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					                                     NHS London Board
                                        7th October 2009

Title:                        A (H1N1) Swine Influenza pandemic statement of readiness

Agenda item:                  6                        Paper                       L
Action requested:             To note

Executive Summary:            This report provides assurance to the NHS London Board that
                              London is prepared for a second wave of the A(H1N1) Swine
                              Influenza pandemic. The paper provides assurance on the
                              leadership, governance and resilience processes in place across
                              London. It also details specific resilience actions in place in a
                              number of critical health care services and identifies ongoing
                              areas of further work.

Summary of                    The NHS London Board is asked to receive this report as a
recommendations:              statement of the readiness and resilience of London to respond
                              to a second and subsequent surge of the A(H1N1) Swine Flu
                              pandemic. The Board is asked to note the ongoing work to
                              further enhance London’s readiness.

Fit with NHSL strategy:       The DH require all Strategic Health Authorities to produce a
                              region wide assurance report based on the resilience planning in
                              each organisation at their September or October Board
                              meetings. A standard template has been produced by DH so
                              that each SHA report is consistent when they are published on
                              the DH website and placed in the House of Commons’ Library.

Reference to other            Letter from Ian Dalton, National Director of NHS Flu Resilience,
documents:                    Gateway 12125

Date paper completed:         23rd September 2009
Author name and title:   Daniel Elkeles            Director name and     Sara Coles
                         Flu Resilience Director   title:                Director of Performance

                                                                         Simon Tanner
                                                                         Regional Director of
                                                                         Public Health

Date paper seen   N/a    Equality Impact   N/a     Risk          Yes     Legal advice     N/a
by EMT                   Assessment                assessment            received?
                         complete?                 undertaken?

                                                                            NHSLB 7 October 2009 L

                                                                                         Page 1 of 8
           A (H1N1) Swine Influenza statement of readiness
1     Introduction

1.1   This report provides assurance to the NHS London Board that London is prepared for a
      second wave of the A(H1N1) Swine Influenza pandemic. For convenience this document
      abbreviates the name of this virus to ‘Swine Flu pandemic’.

1.2   The better prepared London is as a health economy to respond to a ‘surge’ in flu illness in
      its population the more likely it is that there will be no avoidable deaths, illness or
      unnecessary waits or delays this winter.

1.3   The first case of Swine Flu in Britain was identified in April 2009. London experienced a
      small surge of Swine Flu during the summer which has now subsided (appendix 1). If the
      Swine Flu pandemic follows a similar trajectory to those experienced in 1957 and 1968 then
      it is likely that there will be a second wave of the virus starting this Autumn and Winter. The
      DH continues to update its planning assumptions for this second wave based on evidence
      about the virus from around the world. The most recent guidance published on 3 rd
      September predicts a clinical attack rate of 30% of the population, a case hospitalisation
      rate of 1% and a fatality rate of 0.1%. The levels are lower than first predicted but would still
      put the NHS under great pressure if realised.

1.4   Every winter increased demand is placed on the NHS’ emergency care systems. The
      impact of a flu pandemic on the NHS is a more extreme version of this. Because the impact
      of winter and a flu pandemic has a similar effect on the operational capacity of the NHS,
      NHS London has taken the decision to integrate each organisations winter and Flu
      resilience processes.

1.5   All NHS Boards have been asked by Ian Dalton, National Director for NHS Flu Resilience to
      publish a statement of their Swine Flu resilience at their September Board meetings (this
      includes Foundation Trusts). All Strategic Health Authorities are then required to produce a
      region wide assurance report based on the resilience planning in each organisation. This
      report is based on evidence available as at 16 th September but the Board should note that
      this is a changing situation and where appropriate a verbal update will be given at the NHS
      London Board meeting to supplement the information contained in this report.

1.6   The report provides assurance on a range of issues under the domains of leadership,
      governance, resilience and specific service plans for critical health care services.

