The Scottish Government

NHS Preparations for Winter

Background
Investment
Preventative Measures
Capacity
NHS 24
Critical Care
Delayed Discharges
Waiting Times
Partnership
Pressures
Diarrhoea and Vomiting
Flu
Pandemic Flu

The NHS is preparing in advance for the inevitable winter pressures and is well placed to respond to the typical seasonal peaks in demand.

Following the exceptional winter of 1999-00 the Scottish Health Minister set up a service-led Winter Performance Group (WPG) to learn lessons from that experience and recommend ways for local health systems to improve planning and performance in future winters.

The WPG report that was issued in August 2000 contained many examples of good practice that already existed within NHSScotland and encouraged the dissemination of this good practice around the country.

Building on the good practice in the WPG report and the valuable lessons learned during the extremely difficult winter of 1999-00, NHS Boards across Scotland, along with their planning partners in the local authorities and voluntary sectors, prepared detailed robust plans in order to deal with the forthcoming winter.

As a result, NHSScotland entered recent winters better prepared than ever before. This year the NHS continues to build upon those experiences as it faces the challenge of this winter. All NHS Boards now factor winter pressures into their regular operational preparations so there is no longer any artificial boundaries in the local planning system that inhibit the seamless year round planning required to deliver effective health services.

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The huge planning efforts being made by both NHSScotland and their planning partners to prepare for winter is underpinned by the commitment of significant funding by NHS Boards.

There is an average increase on NHS Board allocations of 7.6% for 2005/06. Health expenditure for 2005/06 is £8,083m.

Around £18 million is being spent on this year's flu immunisation programme.

Investment of £30 million a year continues to help tackle delayed discharge allowing more people to move to more appropriate forms of care.

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The Executive has committed around £18 million to a major flu and pneumococcal immunisation programme including cost of vaccines, payments to GPs and an extensive marketing campaign.

Our target again this year is for 70% of those aged 65 and over to be immunised against flu. Following advice from the Joint Committee on Vaccination and Immunisation (JCVI), the influenza immunisation policy for 2005-06 remains unchanged We have set a 60% uptake target for patients in the at risk groups.

Community pharmacists will once again play a vital role in providing information to the population.

Local immunisation programmes worked well in support of the national campaign last year and will be built on this year in order to immunise as many individuals in the "at risk" group as possible.

To address any potential shortfall in vaccine, the Executive has sourced an extra 40,000 flu vaccines for our contingency supply, to help ensure that our priority groups can be protected.

The 40,000 doses will be additional to the 75,000 vaccines we have already ordered for our contingency supply. We will be distributing our current supply of flu vaccines to NHS Boards next week. The remaining doses and our additional 40,000 vaccines will also be distributed in the coming weeks, as required.

These additional doses of flu vaccine should help to ensure that all people who are at risk of complications from catching flu, such as those aged 65 or over and those with certain illnesses such as diabetes and asthma, will be protected this winter.

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The substantial extra investment in health funding has helped NHSScotland to prepare for winter. The uplift in NHS Board budgets in 2005-06 will help make a real difference to the services available during any peak in winter pressures. Examples include:-

• NHS Lothian has plans for an additional 87 nursing and 4 medical staff to cope with any winter pressures with the ability to provide an additional 99 beds if required.
• NHS Argyll and Clyde as part of RAH general capacity planning, have approved an additional 18 general medical beds, 4 additional HDU beds and an additional ITU bed to be ready in time for winter.
• NHS Dumfries and Galloway have 4 to 16 extra acute beds available as a contingency measure.
• NHS Forth Valley have redesigned the way in which they handle emergency activity in order to manage capacity to the full this is supported by additional staff and the ability to open up to 20 more beds.
• NHS Greater Glasgow has plans for a nurse led rehabilitation ward that would bring an additional 20 rehabilitation beds into use.
• NHS Lanarkshire plans an additional 40 WTE nursing staff.
• NHS Highland will have additional staffing for the 7 bed A&E short stay ward in Raigmore, reducing any possible impact on elective patients.
• NHS24 is now operating nationally, giving 24-hour phone access to health information and advice to Scotland's population referring people on to local out-of-hours services where required. More call handlers, new mini contact centres providing more nurse advisors and improvements to the call handling process are all serving to improve access for patients.
• All NHS Boards have plans to call on additional nursing and medical staff through the use of recruitment, bank and agency staff.

