, provide a handover and continuity on the next working day.

3.1.2 Legal Support

Legal advice is available 24 hours per day and is provided by Browne Jacobson Solicitors. This cover is provided out of hours by a legal rota. Numbers can be found in CONTACT DETAILS.

3.2 Service Pressures

Service pressures are escalated to the CCG on-call manager when they reach a specific trigger point. This can either be in relation to an individual patient or as a result of system pressures.

The national escalation levels, which are also used locally include the following:

Operational Pressures Escalation Levels OPEL 1 The local health and social care system capacity is such that

organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. The Local A&E Delivery Board area will take any relevant actions and ensure appropriate levels of commissioned services are provided. Additional support is not anticipated.

OPEL 2 The local health and social care system is starting to show signs of pressure. The Local A&E Delivery Board will be required to take focused actions in organisations showing pressure to mitigate the need for further escalation. Enhanced co-ordination and communication will alert the whole system to take appropriate and timely actions to reduce the level of pressure as quickly as possible. Local systems will keep NHS E and NHS I colleagues at sub-regional level informed of any pressures, with detail and frequency to be agreed locally. Any additional support requirements should also be agreed locally if needed.

OPEL 3 The local health and social care system is experiencing major pressures compromising patient flow and continues to increase. Actions taken in OPEL 2 have not succeeded in returning the system to OPEL 1. Further urgent actions are now required across the system by all A&E Delivery Board partners, and increased external support may be required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally. National team will also be informed by DCO/Sub-regional teams through internal reporting mechanisms


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OPEL 4 Pressure in the local health and social care system continues to escalate leaving organisations unable to deliver comprehensive care. There is increased potential for patient care and safety to be compromised. Decisive action must be taken by the Local A&E Delivery Board to recover capacity and ensure patient safety. All available local escalation actions taken, external extensive support and intervention required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally, and will be actively involved in conversations with the system. Where multiple systems in different parts of the country are declaring OPEL 4 for sustained periods of time and there is an impact across local and regional boundaries, national action may be considered.

Local A&E Delivery Board areas will operate Operational Pressures Escalation Level (OPEL) 1 when operating within normal parameters. At OPEL 1 and 2, operations and escalation for on-call is managed as per 4, 8, 10 and 12 hour waits which is in the action card. At OPEL 3 and 4 the A&E Board will hold an urgent meeting and if there are any instructions for the on call manager, these will be communicated from this meeting.

3.3 Public Health

Public Health England (PHE) in the East Midlands co-ordinate the out of hour’s public health on call rota. Their office is based at the Institute of Population Health, Clinical Sciences Building, City Hospital, Hucknall Road, Nottingham NG5 1PB - See CONTACT DETAILS.

EMAS provide the Gateway to access this advice. The 1st on call who responds to your call (who might be a public health trainee or PHE nurse) is able to access further specialist advice from the 2nd on call who is a Consultant in Communicable Disease Control (CCDC) if required. Please note there is only one CCDC on call for the whole of the East Midlands The 3rd on call on the rota is made up of East Midlands Public Health Consultants – their role is to liaise with the relevant NHS England North Midlands Team or other Trusts if further NHS resources are required and also provide additional support to the 1st and 2nd on call In extenuating circumstances the CCG on call manager may be contacted to approve funding, in relation to a single public health incident as commissioners are responsible for funding the provider response.

3.3.1 Communicable Diseases

A communicable disease incident can be defined as any incident involving communicable or infectious disease which presents a real or possible risk to the health of the public and requires urgent investigation and management. An outbreak can be defined as two or more persons with the same disease or symptoms or the same organism isolated from a diagnostic sample, who are linked through common exposure, personal


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characteristics, time or location; A greater than expected rate of infection compared with the usual background rate for the particular population and period.

An action card has not been provided for communicable diseases as it is expected that the majority of incidents or outbreaks will usually be identified through normal working practices undertaken within the Local PHE Acute Response Centre, e.g. following the receipt of disease notifications, enquiries or through the monitoring of routine laboratory data or quarterly surveillance data.

Any action through the on-call rota will be managed through a major incident and the Local Resilience Forum. CCGs will engage in relation to what needs to be commissioned, supporting NHS England and resilience response, communication messages from NHS England.

Whilst not all incidents involving communicable diseases will require a response involving the whole of the local health community, the Local Health Resilience Partnership (LHRP) is an appropriate forum to plan and agree these response arrangements. It provides strong links to organisations within the local public health network and an opportunity to align response arrangements with more generic major incident plans.