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                                                                                              Page 2 of 8
2     Assurance requirements

2.1   Leadership

2.1.1 There is a robust plan in place to support delivery of a co-ordinated response to the
      Swine Flu pandemic across the region with the equivalent of a full-time Director
      dedicated to flu preparedness and resilience
       NHS London appointed Sara Coles, Director of Performance and Dr Simon Tanner,
         Regional Director of Public Health to take Director Responsibility for Swine Flu.
       Daniel Elkeles has been seconded, since July, from North West London Hospitals NHS
         Trust where he is Chief Operating Officer to take on the role of Flu Resilience Director
         for NHS London.
       A small team of staff from across the Performance, Public Health, People and
         Organisational Development and Communications Directorates has been pulled
         together to create a dedicated Flu Resilience Team.
       A pool of staff from other directorates has been identified to assist the Flu Resilience
         team if required.

2.1.2 There is a Director level led vaccination programme in place to ensure the maximum
      possible uptake of both swine flu and seasonal flu vaccine
       Dr Simon Tanner as Regional Director for Public Health is the vaccination lead at NHS
       NHS London has required each PCT to have completed and agreed its vaccination
         delivery plan by 30th September. These have been prepared by the Directors of Public
         Health for the PCTs. They are based on the DH guidance on the priority groups who will
         receive the vaccination first.
       NHS London conducted a stock take of current PCT plans on 8th September and results
         from this were fed back to PCTs. It has now been confirmed that the primary distribution
         mechanism for the vaccine will be GPs supplemented by PCT Provider Arms, antenatal
         services and community pharmacies as required. Detailed planning guidance has been
         sent out by the DH in the week commencing 14 th September. It places accountability for
         the delivery of the vaccination programme with each NHS Board.

2.2   Governance

2.2.1 All NHS Trust Boards have agreed and signed off their assessment of readiness
       All NHS organisations, including Foundation Trusts, have taken a paper to their
          September Board outlining their assessment of readiness.
       NHS London has provided detailed feedback to each organisation, in advance of that
          organisation’s Board meeting, with our assessment of their state of readiness.
       Our assessment is based on a multi-disciplinary team review of the evidence provided
          by each organisation to a 30 question checklist covering all components of flu and
          Winter resilience. A copy of the checklist is provided in Appendix 2 . Organisations have
          been given 14 days to respond to requests for further information to be provided.

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                                                                                          Page 3 of 8
         The process of reviewing each organisation’s initial plans will be complete on 6 th
          October and a verbal update will be given at the Board on the overall state of readiness
          of these plans across London. We expect that all organisations in London will receive a
          risk rating of Green or Amber following the completion of this process.

2.2.2 There is a robust governance accountability framework and reporting mechanisms in
      place from NHS organisations to NHS Resilience Directorate
       Every NHS organisation in London has appointed a Flu Resilience Director. There is a
          clear line of accountability for these individuals through to the NHS London Flu
          Resilience Team and then onto the NHS Resilience Directorate.
       NHS London sends out a daily email (Noon Brief) to 500 named individuals providing
          guidance, updates and latest news.
       A cycle of weekly teleconferences has been set up with London’s Flu Resilience
          Directors. NHS London organised a flu resilience conference and a winter planning
          conference both attended by 150 individuals during July.

2.2.3 There is a communications strategy in place to convey consistent and timely
      messages to both staff and the public
       In May 2009, NHS London published a London Health Community Pandemic Flu
         Communications Framework which sets out the roles and responsibilities of each
         organisation and details the key messages to be communicated at each phase of the
         pandemic. It was successfully implemented during the first wave of the pandemic.

2.2.4 Maintenance of accurate records of decisions
       NHS London has set up a weekly Flu Preparedness and Resilience Committee chaired
         by Sara Coles, Director of Performance. Action points from this meeting are recorded.
         Minutes are taken at all teleconferences hosted by NHS London.

2.3   Resilience

2.3.1 Each organisation has undertaken the Health Protection Agency (HPA) resilience test
      and exercise
       NHS London undertook the HPA resilience exercise ‘Peak Practice’ on 22 nd September.
         Ruth Carnall led the exercise. There were 250 delegates comprising the Flu Resilience
         Directors and Chief Executives and or senior directors from every NHS organisation in
         London as well as representatives from Local Authority Social Services departments. A
         verbal update of the evaluation and learning from the exercise will be provided to the

2.3.2 Pandemic plans have been stress tested to ensure high-level delivery of care
       Many of the health economies in London have already conducted their own simulation
         exercises at a local level. NHS London requires that this takes place in every health
         economy before the winter and this forms part of the checklist detailed in section 2.2.1.

