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5. Surge capacity

The emergency response in the following two situations has some common features, but there are also important differences.

• A sudden focal event will produce large numbers of casualties over a short period, with the primary impact on secondary healthcare facilities;
• a 'rising tide' event will continue to produce large numbers of sick people for considerable periods and the impact will be across all healthcare facilities, including primary and community care and social care. It is recognised that most ill people will have to be cared for outside of hospital and the presumption must be that they will remain at home with such support as relatives/neighbours/friends/volunteers and health and social care can give.

The current healthcare response to a sudden focal event relies on mutual aid agreements with other hospitals; in the rising tide situation, where widespread disruption may be present over a prolonged period and across a wide geographical area, health communities will not be able to rely on this assistance.

This document focuses on the response to pandemic influenza, a 'rising tide' event. Guidance on the NHS response to a sudden focal event already exists. ⁸

5.1 Defining 'surge capacity'

The term 'surge capacity' has been coined to describe the response in these scenarios and is an evolving concept in emergency preparedness. The National framework defines surge capacity as: 'the ability to expand provision beyond normal capacity to meet transient increases in demand, e.g. to provide care or services above usual capacity, or to expand manufacturing capacity to meet increased demand'. ⁹ In respect of this guidance, a shortened definition is used: Surge capacity is the ability of the health service to expand beyond normal capacity to meet an increased demand for clinical care.

5.2 Guiding principles

There are seven guiding principles that need to be considered when planning for a surge:

• The care that can be given to people when resources are stretched should be maximised.
• Plans should be consistent with the overall aim of preserving and maintaining essential healthcare services.
• Changes to services and clinical standards should be incremental and should reflect changes in local demand and the resources that are available.
• Changes should be consistent with the established ethical principles.
• Plans should take a whole-system approach and encompass primary, community and secondary care.
• Plans should support the attainment of strategic objectives at each stage of a pandemic.
• Implementation of this guidance should be coordinated at a strategic level in a health economy to ensure consistency of interpretation and effect.

5.3 Surge capacity - elements

Designing a structure able to respond to surges of hundreds or even thousands of patients, when the healthcare system is itself affected and already almost at capacity, will require exceptional solutions. Initially, it may be possible to increase capacity in line with increased demand, without affecting standards of care. However, as the pandemic develops, it will be necessary to alter the level of care provided, until at the peak the emphasis will be on managing the demand for healthcare by prioritising patients and procedures. A conceptual model is shown in Figure 2 overleaf.

Figure 2: Surge capacity - a conceptual model

Source: Adapted from Mass medical care with scarce resources: A community planning guide, Agency for Healthcare Research and Quality, 2007, emergency publication no. 07-0001.

In developing surge capacity in the context of pandemic influenza, there are three interrelated elements to consider:

• the physical aspects of creating extra capacity, i.e. creating space, providing staff, supplying resources and/or managing the process (section 5.4)
• prioritising services to release capacity ( chapter 7)
• prioritising patients and clinical interventions to control demand.

These three elements will be present to a greater or lesser extent along a spectrum of actions, depending on the magnitude of the challenge and the resources available.

5.4 Increasing capacity

This component of surge management involves 'the four Ps': processes, premises, providers and people. Each of these components should be considered individually, as well as considering how they would operate together.

• Processes - all local health communities should have clear arrangements for command and control (see the National framework for further information on command and control arrangements). Systems changes such as staffing levels require planning so that changes can be implemented easily and quickly during a pandemic.
• Premises - all hospitals should be able to make significant expansions in their acute bed capacity and double the provision of critical care beds ¹⁰ within a one- to two-day period. In primary care, ¹¹ extra space could be created for additional clinical contact opportunities through the suspension of health promotion and some chronic disease management clinics. As far as possible, non-flu patients should access and receive care in the ways in which they would do so in 'normal' circumstances (eg practice-based care). Influenza patients will, however, need to be supported to remain at home, for example through home visiting and telephone assessment. Expansion of community hospital and continuing care capacity should also take place where possible.
• Providers/provisions - healthcare organisations should consider what their key vital supplies are and what is likely to be required to meet the surge in demand for emergency care. They should make provision for these items well in advance of the pandemic. However, certain commodities such as blood and blood components cannot be stockpiled, and reference should be made to the national plans. ^{12, 13}
• People - healthcare organisations will need to determine and maximise the pool of skills they have at their disposal from their employed, reserve, trainee and volunteer staff, so that redeployment is managed to best effect.

Detailed guidance on this can be found in Pandemic influenza: Guidance on preparing acute hospitals in England and Pandemic influenza: Guidance for primary care trusts and primary care professionals on the provision of healthcare in a community setting in England, available at www.dh.gov.uk/pandemicflu; or in their country-specific equivalents. Guidance on workforce issues is also available. ^{14, 15}

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