The Community Risk Register includes four major risk areas relating to communicable disease outbreaks that individual LRFs use to assess their local risk and control measures. These are:

• Influenza type disease (pandemic) • Emerging infectious diseases • Localised outbreak of infectious disease • Biological substance released from facility where pathogens are handled.

The key funding streams are as follows: • NHS commissioned services: the funding stream is through the NHS Mandate and the

allocations to direct commissioning functions and CCGs, and through the Section 7A. These allocations fund contracts with NHS providers to deliver their element of the incident response.

• LA commissioned services: the funding streams are the core local authority budget for the environmental health and other teams, and the Public Health Grant that is allocated to each upper tier local authority, which is ring-fenced at least until 2015-16. This allocation funds the local authority’s public health team and contracts with providers to deliver their element of the incident response.

• Public Health England: the local specialist health protection and public health microbiology services are funded through the “grant in aid” funding provided to the Agency.

In practice the funding at local level of clinical interventions whether investigative or curative, is a responsibility of the NHS. NHS England and CCG finance officers will agree an appropriate methodology for sharing costs on a case by case basis from within budget allocations, to support the locally agreed clinical responses. The sharing of more significant costs will be agreed as appropriate, with NHS England Regional and National Finance Directors. NHS providers are required to deliver the response to incidents and outbreaks under the guidance of the incident management team. The need to respond appropriately and in a


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timely manner is part of the NHS Contract. Providers need to ensure that they have suitably qualified and skilled staff to deliver their contribution to the response. In responding to communicable disease incidents and outbreaks, local NHS-funded providers of care are required to:

• Collaborate with multi-agency partners, including Public Health England and the relevant Local Authorities, to facilitate a combined response;

• Activate escalation and service continuity plans as required to manage increases in demand and the risk of disruption;

• Request additional assistance from commissioners under Major Incident clauses as appropriate to the situation and in line with national guidance.

3.4 Weather Alerts

The CCG on call response to weather alerts will be relevant to a surge in demand and therefore the activation of action cards for system pressures will likely be requested. In very severe situations CCGs may be involved in the response to a multi-agency major incident which, depending on circumstances, can be called nationally. An action card has been produced to cover situations relating to business continuity concerns, separate to a surge in demand. CCGs are responsible for ensuring that providers have business continuity plans in place to respond to weather alerts and the risk of a surge in demand. CCGs request assurance from providers and may confirm through the contracting team that plans are being implemented when alerts are received. Individual CCGs have the relevant detail for their own staff in their business continuity plans. It is important that CCG staff are aware of how to take care of themselves in severe weather. CCGs with operational responsibility for the on call rota are signed up to receive met office alerts for hot and cold weather. Alerts are communicated to on-call staff in order to ensure they are aware of the risks impacting on local services. Cold Watch System

A ‘cold weather watch’ system now operates in England from 1 November to 31 March each year. During this period, the Met Office will forecast severe weather and the alerts are published in 4 levels depending on the risk of severe winter weather. Each level provides recommended actions and advice for: health and care services, the voluntary sector and individuals and families.

The 4 levels are:

Level 0 Long-term planning All year

Level 1 Winter preparedness and action programme (1 Nov to 31 March)

Level 2 Severe Weather is forecast – Mean temperature of 2°C and/or widespread ice and heavy snow are predicted within 48 hours, with 60% confidence • continue to communicate public health media messages • communicate alerts to staff and make sure that they can take appropriate actions • ensure key partners, including all managers of care, residential and nursing homes, are


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aware of the alerts • and can access Department of Health and other advice • ensure that organisations and staff are prompted to signpost vulnerable clients onwards

(eg for energy • efficiency measures, benefits or related advice) • support local community organisations to activate community emergency plans • activate business continuity arrangements and emergency plans as required • consider how to make best use of available capacity, for example by using community

beds for at-risk • patients who do not need an acute bed and enabling access to step-down care and

reablement • work with partner agencies (eg transport) to ensure road/ pavement gritting preparations

are in place • to allow access to critical services and pedestrian hotspots

Level 3 Response to severe winter weather - Severe winter weather is now occurring: mean temperature of 2°C or less and/or widespread ice and heavy snow

Be aware of a possible surge in demand during and following cold spell. Ensure staff are aware of risks.