2.3.3 Effective Human Resource policies and practices are in place to support resilience
       All organisations in London have completed the specific DH Flu workforce assurance
          framework in each of the 3 months July, August and September. These are currently

                                                                              NHSLB 7 October 2009 L

                                                                                          Page 4 of 8
           being analysed by both the NHS London People and Organisational Development team
           and the DH workforce team. Based on the information contained in these returns to
           date we expect that all organisations in London will receive a risk rating of Green or
          Each organisation is putting in place arrangements for all front line staff to receive
           seasonal and Swine Flu vaccinations. Whilst it is unlikely that specific targets will be
           set for the percentage of staff to be vaccinated, the uptake of vaccination in each
           organisation will be closely monitored and action taken where take up rates are lower
           than expected.

2.3.4 A service priority assessment tool has been completed
       Each organisation has categorised the services it delivers into essential and non-
         essential. Staff training plans and redeployment plans are being drawn up so that non-
         essential service staff can support essential services.

2.3.5 Mechanisms in place to support Local Authorities with their planning
       NHS London is working with the Government Office for London to ensure that Social
         Care plans across London are resilient. Specific links have been made by the London
         Region Social Care Team with the Greater London Authority to engage with Local
         Authorities and the community and voluntary sector. Further work is underway.

2.4    Service Specific plans

2.4.1 Antiviral Collection Points set up to support the delivery of the National Pandemic
      Flu Service
       London’s PCTs have set up a network of 174 Anti Viral Collection points across
          London. If demand increases then an additional 226 points can be opened. There is
          good geographical coverage across London.

2.4.2 Critical Care
       The service that is likely to come under the most pressure in a second surge is critical
          care (Intensive and High Dependency Care). The NHS has given a commitment that it
          can double its critical care capacity. NHS London has undertaken a detailed planning
          exercise with the acute Trusts and can confirm that London is in a position to achieve
          this. The total number of critical care beds can be increased from 773 to 1,575 for a
          maximum of 8 weeks. The capacity will be created by opening currently closed beds in
          existing critical care facilities and switching resources from operating theatres. This will
          lead to a corresponding reduction in the levels of planned surgery that can be
          undertaken. The NHS London Medical Director is setting up a pan London group of
          Consultant Intensivists to advise on critical care issues across the capital during this

2.4.3 Acute services
       NHS London has required organisations as part of their winter resilienc e plans to
         demonstrate that they have put in place senior clinical decision making for the initial
         assessment of emergency admissions, ensured that the provision of A&E and Urgent
         Care Services are seamless in each health economy and have clear policies in place to

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                                                                                             Page 5 of 8
          prioritise pregnant women who need hospital care. The next focus will be on designing
          a framework to assess the readiness of paediatric services.

2.4.4 Ambulance services
       London Ambulance Service has participated fully in the regional and national planning
        for a Flu Pandemic. It has implemented the flu pandemic protocol within the NHS
        pathways system used in the control room to prioritise demand (Card 36). The
        resilience of the control room has been boosted through additional staff recruitment.

3     Impact on the NHS in London

3.1   The statement of readiness of NHS London’s ability to respond to a second Swine Flu
      surge set out in this report is positive and recognises the tremendous dedication and hard
      work of colleagues across London’s health care system.

