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7. Service prioritisation

A key component of surge management is the identification in the pre-pandemic period of essential or priority services in health and social care organisations across all levels of care. This will then allow:

• the potential gain in capacity by deferment of non-essential services to be assessed
• staff training plans and staff deployment plans to be made to support prioritised services
• the impact of service prioritisation on other health and social care organisations to be considered
• any negative impact of service prioritisation on potential service users to be minimised
• optimal utilisation of limited resources during the pandemic.

For example, analysis has suggested that it would be possible to release almost 33% of the total acute bed capacity - over 30,000 acute beds in England - within five to ten days of any decision to cease elective work. This measure will not only increase bed availability but will also release staff. ¹⁹

Figure 6: Effect of stopping elective admissions on bed availability

7.1 The Service Priority Assessment Tool

To facilitate the prioritisation process, a Service Priority Assessment Tool has been developed. It has been designed to aid service providers in the task of service and treatment prioritisation by:

• setting out a range of criteria for the prioritisation of key services
• identifying key interdependencies between services
• identifying alternative or novel methods of service delivery during an influenza pandemic.

In order to facilitate the work of local and regional planners, national organisations (e.g. medical Royal Colleges and their faculties) are being asked to participate in the prioritisation of medical services. The prioritisation of services remains an ongoing process. Current details of services prioritised can be accessed online. ^* Local and regional planners should access the website to obtain the most up-to-date information, which can be adapted to local circumstances. Further details on how to use the tool are given in Appendix 3, and some examples from the College of Emergency Medicine in Appendix 4.

7.1.1 Using the Service Priority Assessment Tool

Prior to a pandemic, regional planners should ensure that they have available a locally agreed matrix of services with possible deferral periods and alternative ways of delivering care. For example, in the secondary care setting, the following issues should have been addressed:

• elective inpatient work which can be deferred during a pandemic
• identification of any elective inpatient work that should be continued if possible
• which non-urgent admissions are essential to prevent subsequent mortality
• which non-urgent outpatient work can be deferred
• any components of long-term outpatient care which need alternative or modified delivery
• mechanism for dealing with urgent new referrals.

Using the Service Prioritisation Assessment Tool, services may readily be grouped into broad categories appropriate to local planning needs, e.g. hospital services could be grouped into those dealing with:

• non-life-threatening conditions with no severe adverse health consequences if delayed
• non-life-threatening conditions with severe adverse consequences anticipated if delayed
• life-threatening conditions.

Using the prioritisation tool, planners should be able to:

• identify services which are prioritised to continue in a pandemic
• consider alternative modes of delivery for these services
• identify strategies to mitigate any negative impact of having to defer services
• identify key resources for delivery of prioritised services, eg blood and blood components
• identify staff available for redeployment to high priority services (from services with a 'low' priority for continuation in an influenza pandemic and other areas including non-priority NHS teaching and research). ²⁰

7.1.2 Service prioritisation interactions

Any decision to reduce or create a service needs to consider the potential impact this may have on other services across the health and social care system. For instance, availability of blood and blood components may impact on both the continuing provision of services and reintroduction of deferred services. ^{21, 22, 23} Therefore, issues of service prioritisation should be considered in conjunction with other changes to the health and social care system which may have to be made in a pandemic, namely

• increasing physical capacity
• altering admission and discharge processes
• restricting the range of treatments offered
• prioritisation of patients for health and social care facilities.

Prioritisation will need to occur in primary and secondary care so that clinicians offering the highest levels of intervention do not become the only clinicians making decisions around clinical priorities.

The interplay between these surge strategies will depend on a range of factors, including the severity of the pandemic, local demand for services and national directives as illustrated in Figure 7. The most stringent measures should be instituted for as short a period as possible, and only when other options have been considered.

In the event of an influenza pandemic in which demand greatly exceeds resources, a major shift in the service provision of the NHS would need to occur. This could result in services that require intensive technological or staff input not being offered, even if prioritised for delivery and potentially life-saving.