• continue to communicate public health media messages • communicate alerts to staff and make sure that winter plans are in operation • ensure key partners are undertaking action in response to alerts • support local community organisations to mobilise community emergency plans • ensure continuity arrangements are working with provider organisations • work with partner agencies (eg transport) to ensure road and pavement gritting

arrangements • are in effect to allow access to critical services and pedestrian hotspots

Level 4 Major incident – Emergency response Central Government will declare a Level 4 alert in the event of severe or prolonged cold weather affecting sectors other than health NATIONAL EMERGENCY Continue actions as per Level 3 unless advised to the contrary Central government will declare a Level 4 alert in the event of severe weather affecting sectors other than health and if requiring coordinated multi-agency

For more detailed information on the cold weather plan go to https://www.gov.uk/government/publications/cold-weather-plan-for-england-2014

Heatwave Alerts

A ‘Heat Health Watch’ system operates in England from 1 June to 15 September each year. During this period, the Met Office may forecast severe heatwaves, as defined by day and night time temperatures and duration.

Level 0 Long-term planning All year

Level 1 Heatwave and Summer preparedness programme 1 June – 15 September

Level 2 Heatwave is forecast – Alert and readiness 60% risk of heatwave in the next 2–3 days average threshold temperature is 30ºC during the day and 15ºC overnight. Communicate public media messages – especially to ‘hard to reach’ vulnerable groups Communicate alerts to staff and make sure that they are aware of heatwave plans


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Implement Business Continuity Increase advice to health and social care workers working in community, care homes and hospitals

Level 3 Heatwave Action Temperature reached in one or more Met Office National Severe Weather Warning Service regions Media alerts about keeping cool Support organisations to reduce unnecessary travel Review safety of public events Mobilise community and voluntary support

Level 4 Major incident – Emergency response Central Government will declare a Level 4 alert in the event of severe or prolonged heatwave affecting sectors other than health

NATIONAL EMERGENCY Continue actions as per Level 3 unless advised to the contrary Central government will declare a Level 4 alert in the event of severe or prolonged heatwave affecting sectors other than health and if requiring coordinated multi-agency

3.5 Blue Light Protocol

The ‘Blue Light’ meeting offers the commissioner advice, steps and prompts to help avoid unnecessary admissions of people with learning disabilities. It recognises that where an admission request is at very short notice it is not always practical to set up a full Care and Treatment Review. A meeting, possibly by teleconference, should be set up to engage the person their family and all those around the individual to think creatively about what alternative supports and interventions could be put in place. The aims are to:

Ensure that people with learning disabilities or autism are not admitted unnecessarily into inpatient learning disability and mental health hospital beds

Help identify barriers to supporting the individual to remain in the community

Make clear and constructive recommendations as to how these barriers could be overcome.

To produce a report (see Appendix 7) to be shared with all relevant stakeholders reflecting key details, outcomes and recommendations with details of those that took part.

Adverse and confounding effects on assessment of the hospital environment and the potential trauma of the process to the individual and their family must be taken into account. Planning for discharge and robust commitments to returning home or being clear why this would not be the right discharge plan should be firmly established and documented prior to admission. Admissions for assessment and treatment should not be used as ‘step-down’ or intermediate placement while planning longer-term community support. Hospitals should only be used when not to do so would place the individual or others at risk of significant physical, emotional or psychological harm. This should be based on a


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comprehensive risk assessment by a multidisciplinary health and social care team, adhering to locally agreed protocols, within the context of all appropriate legal and procedural frameworks. The risk assessment process should reflect levels of evidenced risk, and must seek to balance the safety needs of local communities against the rights and freedoms of the individual. Consent The blue light protocol and any related recording or disclosure of personal information will be with the explicit consent of the individual (or when appropriate someone with parental responsibility for them). If the person lacks capacity, a best interest’s decision making process under the Mental Capacity Act 2005 should be carried out unless they have a representative with lasting power of attorney for health and wellbeing that can make the decision on their behalf. Preference of support arrangements are as follows: 1st preference Support the person to remain at home. Funding for additional support will be considered favourably by commissioners where this avoids the person having to leave home. 2nd preference The person is supported in a local non-inpatient unit, using residential nursing care, or short breaks services (an option where a person already accesses short breaks). 3rd preference An appropriate local inpatient service in the CCG area. Consideration should be given as to whether the person’s needs can be met within acute mental health services or whether they could only be met in a specialist LD unit. Out of area placements should be avoided due to the long term impact of this. If an out of area placement is suggested it needs to be approved by the NHS commissioner in line with the contracting process and would only ever be considered when the move is justified by clinical need and / or risk management and all other avenues have been exhausted. Where it is agreed, it should be clearly time limited from the outset. Any gaps in local health or social care services should be reported to the relevant commissioner if the person’s needs cannot be met locally. power of attorney for health and wellbeing that can make the decision on their behalf. 5.2 Confidential information can be recorded and shared to help a child or young person who is or may be at risk of harm, or an adult who is or may be at risk of offending or of suffering harm or loss from their offending behaviour. The information recorded or shared should be in proportion to the risk in each case and a record made of the basis of the judgement. Patients or their advocates will be provided with details of who will have access to their data and the purposes it will be used for, with appropriate support offered to address any questions.