3.2   The NHS London risk register includes a specific risk for the potential impact of a Swine Flu
      pandemic on the operational capability of London’s health care system. The risk rating is
      currently scored as a high risk (score of 15 out of 25). Once all the ac tions described in the
      paper are in place then the risk rating will be mitigated to a medium risk (score of 10 out of
      25). It is felt that the risk cannot be mitigated further because the evolution of the virus is
      not predictable. However the infrastructure in place across London should enable each
      organisation to respond appropriately to all eventualities. It is clear that the more
      successful the vaccination programme is, the more likely the impact of Swine Flu will be

4     Next steps

4.1   NHS London continues to actively plan to minimise the effect of a second surge of Swine
      Flu. The particular areas where further work continues are:

         Ensuring that every organisation in London scores at least an amber level of resilience
          against NHS London’s winter and flu resilience checklist and the DH’s workforce
          assurance checklist by the middle of October.
         Embedding the learning from the Peak Practice resilience exercise in all organisations’
         Further refining plans for doubling critical care capacity, enhancing paediatric capacity
          and working with Local Authorities on social care capacity.
         Working with all PCTs to ensure effective planning and delivery of the seasonal and
          swine flu vaccination campaigns.

4.2   The NHS London Board is asked to receive this report as a statement of the readiness and
      resilience of the organisations in NHS London to respond to a second and subsequent
      surge of the A(H1N1) Swine Flu pandemic.

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                                                                                            Page 6 of 8
Appendix 1

Figure 1 – London Antivirals issued and collected per day (Source NHS Direct)

Figure 2 – London Critical Care & Inpatients numbers over time (Source: Daily Sitreps)

Figure 3 – Active ACP distribution in London
                                                                                                                               Appendix 2 -
         Winter and Flu Resilience plans checklist                                                                                     GREEN - all relevant evidence provided and / or reviewer assured that complete now
                                                                                                                                       AMBER - majority of evidence provided and / or reviewer assured that will be complete by end Sept
         Organisation name:                                                                                                            RED - limited evidence provided and / or reviewer / organisation believe will not be complete until after end Sept

Q        Action                                                                                                                        Information that could be expected as evidence to support the organisation's self assessment                                  Reviewer's assessment of
                                                                                                                                                                                                                                                                     readiness against criteria
                                                                                                                                                                                                                                                                     RED, AMBER, GREEN

         Health economy wide issues

     1 Leadership - organisations in the Health Economy demonstrate joined up multi-agency approach to planning. Flu        ● Minutes of the local Influenza Pandemic Comittee meetings - showing representation from key agencies and showing
       Resilience plans for each organisation in the Health Economy have been shared and agreed. Agreements in place on any a series of agreed actions that have been implemented
       local cross borough border issues to ensure patient care is seamless.                                                ● Evidence that Trusts have undertaken the Roles and Responsibilities checklist for IPCs in the London Regional
                                                                                                                            Resilience Flu Pandemic Response Plan
                                                                                                                            ● Evidence from each acute trust that they do not have particular problems with any other agency outside their host
     2 Local leaders - every organisation has senior leadership arrangements in place to manage Flu and Winter resilience   ● Organisation chart showing responsibilities
       which is clearly documented. There is a reliable system in place for keeping the CEO, Board and Flu Lead Director    ● Evidence that winter and flu performance is regularly discussed in decision making meeting forums in the organisation
       appraised of progress, receiving exception reports and for escalating their involvement as required.                 ● Evidence of learning from last winter and accociated action planning
                                                                                                                            ● Out of hours management cover arrangements
                                                                                                                            ● Trust on-call arrangements

     3 SITREP reporting - every organisation has in place robust procedures to comply with all SITREP reporting processes.             ● Description of how SITREP reporting processes work - ensuring that does not fall to one individual only
                                                                                                                                       ● Evidence of a resilient system with the potenetial of 7 day reporting
     4 Resilience plans tested - assurance that both Winter and Flu resilience plans have been tested or exercised particularly        ● Evidence of simulation exercises undertaken with partenrs in the last 6 months - with learning from the event and
       known stress points in the plan.                                                                                                accociated action plan

     5 Infection control - plans take into account both Swine Flu and also major increase in activity in 'surge' conditions.     ● Infection control policy with clear plans on management of both Swine Flu, surge activity and management of
                                                                                                                                 norovirus (D&V) for the winter
     6 Escalation processes – there is a clear well communicated multi-agency plan for health economy response to ‘surge’        ● Escalation plan is attached - showing what happens at each level from each agency.
       demand that is owned and shared with all key health and social care partners in the health economy. The trigger levels to ● Evidence of how the plan is used each day to determine status of the organisations in the health economy
       move to each escalation level are well defined and understood by all agencies.                                            ● Evidence of how the escalation levels are determined