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Using last year's data, and after having consulted with its Out Of Hours (OOH) Service partners, NHS 24 expects to receive over 166,000 calls to the service over the 21 day festive period from 19th December 2005 to 8th January 2006 inclusive. This can be compared against a total of 124,000 calls dealt with across the whole of October 2005.

The graph below shows how the demand is expected to arrive on a day to day basis. The days where demand exceeds 15,000 calls are days three and four respectively of the two four day periods where GP surgeries are closed throughout Scotland. On each of these four days, the demand will exceed that of a normal weekend - which are in themselves the busiest time for NHS 24.

In addition to the increased volumes of calls, the daily profile of how it is expected that these calls will be presented adds an additional challenge. On each of the four days, it is expected that around half of the calls will be made between 9am and 1pm. To put this in context and taking Monday 26 December as an example, this means that NHS 24 will deal with around 9,000 calls in that four hour period - about 2,000 more than a normal Saturday.

NHS 24 is currently employing around 260 call handlers and 310 nurse advisers (whole time equivalents). In order to respond to the expected demand over the winter period, and in particular over the 2 four day holiday weekends, all frontline staff will be working on a minimum of 6 of these days. At some of these peak demand times, there will be as many as 200 NHS 24 nurse advisers available to deal with calls. These staff will be based in the 3 main contact centres and in the new satellite centres in Highland, Ayrshire, Lanarkshire, Tayside and Dumfries and Galloway.

NHS 24 and NHS Boards have been working much closer together this year to ensure that, during periods of exceptional demand like those mentioned above, the OOH Service has resources set aside ready to take un-triaged calls. NHS 24 will continue to work with all the OOH Services to provide hour-by-hour / day-by-day updated details of how many un-triaged calls will require to be taken by its partners to ensure patients are dealt with in a manner commensurate with their clinical presentation. Across the 2 four day holiday periods, it is understood that the support to deal with un-triaged calls in local OOH services is being increased at peak times by more than 150% above normal Saturday levels.

NHS 24 has established and is refining a number of in house initiatives to ensure that patients who require to access the service can do so in a reasonable timeframe. For example, NHS 24 has employed 14 pharmacists to give advice about medicine related calls. And call handlers have been re-trained to ensure that calls such as those that could be dealt with by a pharmacist, are transferred directly to them.

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In preparation for winter 2005-06 critical care capacity in Scottish hospitals has increased by around 17% when compared with 1999.

Intensive Treatment Unit (ITU) beds in Scotland have grown year on year. The Scottish Intensive Care Society (SICS) monitors the average number of ITU beds available each year.

1999 - 125

2000 - 133

2001 - 137

2002 - 139

2003 - 141

2004 - 145

2005 - 146

For this winter NHSScotland continues to use its critical care resources flexibly and so yet again there will be an increase in the number of available ITU beds at times of greatest demand.

The electronic bed bureau, which enables NHSScotland to quickly identify the availability of intensive care facilities, will again be a vital tool in managing ITU beds this winter.

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Delayed discharge is a year-round challenge, faced by NHSScotland and its planning partners. Winter pressures increase demand on the available services and so sharpen the challenges faced.

Over the past few years, there have been massive strides taken locally by the NHS and local authorities in joint planning and resourcing. The Delayed Discharge Action Plan was launched in March 2002 listing a range of short-term and longer term measures to reduce the numbers of patients inappropriately delayed in hospital.

The Executive is investing £30m a year until 2007/08 to help local authorities and NHS Boards tackle delayed discharges. Since the launch of our Action Plan in March 2002 the number of patients delayed fell from 3,116 to a low of 1332 in April 2005 (-57%). The number of patients delayed for more than 6 weeks reduced from 2,075 to 636 (-69%) over the same period.

