covid -19: silver operational command: terms of reference · 2020. 5. 4. · the three cells within...

1. Purpose To oversee decision making and to identify issues for escalation to Gold Command

To delegate and assure key tasks and actions as defined and required by Gold command.

To act as a point of escalation and resolution where issues have not been able to be resolved through the Bronze command super cells.

To prioritise the most effective deployment of available resources in collaboration with partner organisations and with delegated authority:

For financial expenditure delegated authority has been defined as up to £1m from the allocated COVID budget.

For human resources any decisions on redeployment will be made under the delegated authority of the members of Silver to commit their organisations.

To report regularly to the Gold Command

To coordinate the response of the Local Authority and NHS, appropriate to the current and predicted impact

To ensure the Local Authorities, NHS and partners are kept appraised of the evolving situation

To coordinate the assignment of tasks to supercells and cells within the Silver and Bronze command structure

To oversee decision making within the Silver and Bronze commands and to escalate issues for decision to Gold Command

To oversee the most effective deployment of available resources in collaboration with partner organisations; to understand and create additional capacity for care and treatment

To ensure a Recovery Working Group (RWG aka ‘system recovery cell’) is established to run parallel with the response

To ensure situation reports are collated and disseminated where required

To act as a central point of contact for stakeholders and partners regarding the joint local authority and NHS response

To coordinate messages to ensure consistent, clear and timely messaging across the local authorities, NHS, partners, public and the media

To oversee the Local Authority and NHS response to pandemic-related surge, ensuring critical care resources and surge capacity demands are managed through appropriate discussion, escalation and resource allocation

To liaise with local authority and NHS Organisation Incident Management Groups

To liaise with Strategic Coordination and regional coordination groups

To liaise with specialist / direct commissioning functions to ensure co-ordination of local response & specialist / directly commissioned services

2. Ways of working Will report twice weekly to Gold Command on the system response to COVID-19 and

escalate issues for decision

Will receive tasks from Gold Command and assign tasks to cells or supercells

COVID -19: SILVER OPERATIONAL COMMAND: Terms of Reference

BRONZE COMMAND STRUCTURE: Terms of Reference

Will receive decisions and updates from the Bronze Command and act as a point of escalation for:

o Operational Command o Strategic Change Command – which will also encompass the recovery working

group o Finance and Analytics Command

Will task cells based on any new information received via the supercells

Will triangulate information from all cells to maximise intelligence

Will capture opportunities for improvement regularly, to enable continuous improvement of delivery over timeline

3. Scope Can approve decisions escalated by the Bronze supercells or cells under the delegated

authority of its members to commit their organisations or under delegated authority from the Gold Command.

Can move resources around the system under the delegated authority of its members to commit their organisations or under delegated authority from the Gold Command:

o For financial expenditure delegated authority has been defined as up to £1m from the allocated COVID budget.

o For human resources any decisions on redeployment will be made under the delegated authority of the members of Silver to commit their organisations.

Cannot take any clinical decision but can commission advice and recommendations from Clinical Cabinet

Can authorise additional expenditure up to £1million for an individual transaction, any expenditure above this amount will need to be approved by Gold Command.