     7 Antiviral Collection Points - facilities in place so that anyone with suspected swine flu gets issued with antivirals within    ● Location of all ACPs in the Borough
       48 hours including those patients without a GP and vulnerable groups - include PCTs full roll out plan of ACPs.                 ● Evidence that at least one ACP is not a community pharmacy and is open / could be opened within 48 hrs if required
                                                                                                                                       ● Policy for accessing service for those patients without GPs
                                                                                                                                       ● Policy for accessing service for vulnerable groups

     8 Vaccination programme for each PCT's patients is in place and is flexible enough to respond to vaccine supply issues            ● Evidence that a degree of planning has gone into vaccination programme and that it looks like it has a flexible
       and priority group issues.                                                                                                      delivery plan, this should include both seasonal and pandemic flu

         Winter resilience plans

     9 Discharge processes – multi-agency co-ordination to minimise the number of delayed transfers of care.                           ● Levels of DTOCs in health economy over past months
                                                                                                                                       ● Evidence of multi-agency meetings to minimise DTOCs
                                                                                                                                       ● Levels of morning discharges
                                                                                                                                       ● Evidence of simplified processes for organisations that relate to more than one social services department
                                                                                                                                       ● Evidence of daily senior clinical decision making ward rounds in hospitals
                                                                                                                                       ● Evidence that community facilities patient length of stay is measured and actions taken to reduce where necessary

    10 A&E performance - specific plans to cope with 2 known dips in A&E performance early December and early January.                 ● A&E performance improvement plans where appropriate

    11 Business continuity - evidence that organisation has a robust plan to respond to issues such as bad weather (snow).             ● Business continuity plan submitted as evidence - and particular section on response to bad weather.
                                                                                                                                       ● Plans should include elements of absenteeism and supply chain disrution.
         Flu Pandemic second wave resilience

    12 Enhanced capacity in 'surge' demand- details of capacity that can be made available in each organisation for each key           ● Evidence provided about the capacity
       service including staffing and equipment resources. Details of the trigger levels to release this capacity into the             ● Evidence provided about the process that will be used to trigger this capacity
    13 Capacity modelling - each health economy has taken account of worst case scenario set out by DH in July 2009 and has          ● Evidence that organisation has used the scenario modelling - basic level has described what the modelling says for
       plans in place to respond to the peak weeks of the pandemic.                                                                  the health economy. Highest level has a plan to show how will meet the demand on GPs / hospitals / ITU / mortuary
                                                                                                                                     that model is based on
    14   Essential services - plan identifies clinical and non-clinical essential services that must continue to be provided or that  ● Description of what services the organisation considers as essential and critical - ideal justification of these decisions
         can be scaled back in a pandemic, as well as identifying critical and non-critical functions.                               provided
    15   Logistics - plans identify and regularly review key vital supplies, without which the trust could not function, and include  ● Evidence provided - details of current stock levels - written confirmation from key suppliers about their contingency
         local plans as to how these supplies can be maintained (e.g. utilities, food, linen, medical supplies).                     plans and that these fit with what the NHS organisation is expecting
    16   Communication - plan for effective communication to staff, patients and the wider community before, during and after the ● Communications plan attached
         pandemic.                                                                                                                   ● This should include arrangements for 24/7 cover
    17   Recovery from pandemic -plan includes detail on recovery from a pandemic.                                                   ● Recovery plan attached and fits in with DH guidance on how to do this (attach as an appendix)

         Specific organisational capacity issues

    18 Acute hospital capacity– senior clinical decision making for initial assessment of emergency admissions / inpatient             ● Details of how emergency paed / surg / med process work in terms of senior decision makers availability
       capacity / A&E - UCC interface / Maternity Services Capacity – clear policies exist which prioritise women who need             ● Capacity plans for inpatient beds showing number of beds available each month and how this responds to known
       hospital care and limit unnecessary admission.                                                                                  winter increase in emergency capacity
                                                                                                                                       ● Details of joint working arrangements between UCCs and A&Es where appropriate
                                                                                                                                       ● Maternity plan
    19 Critical care capacity– organisation has been through critical care checklist provided by DH (available early August) and       ● Ideal completed critical care checklist with evidence that have responded to each question
       have specific plans to increase capacity by 100% to respond to Flu and clear and agreed prioritisation plans.                   ● Attach submission of surge capacity template that sent to NHSL on 11/8