There have been subsequent disappointing increases in the July and October figures with 1,576 patients ready for discharge as October, 876 delayed for more than 6 weeks. We expect local authority / NHS partnerships to take immediate steps to reduce the numbers of patients inappropriately delayed in hospitals.

Despite this, positive work continues to be undertaken. Some partnerships are developing additional "rehabilitative" capacity within the NHS to relieve pressures on the acute sector and prepare people better for discharge.

Examples of initiatives from partnerships across Scotland include:

• NHS Dumfries and Galloway and their local authority colleagues have introduced a Short Term Augmented Response Service (STARS) intended to support early discharge from hospital as well as preventing unnecessary admission.
• In NHS Greater Glasgow there will be extension of the supported discharge team to allow more patients to receive their rehabilitation at home, with 3 additional qualified staff and investment in homecare equipment.
• NHS Highland will have increased nursing provision for the Intermediate Care Team, including the provision of a "sitting service". This is augmented by increased physiotherapy and occupational therapy to support early discharge and rehabilitation in community hospitals.
• NHS Tayside with local authority partners have put funding in place to purchase additional nursing home places, equating to around 20 places per month.
• In Grampian, investment of £160,000 in the Admission and Discharge Team helping to co-ordinate discharge planning for the benefit of patients.
• With the continued drive to address delayed discharge in all NHS Board areas, more acute beds will be available to patients who need them.

Over Scotland there will be extra beds in nursing and residential homes and more equipment available to allow people to stay in their own homes.

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NHSScotland is tackling waits in A & E Departments by investing in better designed facilities, better equipment, better IT systems and by developing minor injuries units for people with less serious problems.

• 30% increase in the number of A & E consultants since 1999.
• Priority always given to urgent cases and those with crucial conditions. People with minor injuries have to wait longer at busy periods.

As with previous winters, NHSScotland has plans in place to minimise the impact of any seasonal pressures on admissions to hospitals for in-patient or day case treatment.

• Almost 54% of the patients treated in NHSScotland hospitals receive immediate treatment and never join a waiting list. Of those who do, over 41% are admitted for treatment in one month and 7 out of 10 in 3 months.
• National maximum waiting time for hospital in-patient and day case treatment will be reduced from 9 months to 6 months from the end of 2005 to 18 weeks from the end of 2007.
• These waiting times are firm guarantees. If a patient's host NHS Board is unable to provide treatment within the maximum waiting time, the patient will be offered treatment elsewhere in the NHS, in the private sector in Scotland or England or in exceptional cases, overseas.

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This year has seen NHSScotland preparing for winter with its planning partners as an integral part of the planning cycle. This has included:

• local authorities
• GPs
• pharmacists
• nurses
• voluntary sector; and
• ambulance services

This year's preparations are again built on the experience of previous years, which is underpinned by significant investment. The Centre for Change and Innovation is working with NHS Boards through its Unscheduled Care Collaborative to ensure improved access and reduced waits for patients and to help Boards meet the Executive's commitment that from the end of 2007 no patient will wait more than 4 hours from arrival to admission, discharge or transfer.

Working with pharmacists, plans are in place to allow the urgent supply of repeat prescriptions, over the forth coming festive season. This will allow the patient to receive one cycle of their repeat prescription from a community pharmacy when their GP is unavailable and cannot issue a repeat prescription.

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In 1999/2000 the NHS across Scotland came under very heavy pressure due to a combination of viral infections affecting many people, and bad weather. For five years now we have experienced relatively mild winters and an extremely low incidence of flu. Despite this, pressures still existed in the NHS but robust plans were in place to manage these.

Healthcare systems have plans in place to manage pressures at any time during the year, particularly during winter. The number of emergency admissions resulting for example from broken bones sustained in falls and from respiratory infections (both especially prevalent among the elderly) tends to rise in winter. If this demand moves materially above normal levels, hospitals have plans in place to ensure that emergency patients continue to get the attention they need. These plans may include, for example, postponing and rearranging some planned operations and diverting patients to other hospitals where necessary care can be given.