4. Membership Organisation Role Name

Bristol City Council Director of Public Health Christina Gray

Director of Adult Social Services Jacqui Jensen (for

vacant post) / Terry

Dafter

North Somerset Council Director of Public Health Matt Lenny

Director of Adult Social Services Sheila Smith / Hayley

Verrico

South Gloucestershire

Council

Director of Public Health Sara Blackmore

Director of Adult Social Services Anne Clarke

BNSSG CCG Chair Sarah Truelove

Accountable Emergency Officer, Chair of

Operational Command and Deputy Chair

Lisa Manson

Chair Clinical Cabinet / Chair Primary

Care Cell

Martin Jones

UH Bristol & Weston Accountable Emergency Officer / Deputy

CEO & COO

Mark Smith

Deputy Chair of Finance and

Analytics Cell / Director of Finance

Neil Kemsley


Organisation Role Name

Accountable Emergency Officer Mark Marriott

North Bristol Trust Accountable Emergency Officer / Deputy

CEO &

COO

Evelyn Barker

Sirona care and health Director of Transformation Julie Sharma

Finance and Analytics Cell /

Director of Finance

Clive Bassett

AWP Accountable Emergency Officer Matthew Page

SWASFT County Commander Sarah Jenkins

Severnside: Local Co-

ordination Centre

Medical Director Kathy Ryan

Managing Director Nigel Gazzard

Communications cell Chair Michelle Smith

Workforce cell Co - chairs Jacqui Marshall/ Matt

Joint

This membership will evolve and will be kept under review.

5. Frequency of meetings From week commencing 13th April 2020 Silver Command teleconferences will be held on Mondays and Wednesdays between 0800 and 0900.

6. Secretariat for the meeting The agenda will be collated by the ICC Director and manager and agreed with the Chair of Silver via the CCG EPPR team. Administrative support will be provided by the relevant administrator supporting the Incident Control Centre that day. Regular reports will be provided to Silver command from the cells using the NHS Futures platform – this will be accurate at 4pm from the previous day.

7. Capturing Outputs and Reporting Silver Command will use the NHS Futures platform for all documentation related to the meetings. Silver Command will report into Gold command through a Chairs update.

1. Introduction The Silver command structure will coordinate the delivery across the cells which have formed to manage the critical incident in Bristol, North Somerset and South Gloucestershire. The three cells within the Silver portfolios are:

Operations - known as Bronze

Strategic change

Finance and analytics

The above three supercells will constitute the silver command structure.

The terms of reference below, outline how the Bronze cell functions and reporting

arrangements

2. Purpose of Bronze cell This cell will oversee and coordinate the operational and tactical response and delivery of

additional capacity to the critical incident. The current cells established will report in Bronze but further cells may be stood up and others stood down based on the operational and tactical to the needs of the system.

o Capacity and Impact Response o Resilience o Primary Care o Voluntary Agencies o Logistics o Workforce o Organisational ICCs

The cells report to Bronze Operational Command. Regular updates will be received to the call on a rotation basis as below or as when issues are escalated or urgent decision required. Sunday will not have a designated cell update.

Day for regular update Cells

Monday Organisation ICCs Primary Care

Tuesday Resilience Workforce

Wednesday Voluntary Agencies Logistics

COVID -19: BRONZE OPERATIONAL COMMAND: Terms of Reference


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Thursday Capacity and Impact response Infection Prevention and Control

Friday Medicines and Pharmacy Vulnerable groups (including children) Care Providers

There is an expectation that the cells that sit under the bronze operational command will have links with cells in the other super cell groups and co-dependencies will be addressed directly or via silver command.

3. Membership Name Organisation

ICC Strategic Director (Rotational) CHAIR BNSSG CCG

Christina Gray or deputy Bristol City Council (Public Health)

Ros Cox Bristol City Council (Adult Social Care)

Gerald Hunt / Hayley Verico North Somerset Council

Anne Clarke or deputy South Gloucestershire Council / Care

Providers Cell

Lucy Parsons/ Mark Marriott or deputy UH Bristol & Weston

Rosanna James North Bristol Trust

Jenny Theed or Deputy Sirona care and health

Matthew Page/ Sarah Branton/ Adrian Bolster/

Alan Metherall

AWP

Sarah Jenkins / Craig Rankin/Dave Manners SWASFT

Kathy Ryan / Deb Lowndes / Nigel Gazzard or

deputy

Local Co-ordination Centre

Martin Jones/Jenny Bowker/David Moss Primary Care cell

Sian Trew Communications cell

Jacqui Marshall/Heather Toyne Workforce cell

Justine Rawlings Voluntary Agencies

Steve Sandercock Logistics

Lisa Manson Capacity and impact response.

Rosi Shepherd Infection Prevention & Control

Debbie Campbell Medicines and Pharmacy

TBC Vulnerable people (including children)

4. Administration Administration will be provided by the ICC administrator, and all relevant actions and

decisions logged. Issues for escalation will be highlighted through to silver command.