    20 Primary care capacity - including normal GP capacity and out of hours services. Plans in place to ensure that those most ● Capacity plans provided particularly for Out of Hours services
       likely to access healthcare services have care plans to reduce the likelihood that they will be admitted.                ● Evidence of chronic disease registers and steps taken to have care plans for these patients to keep them out of
                                                                                                                                ● Evidence of planning to identify and support vaulnerable groups in the community
    21 Intermediate care capacity – implementing simplified access criteria, enhancing admission avoidance and palliative care ● Evidence provided of the admission criteria to intermediate care and ideal how these have been simplified
       services.                                                                                                                ● Details of admisssion avoidance schemes
                                                                                                                                ● Details of palliative care provision - and schemes to keep terminally ill out of hospital to die
    22 Social care capacity – streamlining placement process, understanding total potential nursing and residential home        ● Evidence that the PCT knows what its nursing and residential home capacity is and how much of it is using and plans
       capacity in each Borough with ability to utilise capacity. Plans in place to ensure social care workforce resilience.    to increase capacity
                                                                                                                                ● Evidence of discussions with Social Services about their resilience
                                                                                                                                ● Evidence of planning to identify and respond to vaulnerable groups in the community
    23 Mental Health capacity- robust acute psychiatric liaison services to minimise A&E breaches and timely assessment of      ● Description of the current service with any issues identified
       inpatients.                                                                                                              ● Suspect that this is the place that mental health trusts will put their specific plans
    24 Ambulance capacity - plans from each hospital to deliver the required 'hand over' waiting time targets.                  ● Expect to see specific policy on management of ambulance hand over times
                                                                                                                                ● Suspect that LAS will provide their specific plan here
    25 Diagnostic and therapy capacity – enhanced levels of services working 7 days per week in both primary and secondary ● Expect to see weekend provision for some therapy (OT and Physio) and Radiology CT and plain film in secondary
       care.                                                                                                                    care and some access in intermediate care. Primary care access not necessary

    26 Seasonal and Swine Flu vaccination plans for organisation's staff, that prioritises staff to be vaccinated according to         ● Expect to see detailed roll out plan across staff groups identified in priority order
       service needs.                                                                                                                  ● Evidence that the organisation has considered who their key 'front line health staff' are for primary vaccination
    27 Medical staff plans - demonstrate that have recruited sufficient staff to cover EWTD rotas in all critical services and that    ● Should expect that the workforce assurance template that they have sent to the DH is included and completed with a
       number of medical staff available take account of the busiest times of day. If the decision is taken nationally for a           full commentary
       temporary derogation of WTD compliance to be instated, the terms and conditions of job offers to all medical staff are
       amended to reflect this.
    28 Maximise available staffing levels in all roles during an influenza pandemic, including arrangements for temporary              ● Should expect that the workforce assurance template that they have sent to the DH is included and completed with a
       postponement of all training, appropriate re-deployment of staff, re-employment of newly retired staff or staff who have left   full commentary
       recently, flexible working arrangements (part-time to full-time, working at home, etc) and refresher course for staff who
       have a clinical background, but who no longer practice.
    29 Response to likely absence levels due to sickness, carer responsibilities and the impact of the anticipated closure of          ● Should expect that the workforce assurance template that they have sent to the DH is included and completed with a
       schools, that are not reliant on temporary staffing solutions. Cover arrangements are in place for all key members of staff     full commentary
       who may be taken ill, such as CEO, the Board, senior clinicians, and Flu Resilience team. Review of all policies that may
       affect staff attendance to ensure that they clarify how staff should report sickness during the pandemic.
    30 Engagement with the Trade Unions to ensure their contribution and support for staff arrangements over the period of the         ● Evidence of meetings with staff side where this has been discussed

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