The NHS tries to avoid taking such steps, although they are all part of the Service's planned response to increased pressures. To help ensure that such measures are kept to a minimum, it is very important that our vital NHS services are as well prepared as possible for winter. This enables the Service to deal with pressures effectively and safely, while as far as possible maintaining routine services for patients that the public rightly expects. What happens…?

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Postponement of Elective Operations - when pressure increases on the NHS plans are in place to ensure that patients who require urgent or emergency care continue to have access to appropriate hospital services. As winter is traditionally a busy time for the NHS, hospitals work with planning partners to profile their annual activity in order to reduce the number of elective (non-urgent) operations during the winter and so give over more capacity to deal with urgent or emergency cases. Even with the profiling of activity the NHS will, from time to time, come under periods of severe pressure. During these periods, occasions will arise where in order to protect the capacity to care for those in most need elective operations will be postponed. This is a normal response to increased pressure, it can and does happen throughout the year but is more likely to happen during the winter. The postponement should have no adverse clinical impact and when it does happen, patients should always be given an early re-arranged date. Waiting times are a priority for NHS Scotland and any decision to postpone procedures is not taken lightly.

Ward closure - the most common reason for a hospital to close a ward to new admissions during winter is an outbreak of infection such as diarrhoea and vomiting. This virus (detailed later in the pack) that exists in the wider community is especially virulent and, when it does enter the hospital environment, it is important that hospitals take swift action in isolating those who are affected and thoroughly cleaning the affected ward in order to stop any spread to other parts of the hospital. While outbreaks of this virus will occur more commonly in winter, it is not a specific hospital problem. The excellent infection control procedures that are in place in hospitals are there to stop any spread to vulnerable individuals.

Accident and Emergency Waiting - the Scottish Executive has already signalled that excessive waits for patients in A&E are unacceptable. By the end of 2007, there will be a maximum 4 hour wait from arrival to discharge or transfer from A&E treatment. Across Scotland, health care systems are participating in the unscheduled care collaborative programme working toward reducing A&E waits. A&E services will always deal with the most serious cases first. At very busy times, there can be longer waits for those patients who have been clinically assessed as a lower priority. This can obviously be frustrating for all those involved, including hospital staff that are responsible for delivering the appropriate care for patients. While all that can be done, will be done to minimise delays, it is important that patients receive appropriate care within a reasonable time. After initial assessment / treatment in A&E, some patients may be delayed in being admitted to a ward. Where patients are delayed, the hospital will do everything it can to make them comfortable.

Accident and Emergency Diversions - diversions of patients away from their local A&E facility to the most appropriate hospital happens when the local A&E facility begins to come under such pressure that continuing admissions will cause an undue wait for treatment and may cause a reduction in the quality of care that should be provided. The mechanism for triggering these diversions is embedded in the planning arrangements of all NHS Boards ensuring that this happens in a planned and controlled way. Local GPs are alerted to the situation and the Ambulance Service is able to adjust their response dependent on the emerging situation. A&E diversion is rare and only used by the NHS to ensure that the care of patients in need of urgent attention is not compromised. Normally such circumstances last for a few hours at most. "999" calls will always be sent to the nearest A&E facility.

Hospitals diverting admissions - like A&E diversions, this is rare and again this planned step is only taken to preserve care standards for patients. Locally, a strict protocol is used for advising of a closure and GPs and the Ambulance Service are given warning of any emerging situation so they can work collaboratively with the rest of the care system. As in any situation giving rise to severe pressures, hospitals have recognised links to other areas to provide mutual aid and minimise any impact on patients.

ITU transfers - this is extremely rare and will only happen where a local hospital has exhausted all appropriate resources in caring for very ill patients. Well established systems are in place to manage transfers to ensure that such patients get the care they need. In Scotland the electronic bed bureau allows local clinicians to quickly view where ITU capacity is available in the system and inform any decisions on transfers that need to be made. While NHS Scotland has an average of around 146 ITU beds, hospitals can and do augment that number by converting high dependency beds or utilising theatre recovery rooms where the sort of specialist ITU equipment required is available.

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Noro virus infection (previously known as Small Round Structured Virus (SRSV), Norwalk agent or winter vomiting disease) is a common cause of viral gastro-enteritis worldwide. Sudden onset of nausea, vomiting and diarrhoea 12 to 48 hours after exposure to infection is typical.