Figure 7: The interplay between elements of the surge capacity strategy

7.2 Facility-based plans

Pandemic flu preparations should build on familiar procedures for emergency responses. Previous experience with severe winter pressures may also be useful in developing appropriate plans. The communication of information between providers in the health and social care setting, and to regional and national command and control systems will be critical (Figure 8).

Figure 8: Reporting

Source: Preparing for Pandemic Influenza: Guidance to Local Planners. London: Civil Contingencies Secretariat, Cabinet Office, 2008.
www.ukresilience.gov.uk/pandemicflu/guidance/~/media/assets/
www.ukresilience.info.flu_lrf_guidance1%20pdf.ashx.

It is unlikely that measures such as increasing capacity and prioritising services will be sufficient, on their own, to meet patient demands during an influenza pandemic. Additional measures to control the demand for hospital and community services will be needed (Figure 9, Table 7). Such measures may include:

• prioritisation of patients for access to primary, hospital and critical care facilities
• rapid early discharge
• restrictions on the range of treatments available
• restrictions on some preventive interventions and screening.

The more stringent measures may have profound consequences for patients and should therefore be instituted only when necessary and for as short a period as possible.

Figure 9: Surge strategy components over time

Table 7: Service strategies and actions based on local demand (Adapted with permission from Ontario Health Pandemic Influenza Plan, 2005)

DH: Department of Health, DAs: Devolved Administrations, HPA/S: Health Protection Agency/Health Protection Scotland

PSI (Pandemic Severity Index) is either WHO based, or based on national assessment of the likely impact based on experience in other countries. ²⁴

The local/regional/national decision maker is country-specific; e.g. for England this could be Primary Care Trusts, Strategic Health Authorities and the Department of Health respectively, whereas in Scotland, local decisions would be made at NHS board level and regional decisions at Scottish Government level.

Within facilities, a mechanism is needed whereby information relevant to service prioritisation can be assessed and turned into action. The mechanism for this process is best decided locally, but one way of achieving this is through a 'service prioritisation group'. Roles to enable prioritisation decisions to occur in the facility should be clearly identified to guide appropriate membership of the group. For example, in a general practice, a service prioritisation group might consist of a practice manager, nurse and GP; in an acute hospital, a service prioritisation group might have representation from senior management including operational delivery, medical, nursing and pharmacy staff, and infection prevention and control. Key actions to be addressed would include:

• ensuring that elements contributing to the surge capacity response are appropriately balanced to minimise harm
• adapting protocols for surge management as required
• ensuring that frontline staff or triage officers are aware of any restrictions in operation
• communicating prioritisation decisions to local or regional centres as appropriate.

Clear recording of assessments and decisions taken will help avoid confusion and ensure consistency at a time of significant disruption.

A generic checklist ( appendix 5) has been provided which addresses some of the broad issues relating to surge preparation that may be faced locally in health and social care organisations. Service providers may wish to adapt and add to this for their own planning purposes, taking into account central and local pandemic coordination arrangements relevant to their geographical area. The needs of any patient or client populations that may be disproportionately affected during a pandemic should be specifically considered.

7.3 Implementation of service prioritisation at a national and local level

National agreement on the prioritisation process will give:

• reassurance of a consistent approach across the UK
• transparency and clarity of the approach to be adopted
• public and professional discussion and sign-up in advance of a pandemic
• support for clinicians during the pandemic
• an opportunity for appropriate indemnity and professional support to be agreed and in place beforehand.

However, even with the support of these tools or policies, primary and secondary healthcare services will have to take on the role of implementing the national guidance across their local health community in a commonly agreed and consistent manner.

Prior to the pandemic, health and social care provider organisations should have identified the services that they provide, prioritised their services and planned alternative mechanisms of service delivery where necessary. This work will need to be undertaken in coordination with other local providers through existing local and regional health and social care forums to ensure a joined-up, consistent approach. Health authorities/boards will have a key role to play in ensuring that health services across all levels of care are prepared.

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