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4.0 Incidents

4.1 Incident Classifications

For the NHS, incidents are classed as either:

Business Continuity Incident

Critical Incident

Major Incident Each will impact upon service delivery within the NHS, may undermine public confidence and require contingency plans to be implemented. NHS organisations should be confident of the severity of any incident that may warrant a major incident declaration, particularly where this may be due to internal capacity pressures, if a critical incident has not been raised

previously through the appropriate local escalation procedure. Business Continuity Incident A business continuity incident is an event or occurrence that disrupts, or might disrupt, an organisation’s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed) Critical Incident A critical incident is any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions. Major Incident A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented. For the NHS this will include any event defined as an emergency as follows: “(a) an event or situation which threatens serious damage to human welfare in a place in the United Kingdom; (b) an event or situation which threatens serious damage to the environment of a place in the United Kingdom; (c) war, or terrorism, which threatens serious damage to the security of the United Kingdom”.


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Hazardous materials (HAZMAT) – accidental incident involving hazardous materials

Cyber attacks – attacks on systems to cause disruption and reputational and financial damage. Attacks may be on infrastructure or data confidentiality

Mass casualty – typically events with casualties in the 100s where the normal major incident response must be augmented with extraordinary measures

4.4. Response Structure

Major incidents are co-ordinated through Strategic and Tactical co-ordinating groups. The CCG on call or an Accountable Emergency Officer may be asked to command a tactical group. CCGs may also be asked to attend the strategic co-ordinating group and instructions for the strategic group will be provided by NHS England.

NHS England will assist CCGs in implementing command and control mechanisms and the deployment of appropriate NHS resources should the response extend beyond the operational area of a single CCG.

4.4.1 Tactical – CCG or NHS England

The purpose of the tactical level is to ensure that the actions taken by the operational level are coordinated, coherent and integrated in order to achieve maximum effectiveness, efficiency and desired outcomes. Where formal coordination is required at tactical level then a TCG may be convened with multi-agency partners within the area of operations. The tactical commanders will:

Determine priorities for allocating available resources

Plan and coordinate how and when tasks will be undertaken

Obtain additional resources if required

Assess significant risks and use this to inform tasking of operational commanders

Ensure the health and safety of the public and personnel The tactical commanders must ensure that the operational commanders have the means, direction and coordination to deliver successful outcomes. The NHS tactical commander at the TCG will be identified and agreed by NHS England in consultation with the CCG. They will ensure that all NHS service providers are coordinated through health economy tactical coordination groups. Where it becomes clear that resources, expertise or coordination are required beyond the capacity of the tactical level it may be necessary to invoke the strategic level of management to take overall command and set the strategic direction.

4.4.2 Strategic – NHS England

The purpose of the strategic level is to consider the incident in its wider context; determine longer-term and wider impacts and risks with strategic implications; define and communicate the overarching strategy and objectives for the response; establish the framework, policy


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and parameters for lower level tiers; and monitor the context, risks, impacts and progress towards defined objectives. Where an event or situation has a particularly significant impact; substantial resource implications, or lasts for an extended duration it may be necessary to convene a multi-agency coordinating group at the strategic level bringing together the strategic commanders from relevant organisations. This group is known as the SCG. The SCG does not have the collective authority to issue commands to individual responder agencies; each will retain its own command authority, defined responsibilities and will exercise control of its own operations in the normal way. The NHS strategic commander at the SCG will be identified and agreed by NHS England in consultation with the CCG(s) and empowered to make executive decisions on behalf of the NHS. In addition the NHS ambulance service(s) will be present in their role as an emergency service. The purpose of the SCG is to take overall responsibility for the multi-agency management of the incident and to establish the policy and strategic framework within which lower tier command and coordinating groups will work. The SCG will:

Determine and promulgate a clear strategic aim and objectives and review them regularly

Establish a policy framework for the overall management of the event or situation

Prioritise the requirements of the tactical tier and allocate personnel and resources accordingly

Formulate and implement media-handling and public communication plans

Direct planning and operations beyond the immediate response in order to facilitate the recovery process

For incidents across multiple SCG areas then NHS England regional and national teams, as appropriate, will undertake command, control and coordination of the NHS and will be responsible for appropriate representation to regional and central coordination structures and groups.