• The community in general, as well as healthcare facilities and nursing homes, will be affected by any outbreak of gastro-enteritis due to SRSV across the UK.
• Community-wide outbreaks lead to admissions to hospital, and transmission of infection within hospitals has been common due to the highly infectious nature of SRSV. The key measures for control of outbreaks are good hygiene, efficient staff management and isolation of those who might be affected. The airborne spread of infection is intrinsically difficult to control: a single case vomiting in a hospital ward can immediately infect many other patients and staff.
• While the disease is mild (if unpleasant) for most, very elderly or frail patients may succumb during an episode of this infection. Outbreaks are mostly short-lived and people and care settings usually return to normal in a short time.
• Outbreaks may affect the work of hospitals for limited periods. The Scottish Executive will continue to monitor the situation and help ensure that the effects are kept to a minimum.

Hygiene is the key to control, and initiatives arising from the Healthcare Associated Infection (HAI) Action Plan produced by the HAI Task Force should further assist NHSScotland in minimising the impact of this infection.

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Scotland's annual winter flu campaign was launched on 5 October with the aim of achieving over 70% uptake for a fourth year.

The influenza campaign encourages everyone aged 65 and over, and those under 65 with long-term medical complaints, to come forward for their free jab to protect them from the influenza virus this winter.

This year's campaign aims to build on the high level of uptake achieved over the last few years and protect those most vulnerable against the complications of flu this winter.

Those over 65 who have not already received it will also be offered pneumococcal vaccination to protect them against invasive pneumococcal infection which can cause severe forms of pneumonia, septicaemia and meningitis.

Once again, individual letters were sent to all those eligible for immunisation on age grounds. The letter reminds them of their eligibility and will urge them to contact their GP practice if they do not hear about an appointment for immunisation by late October.

The Executive's integrated publicity campaigns for flu and pneumococcal immunisation include TV and press advertisements which will run from the end of September to early December. The Executive has also developed public information leaflets and resources for health professionals.

So far, this year, there has been little flu activity but we have learned from previous years that this situation can change rapidly and that there can be no complacency in preparations.

Monitoring flu activity is the responsibility of Health Protection Scotland (HPS). Across Scotland "spotter" practices are used in order to monitor any outbreaks of flu or flu like illnesses. Updates on flu activity are available on a weekly basis from HPS.

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Pandemic flu is not the same as seasonal flu: it generally causes more severe illness and will affect more people than 'ordinary flu'. Influenza pandemics are caused when a new flu virus emerges which is markedly different from recently circulating strains.

Experts around the world share the view that a global pandemic of influenza could emerge and cause millions of cases and hundreds of thousands of deaths. Their view is that the world is overdue for the next pandemic. There is particular concern about the continued circulation of avian (bird) flu in South East Asia and the danger that it could mix with human flu to produce a pandemic strain. A recent World Health Organisation (WHO) report on avian influenza suggests that the Avian Flu virus (also known as H5N1 virus), may be evolving in ways that make it more infectious to humans. The situation in South East Asia continues to be closely monitored and the UK has provided funding to assist this monitoring.

The UK is in the forefront of preparations for pandemic flu and Scotland has been working closely with Health Departments across the UK to put such preparations in place. The Department of Health, on behalf of the UK, has also been working with international bodies such as the World Health Organisation (WHO).

Pandemic Flu Plans have been in place since 1997, and a newly updated UK Health Department's UK Influenza Pandemic Contingency Plan, taking into account the latest available information, was recently published.

Until the pandemic flu strain is identified, it will not be possible to produce a vaccine. It could then take up to six months to produce. Until there is sufficient vaccine for everyone, the Joint Committee on Vaccination and Immunisation (JCVI) has recommended the priority groups for vaccination and these are set out in the Plan. Final decisions on priority groups will be made by the UK Pandemic Influenza Committee, informed by any recommendations of the World Health Organisation and JCVI.

UK Health Departments have produced a leaflet entitled "Pandemic Flu: Important information for you and your family" available at www.scotland.gov.uk .

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