5. Frequency of meetings Meetings will be held at 11am Monday to Friday and Sunday.


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Teleconference facilities will be used: Telephone number - 0800 917 1950; Participant passcode - 87214756 #

6. Quoracy Due to the critical nature of this incident, this meeting is essential to ensure the required

level of coordination across the BNSSG health and social care system. It is therefore

regarded as an essential meeting that all organisations must ensure they provide an

attendee at.

7. Reporting Requirements Any issues that are not able to be resolved in any Bronze command supercell will be escalated to silver for resolution. The standard record of events will be used to record actions, tasks and decisions and be shared regularly with silver command.

Version Date Author / Reviewer Comment

0.1 19.04.20 Rachel Anthwal First draft for review by Lisa Manson

0.2 20.04.20 Rachel Anthwal Update proposed membership

0.3 21.4.20 Gemma Artz/ Lisa Manson.

Update to purpose from feedback from Bronze Cell discussion and following discussion with Lisa Manson.

1. Introduction The Silver command structure will coordinate the delivery across the cells which have formed to manage the critical incident in Bristol, North Somerset and South Gloucestershire. The three cells within the Silver portfolio are:

Operations - known as Bronze

Strategic change

Finance and analytics

The above three supercells will constitute the silver command structure.

The terms of reference below, outline how the Finance and analytics cell functions and the

reporting arrangements

2. Purpose of Finance and analytics cell This cell will oversee and commission analysis to support an effective response to the

incident and ensure that resources are not an obstacle to delivering the response in line with National direction and where necessary making recommendations to silver and or Gold where local resolution is required. This cell acts as a support to both the Bronze and strategic change cells and may be commissioned to support work in those areas or may ask other cells to respond where analysis suggests further work is required. The cell will also link to the Recovery and restoration work and ensure oversight of the resources required for both the incident and the wider recovery, providing understanding of the various resource restraints as the situation develops. The current cells established will report into the Finance and analytics cell but further cells may be stood up and others stood down based on the needs of the system.

o Analytic o Finance

Regular updates will be received to the cell on a weekly basis or as when issues are escalated or urgent decisions required.

COVID -19: Finance and analytics super cell: Terms of Reference

Finance and analytics super cell: Terms of Reference

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3. Membership

Suggest we add in financial representation from LAs and Seb Habibi to increase link to

recovery and restoration work.


Bristol City Council Director of Public Health Christina Gray

Director of Adult Social Services Jacqui Jensen (for vacant

post) / Terry Dafter

North Somerset Council Director of Public Health Matt Lenny

Director of Adult Social Services Sheila Smith / Hayley

Verrico

South Gloucestershire

Council

Director of Public Health Sara Blackmore

Director of Adult Social Services Anne Clarke

BNSSG CCG Accountable Emergency Officer,

Chair of Operational Command and

Deputy Chair

Lisa Manson Director of

Commissioning

Chair Sarah Truelove, Deputy

Chief Executive

Chair of Strategic Change

Command and Deputy Chair

Deborah El-Sayed,

Director of

Transformation

UH Bristol Accountable Emergency Officer Mark Smith, Deputy CEO

& COO

Deputy Chair of Finance and

Analytics Cell

Neil Kemsley, Director of

Finance

Weston Area Health

Trust

Accountable Emergency Officer Mark Marriott, Director of

Operations

North Bristol Trust Accountable Emergency Officer Evelyn Barker, Deputy

CEO & COO

Bristol Community

Health

Accountable Emergency Officer Aileen Fraser

North Somerset

Community Partnership

Accountable Emergency Officer Sara Harding, Director of

Operations

Sirona Accountable Emergency Officer Jenny Theed, Director of

Operations

Finance and Analytics Cell and

Director of Finance

Clive Bassett, Director of

Finance

AWP Accountable Emergency Officer Matthew Page, Chief

Operating Officer

SWAST County Commander Sarah Jenkins

Local Co-ordination Severnside Medical Director / Kathy Ryan / Nigel

Finance and analytics super cell: Terms of Reference

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Centre Managing Director Gazzard

Primary Care Chair of primary care cell Martin Jones, Medical

Director BNSSG

Communications Chair of comms cell Michelle Smith

Workforce Chair of workforce cell TBC

4. Administration Administration of the Finance and Analytics Cell will be provided by Healthier Together. All

papers should be circulated in advance of any meeting. Issues for escalation will be

highlighted through to silver command.