4.4.3 Incident Command Centre (ICC)

While the specific activities undertaken by the ICC will be dictated by the unique demands of the situation, there are five broad tasks typical of ICCs:

Coordination – matching capabilities to demands

Policy making – decisions pertaining to the response

Operations – managing as required to directly meet the demands of the incident

Information gathering – determining the nature and extent of the incident ensuring shared situational awareness

Dispersing public information – informing the community, news media and partner organisations


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NHS England North Midlands (Derbyshire/Nottinghamshire) ICC Locations

Birch House

Ransom Wood Business Park, Southwell Road West, Mansfield, Notts. NG21 OHJ

NHS England North Midlands (Derbyshire/Nottinghamshire) ICC will meet at either Birch House or Cardinal Square. The CCG on call manager will be provided with details of the time and location by NEMS. The CCG on call manager will be required to bring the following items to the Incident Control Room:

Mobile Phone

Mobile Phone Charger

Laptop/PDA with power supply

List of contact numbers

Personal items i.e. medication, money

ID badge

The CCG on call manager may be nominated to attend a multi-agency tactical or strategic co-ordination group. The Multi-Agency Co-ordination centres are as follows:

Multi- Agency Co-ordination Centres

Highfields Fire Station

(Nottinghamshire Fire Service)

Hassocks Lane Beeston Nottingham NG9 2GQ Tel: 0115 957 5200

Nottinghamshire Police Headquarters Sherwood Lodge Arnold Nottingham NG5 8PP NB: Mobile coverage is poor so call Force Control Room if unable to contact anyone on 0115 967 0111

Nottinghamshire Fire Headquarters Bestwood Lodge Arnold Nottingham NG5 8PD Tel: 0115 967 0880

4.4.4 Accessing Medicines in an Emergency

In emergency situations such as fires and flooding etc. residents and members of the public may be evacuated at short or no notice to a place of safety or a local authority rest centre.


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Wherever possible the emergency services will attempt to ensure that people being evacuated bring with them any essential items including any regular medication they may require. However it is not always possible to achieve this for a number of reasons including the urgency of the evacuation. NHS on call teams will need to assist the Local Authority and emergency services in obtaining assistance with medication for persons being sheltered who may not have access to their own medication. See Appendix 3 for further information.

4.4.5 Chemical, Biological, Radioactive, Nuclear Materials (CBRN)

Following the terrorist attacks in the USA in 2001, the four UK Health Departments agreed to establish stockpiles of drugs and equipment that are placed at strategic locations within England, Scotland, Wales and Northern Ireland. The stockpiles would be used for mutual support in the event of a deliberate or accidental release of CBRN materials.

In all instances access to the stockpile is required; the NHS England National EPRR Duty Officer is to be informed through normal escalation channels.

Appendix 2 details how to access pods and injections in the event of poisoning or botulism as a major incident ie 90 people plus.


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Appendix 1 – Ambulance Divert Checklist

Ambulance Divert Escalation Checklist

The requesting acute trust will complete the following checklist prior to contacting the CCG on call manager. The actions on the checklist are to be implemented as early as possible as pressure starts to build, in order to try to minimise the need for a diversion of inbound patients. Actions should be taken, as far as reasonably practicable, before the Requesting Acute Trust contacts the Ambulance Trust to request a divert

Escalation Activity

Health system actions

The health system supports triage of GP patients for admission and all alternative pathways are reviewed.

Emergency Department (ED) bed meetings to include Health & Social Care partners to ensure all actions are understood by the whole health-care system.

Acute Trust – managing and reducing demand

Before requesting a full divert – all internal surge and escalation actions are to be in place

There should be senior clinical leadership (i.e. consultant level) immediately available within the ED

Patients to have initial assessment by registrar or consultant grade, to determine

appropriateness of attendance or need for admission/re-direction wherever possible and not life

threatening, all admissions to be reviewed and agreed by a consultant.

Maximisation of alternative care pathways, prior to arrival of patient at ED through telephone

triage of all GP referrals for admission, led by consultants (i.e. acute physicians, not necessarily

ED consultants – see above) to ensure that admission levels are kept to a minimum, including:

Advising on more appropriate care pathways (i.e. community based) for specific patients or conditions.

Enabling access to diagnostics not normally directly available to primary care.

Support to GPs who have patients on “care of the dying”, pathways to prevent unnecessary admissions.

Brokering urgent Out Patient Department appointments to avoid unnecessary admissions to hospital etc.

Acute Trust – improving supply

Before requesting a Full Divert all internal surge and escalation actions are to be in place

All routine escalation actions should be completed including

Inpatients reviewed early in the morning for discharge by consultants before 10am.

“Case conferences” between specialists such as consultants, medical directors, managerial staff etc. to review inpatients and agree appropriateness of continued stay.

Opening of all possible extra escalation capacity, private wards etc.

Cancellation of all clinically non urgent electives (including private work)

Cancellation / redirection of urgent electives / move of work to other NHS trusts / transfer of work to private sector.

Social Services on call managers have been notified of the situation and requested to expedite care packages. Social Services to be in contact several times a day.


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Ambulance Full Divert Checklist

Date/Time

Name of Hospital Trust requesting

Divert

(The “Requesting Hospital”)

Name and contact information of

person requesting the divert/closure &

confirmation that they are a Director

from the Requesting Hospital

Escalation Actions Checklist received

& completed (Y/N)

Reason(s) for the requested divert

Estimated duration of the divert (confirm

the time up to which the divert will operate)

Detail what departments are effected (i.e.

A&E or Maternity) This may include the

types of patient/s to be diverted i.e. GP

diverts, minor injury/illness, trauma,

maternity etc.

Teleconference details Dial-in:

Participant Code:

Confirmation that following have been contacted:

Receiving Hospital(s) Director On-Call

CCG Director On-Call

For Ambulance Service

Agreement reached with CCG / NHS England North Midlands (Derbyshire/Nottinghamshire) 1

st On Call

Duration of diversion (time up to which the divert will operate) Confirmed communication system with requesting trust & schedule of updates Neighbouring Ambulance Services notified (if applicable)

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Appendix 2 – National Stock Medications

UK Reserve National Stock for Major Incidents – How to Access Stock

A. NHS Trusts, NHS Foundation Trusts and NHS England Regional Teams should access the following items by contacting their local NHS Ambulance Service Trust Emergency Control Room 1. Nerve agent antidote pod – for treatment of nerve agent poisoning (90 people). 2. Obidoxime injection – further treatment for nerve agent poisoning. 3. Dicobalt edetate pod – for treatment of cyanide poisoning (90 people). 4. Botulinum antitoxin – for treatment of botulism. NHS Ambulance Services in England either initiating their own requests or responding to requests from NHS Trusts, NHS Foundation Trusts or NHS England Regional Teams should contact NHS Blood and Transplant as follows: Primary number: 0208 201 3827 Secondary number: 0845 850 0911 The NHS England EPRR Duty Officer must be informed via 0844 822 2888 and ask for ‘NHS 05’ B. NHS Trusts, NHS Foundation Trusts and NHS England Regional Teams should access the following items through the NHS England EPRR Duty Officer: Primary number: 0844 822 2888 ask for ‘NHS 05’ Secondary number: 0845 000 5555 Callers should clearly give the details of the incident, the number of pods requested and their contact details 1. Antibiotic pods (oral ciprofloxacin) – three types of pod available To treat 250 adults and children aged 12 years and above (using 500mg tablets), or 250 children aged 8-less than 12 years (using 250mg tablets) or 50 children aged 0-less than 8 years (using 250mg suspension), for 10 days, with post exposure prophylaxis for anthrax, plague or tularaemia. High quality care for all, now and for future generations 2. Further stocks of unpodded oral ciprofloxacin and doxycycline To treat post exposure prophylaxis for anthrax, plague or tularaemia. 3. Ciprofloxacin intravenous injection For post exposure treatment of anthrax, plague or tularaemia. 4. Gentamicin intravenous/intramuscular injection

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For post exposure treatment of plague. 5. Potassium iodate tablets To block the uptake of radioactive iodine, plus information leaflets for the public. 6. Prussian blue capsules For the treatment of thallium and caesium poisoning. 7. Naloxone injection For the treatment of opioid poisoning. The decision to request any of these medical supplies should be made in consultation with the Health Protection Consultant from the local Public Health England (PHE) Centre and/or the local Director of Public Health

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Appendix 3 – Assessing Medicines in an Emergency

Derbyshire and Nottinghamshire Local Health Resilience Partnerships

Accessing Medicines in an Emergency

Introduction In emergency situations such as fires and flooding etc. residents and members of the public may be evacuated at short or no notice to a place of safety or a local authority rest centre. Wherever possible the emergency services will attempt to ensure that people being evacuated bring with them any essential items including any regular medication they may require. However it is not always possible to achieve this for a number of reasons including the urgency of the evacuation. NHS on call teams will need to assist the Local Authority and emergency services in obtaining assistance with medication for persons being sheltered who may not have access to their own medication. Critical Medications Below is an example of a list of drugs that are considered critical and should not normally be omitted. All should be reviewed by the GP who will decide if an urgent prescription is required. This list is not exhaustive.