5. Frequency of meetings Meetings will be held at 8am Friday or as required should an urgent request require it. Microsoft teams meetings will be set up.

6. Quoracy Due to the critical nature of this incident and the importance of system understanding of the

nature of the issues faced, this meeting is essential to ensure the required level of

coordination across the BNSSG health and social care system. It is therefore regarded as

an essential meeting that all organisations must ensure they provide an attendee at.

7. Reporting Requirements Any issues that are not able to be resolved in any finance and analytics super cell will be escalated to silver for resolution. The standard record of events will be used to record actions, tasks and decisions and be shared regularly with silver command.

Version Date Author / Reviewer Comment

0.1 24.04.20 Sarah Truelove Following discussion with BNSSG DoFs

1

System Change Command

Draft Terms of Reference

Version Date Author/Reviewer Comment

0.1 08/04/20 Cintia Faria First draft, following feedback from all

0.2 09/04/20 Seb Habibi Second draft, updated in line with

proposals that were approved by Gold

Command on 9 April

0.3 14/04/20 Cintia Faria Update to Command’s name as

agreed at the first meeting and

addition to Diabetes Cell.

0.4 30/04/20 Gemma Self Update to demonstrate link to

recovery work

2

1. Purpose

To coordinate delivery of transformational change to enable the system response to

COVID-19.

To facilitate consistent approaches across the system to support new ways of working

for non-COVID patients.

To ensure that accelerated transformation priorities are connected across the system

and related benefits are clearly being delivered.

2. Scope

As of 14 April 2020 the scope of cells under the System Change command includes:

Digital

Cancer

Children’s services

Maternity

CVD

Diagnostics

End of Life Care

Frailty

Outpatients

Respiratory

Stroke

Mental Health/ LD and Autism

Diabetes

Locality development

Primary care transformation

The scope may be varied from time to time according to system objectives and

priorities.

3. Review

These terms of reference will be reviewed after four weeks from 14 April and may be

updated from time to time as required.

4. Functions

Receiving tasks from the Gold and Silver Commands and assigning tasks to cells

within the System Change Command.

Reporting regularly to the Gold and Silver Commands.

Coordinating resources from across the system to support the Cells within the

System Change Command to deliver their objectives.

3

Receiving decisions from Cells and escalating issues for decision by the Gold and

Silver Commands (See ‘Decision Making Framework below).

Working with senior leaders from across organisations to facilitate decision

making on aspects beyond the remit of the Super Cell.

Management of risks and issues and escalating where required to ensure delivery

of transformation objectives.

Developing routes for communication and reporting through to Silver and Gold

Command on the delivery of transformation.

Ensure that message from senior leaders and Silver Command are cascaded

through to cells delivering transformation.

Oversight of any system transformation projects that are progressing at a slower

pace during the critical incident response phase where business as usual

programme governance through Healthier Together steering groups has been

suspended.

Coordinate in with the System Recovery Enabling Group and be tasked with any

recovery related transformation activities.

Providing recommendations and updated proposals to silver and gold where

opportunities, innovations and improvements are critical to achieve agreed

objectives.

5. Governance

6. Principles for escalation to Silver

When there is a risk of reputational damage

For decisions that will affect the long term plan,

For decisions that falls outside of programme budget.