Anti-coagulants -prophylaxis and treatment

(enoxaparin, heparin, warfarin, rivaroxaban, apixaban, dabigatran, phenindione nicoumalone (acenocoumarol))

Medication taken to control epilepsy

Anti-infectives

(Antibiotics, Antivirals, Antifungals, Antiretrovirals, Antimalarials , MRSA decolonisation)

Anti-parkinson medicines

Insulin

Inhalers / Nebulisers

Steroids (oral and parenteral)

Strong opioids prescribed regularly for acute or chronic pain. As a guide, all other drugs should also be given as close as possible to the prescribed time for urgent medication. (Note many medications prescribed to patients are safe to be taken the next day and wouldn’t require an urgent out of hours prescription.)

Options Each option will require either a medical assessment of the patient or access to the patients records via GP systems, Pharmacy records or Summary Care records. A range of options for obtaining a solution are available and some of these will depend on the time of day and local availability. The following are considered to be the range of

solutions available within the local communities:

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Level Time of day Facilities’ available

Actions

1 Mon – Fri 0830-1800hrs

Patients own GP surgery available to assist and issue prescription

Community Pharmacies open and able to process a prescription

Own GP to be contacted for prescription to be processed by Community Pharmacy

2 Mon – Sun Evenings and weekends (up to 0000hrs weekdays & Sat + 1700hrs Sun.)

Patients own GP closed

Extended hours pharmacies open

OOH GP services and WIC able to assist with seeing patients and issuing prescriptions

OOH GP or WIC assesses patient or accesses notes and issues urgent prescription. Either local or extended hour’s pharmacy issues prescription.

3 Outside above times e.g. Overnight and Sun 1700hrs – 0830hrs Mon.

Patients own GP closed and Community Pharmacies closed.

OOH GP Services and WICs able to assist and issue prescription.

Hospital Pharmacies able to process urgent prescriptions via on call pharmacy arrangements.

Cross borders patients e.g. those away from home

OOH GP or WIC assesses patient or accesses notes and issues prescription. By arrangement on call Pharmacist at hospital contacted to dispense prescription

4 In or out of Hours widespread incident requiring co-ordination

For widespread incidents e.g. Flooding affecting whole communities Co-ordination will be required by NHS on call teams to involve GP’s, Community Pharmacies and Hospital pharmacies dependent on scale of issue.

NHS England on call to co-ordinate availability of resources with all providers.

Contact to access details for Pharmacy provision will be via NHS England on call

Liaison will be required with Emergency Services on scene and Local Authority representatives at Rest Centres etc.

All options will be considered but priority will be given to resolve the issue using the patients normal GP and Pharmacy arrangements

The use of Hospital Pharmacies should be limited to urgent requests post-midnight and when all other options have been exhausted.

Wherever possible patients who are not exempt prescription charges, should pay the prescription fee. However arrangements are in place with NHS England for up to 5 days emergency supply of medicines.

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Appendix 4 – Regional Winter Resilience Room

NHS ENGLAND

NORTH MIDLANDS

REGIONAL WINTER RESILIENCE ROOM

OPERATING PROCEDURES

CCG Explanatory Note

Introduction 1.1 The national Tripartite has agreed a model for closer working through winter to

ensure that that there is a shared understanding of the pressures within local

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systems and that actions are being taken locally to address these issues. This process will be managed by the establishment of winter resilience rooms (national and regional), jointly staffed by NHS England and NHS Improvement to pick up issues, maintain up to date information and help ensure system grip.

1.2 The Midlands & East Regional Winter Resilience Room will be opened on 14 December 2015 and will operate until February 2016. Full mobilisation of winter rooms will be from the 21 December 2015 to 15 January 2016. The winter resilience rooms will operate during in-hours office periods anticipated to be c09.00 – 17.30hrs and will hand over to on-call during out of hours and weekend/bank holiday periods.

1.3 Under ‘normal’ escalation conditions, the overall purpose of winter resilience rooms will be to:

• Enable analysis and pooling of up-to date information across NHS England/NHS Improvement and local government which can be readily accessed for tripartite system management

• Provide enhanced information flows between national, regional and local tripartites.

• Act as a focal point for winter briefings, escalation discussions and communications through the winter.

1.4 Under ‘elevated’ escalation conditions, following discussion between tripartite partners, winter resilience rooms at each level will be manned from rotas agreed by tripartite partners to co-ordinate the management of emerging situations. The rooms will revert to ‘normal’ state once a situation is under control, again by agreement between tripartite partners.

Escalation Thresholds and Reporting

1.5 Rising winter pressures will be managed through the winter resilience arrangements as outlined. These have been established to support system resilience group (SRG) partners across local systems to act together to relieve building pressures, where possible, before they escalate to a level where they trigger a response that meets the definitions and levels in the EPRR Framework (Annex A). In circumstances where pressure continues and a significant risk of escalation is identified, the arms-length bodies will support providers and commissioners as they determine the best course of action. This may be to declare an incident to allow the organisation(s) to invoke all measures necessary to respond to the situation.

1.6 To ensure transparency of operational performance the winter resilience/ EPRR escalation thresholds at Annex A are to be used. The common use of the winter resilience/ EPRR escalation thresholds:

Avoids confusion and duplication.

Is known and understood by systems.

Allows the identification of genuine exceptions.

Are levels that out of hour’s on-call will use.

Are escalation levels which cover all scenarios.

1.7 A standard system of exception reports will be produced by DCO teams for systems at level 2 and above (Annex B) and moderated by joint NHSI/NHSE regional winter rooms for onward submission to the national room each day (Mon-Fri) by 13.00hrs. This allows everyone to assess pressure across the whole system and also allow for

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targeted follow up involving communications and any formal briefings. There will be a need for consistent and concise reporting that covers the following themes:

Hospital demand and issues

Primary care

Out of hours

111

65

ANNEX B WINTER EXCEPTION REPORT TEMPLATE

[Insert date]

Trust name:

System

Resilience

Group name:

Issue/pressure

leading to

escalation:

Trust actions taken

in response:

SRG actions taken in

response:

Timeframes for

mitigating actions:

NHS

England/TDA/Monitor

comments:

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Appendix 6 NHS Escalation and De-escalation

69

previously living?

Who identified the need for

admission?

Include contact details.

What is the reason for considering

inpatient admission?

What would the outcomes be for me

from an admission?

What would the impact of admission

be on me and others around me? (For

example, moving away from home &

the people I know, to a new

environment).

Would this be a re-admission? If so, date of last admission and discharge:

Is the person known to health or social care ?

Is the Mental Health Act (MHA)

applicable?

Has a MHA assessment been

undertaken? If so, what was the

outcome?

Use of the Mental Capacity Act

(MCA)?

Any DoLS (Deprivation of Liberty

Safeguards) in place or needed?

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Appendix 8 – Death in a GP Practice Checklist

Patient Death on Practice Premises Checklist Practice Name: Date of Patient Death:

Action Required:

Timescale Undertaken

(Y/N):

Undertaken

by:

Date: Comments:

12. Contact the police Using 101, non-emergency number.

Immediate

13. Inform the CCG In hours contact a member of the CCG’s Quality Team via the PA to the Quality

Team on 0115 8831752

Out of hours contact the CCG’s ‘on call’ Director via: 03004564957

Within 2

hours

14. Informing the coroner Nottinghamshire Police are the coroner’s agents for reporting and investigating

deaths - Ensure that they have informed the coroner of the death.

Within next

working day

15. Inform the CQC A ‘Death of a person using the service’ Statutory Notification must be completed

via: http://www.cqc.org.uk/content/notifications-gp-providers#hide2 This must be

submitted ‘as quickly as possible after the death’. The CQC will review and decide

on whether any follow up (eg. a telephone call / visit to the practice) is necessary.

In addition to describing the incident and what actions were taken, the practice

should reference how they have supported their staff after the incident, and how

they plan to review / share the Significant Event findings and actions.

Within next

working day

16. Complete Significant Event paperwork Complete a Significant Event report identifying actions taken during the event

Within next

working day

17. Electronic Palliative Care Coordination Systems (EPaCCS) Update EPaCCS if appropriate.

Within next

working day

18. Inform NHS England Within 2

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Via email, to the Responsible Officer at: [email protected] Days

19. Debrief practice staff Ensure staff are debriefed / supported appropriately.

Within 3

Days

20. Check lease If in rented premises check lease and any requirements to report a death on site.

Within 3

Days

21. Present Significant Event Present the SE at a practice meeting to share learning and feedback to staff.

Within 4

Weeks

22. Significant Event Learning Consider whether there is any learning to share with other colleagues and

practices.

Within 4

Weeks

Documents

On-Call Handbook€¦ · On-Call Handbook Version 9.1 May 2017 NHS Mansfield and Ashfield Clinical Commissioning Group NHS Newark and Sherwood Clinical Commissioning Group