System Recovery

Enabling Group

Healthier Together

Executive Group

Covid Command Incident Response

Infrastructure

Healthier Together

System Architecture

Critical

relationships

4

7. Membership

Core Team

Name Role

Deborah El-Sayed Chair, Director of Transformation

Seb Habibi Co-Chair, Healthier Together Programme Director

Becca Dunn Vice Chair, Deputy Director of Transformation

Steve Rea Associate Director of Programme Delivery

Gemma Self System Transformation Lead

Andy Newton Planned Care Transformation Lead

Cintia Faria Programme Delivery Manager

Anna Grant PMO Coordinator

Harriet Pine PMO Coordinator

Partners

Name Organisation

Sarah Nadin UHBW

Tim Keen / Niall Prosser NBT

Julie Sharma / Melanie Reeks Sirona Care and Health

Terry Dafter Bristol LA

Gerald Hunt NS LA

Chris Sivers SG LA

Deb Lowndes Severnside

Rhys Hancock / Sarah Jenkins SWASfT

Jane Rowland (to rotate between Mathew Page,

Sarah Branton, Adrian Bolster and Alan Metherall)

AWP

5

This membership will continue to evolve.

Cell’s Representatives

Name Cell

Dan Offord Digital Cell

Gemma Artz Cancer Cell

Ali Ford Children’s services Cell

Hannah Miller Maternity Cell

Ben Stevens CVD and Diagnostic Cells

Christina Lowe End of Life Care Cell

Greg Penlington Frailty Cell

James Dunn Outpatients Cell

Ruth Hughes Respiratory Cell

Jeremy Westwood Stroke Cell

Carol Slater Mental Health/ LD and Autism Cell

Sharon Sexton Diabetes

David Jarrett (tbc) Locality Development Cell

Martin Jones and Ruth Taylor Primary care transformation Cell

Gemma Self System Recovery Cell

8. Meetings

The System Change Command core team members will meet daily as required.

6

All members to meet weekly for 1 or 2 hours. Please note details of these meetings are yet to be agreed.

Cells and Partners are expected to highlight briefly (ideally within 3 minutes): o What they plan to do in the next week or month o What they have achieved o Any barriers that require additional support or escalation

Dial in and conference facilities will be the norm – no face to face contact is to be expected at meetings.

There will be a standard agenda going forwards, however one off agenda may be

required, and if this is the case, it will be built collaboratively.

9. Reporting

Cells will maintain reports on delivery and a log of decisions, risks and issues using the Record of Events template on the NHS Futures Collaboration Platform.

The System Change Command will provide a collated report to the Gold and Silver Commands at least once per week on delivery against cell objectives and assigned tasks.

10. Decision Making Framework

Level Function

names

Level of Permitted Authorisation

General

principles

All The system command cells and supercells are empowered to make decisions that are necessary to deliver their objectives and should consider where decisions should be escalated, having regard to the following principles

i. In general, decision making within the BNSSG STP system command structure is under the delegated authority of system partners for members of the command cells and supercells to commit their organisations

ii. On specified matters, the Silver and Bronze

command cells or supercells may make decisions under delegated authority from the Gold Command.

iii. The rationale for decisions should be documented.

iv. Any decision should be escalated to Gold Command for approval that:

Departs significantly from the strategic direction

7

Level Function

names


set out in the BNSSG Long Term Plan.

Impacts materially on public and patient access to

services.

Carries significant clinical, reputational, legal, or

financial risk.

Requires additional resource over £1,000,000 per

transaction.

Cell Level All Assuming all relevant organisations are represented by

the cell and have been delegated authority on behalf of

their organisations, cells can make decisions required to

deliver their objectives and tasks. This is true unless:

a) This is a change to the agreed scope and

objectives of the cell

b) There is an increase or change in clinical risk that

may need to be managed by the system

c) Additional resource from elsewhere is required

d) There are implications for other organisations

and/or service areas that need to be considered

Any such proposed change would need to be signed off

as set out below

Bronze

Level

Operational

Command

If a cell sits under this line of authority and requires a

decision that:

a) Requires approval of changes to the scope and

objectives of a cell

b) Requires additional resource up to and including

£500,000 per transaction and subject to there

being sufficient delegated budget

c) Has implications for other organisations and/or

service areas through rapid implementation that

need to be considered and managed

d) Needs to be addressed within the next 24 hours

System

Change

Command

– which will

also

encompass

the recovery

working

group

If a cell sits under this line of authority and requires a

decision that :

a) Requires approval of changes to the scope and

objectives of a cell

b) Requires additional resource up to and including

£500,000 per transaction and subject to there

being sufficient delegated budget

c) Has implications for other organisations and/or

service areas through rapid implementation that

need to be considered and managed

8

Level Function

names


d) Requires approval of system-wide changes that are deemed essential as part of the COVID-19 response but that are not included in the Long Term Plan.

Finance

and

Analytics

Command

Can authorise:

Decisions that impact on financial risk

Movement of funding around the system

Rapid payments

Approaches to accounting for system costs in

responding to COVID-19

Changes to information governance

Silver

Level

Silver

Command

Must oversee decision making and report regularly to

Gold Command and:

a) Can initiate new work stream areas and stop/start

other workstreams in response to recognising

requirements of the whole system

b) Authorise changes that require additional resource up

to and including £1,000,000 per transaction and

subject to there being sufficient delegated budget

c) Must authorise any changes that lead to additional

operational, performance or financial risk to the

system

Clinical

Cabinet

Must on behalf of Silver Command authorise recommendations:

a) Changes proposed by an organisation, cross-cutting service or pathway area that may have an unintended consequences in another part of the system but has not yet been tested

b) Changes that will lead to an increase in clinical risk being managed i.e. closure of a service, or change in threshold for an intervention

Gold

Level

Gold

Command

(executive

group)

Must authorise changes that:

Depart significantly from the strategic direction set

out in the BNSSG Long Term Plan

Impact materially on public and patient access to

services

Require additional resource over £1,000,000 per

transaction

Carry significant clinical, reputational, legal,

performance or financial risk

System Change Command Highlight Report

Date report updated: 03.05.20 W/C - 27/04/20

Cell name Objectives Update Items for escalation

01 Digital Agreeing our shared COVID-19 digital priorities, responding to key risks and actions identified via the system or local ICCs.

* Co-ordinating the delivery of key digital functionality across the system as rapidly as possible ensuring a single system wide view of

digital delivery is available to both Silver and Gold Command ERPP structures.

* Adopting a series of key focused objectives for each 2 week sprint focused on delivering critical capability rapidly.

Supporting wider COVID19 cells to resolve issues and presenting problems. To ensure this is a controlled and organised activity, the digital

cell will develop a log of COVID19 related core digital requirements. This set of requirements will be used to define the next sprint/ series

of system level priorities.

* Preparing coordinated responses to regional and national requests for information, opportunities for collaboration and proposed

technical solutions.

* Create the Digital Cell COVID19 communications hub that will hold all up to date information for health and Social care partners as part

of the COVID19 Silver command structure on NHS Futures Platform.

* As the impact on the whole workforce grows the Digital cell will look to co-ordinate mutual aid for staff with digital skills to be able to

respond to the most pressing priorities in the system.

* Maintaining focus upon cyber security as a system priority.

Being accelerated:

On line consultation solutions:

* AccuRx: 100% GP uptake and BNSSG is one of top national users (11,500 video consultations in 3 months); additional template also developed to support specific patient conditions

* Attend Anywhere: 12 month National licence for Trusts and Sirona greed;BNSSG use increased to 350 consultations in 2 weeks

* GP online Triage (aka E-Consult : All BNSSG GPs have procured a solution, with 100% usage planned by end of April

Charlson Comorbidity Index:

* Deployed into Connecting Care on 9th April. Work underway to increase uptake by reducing barriers to its use

Equipment:

* Laptops: 400 GP, 137 Acute, 134 AWP, 84 Sirona laptops procured and distributed; more to follow next week

* Webcams – the main current concern, due to delayed supply chains and requirement for online consultations.

Cyber Security:

* All providers feedback on adherence to national cyber protocols – including back-ups

* Next digital increment to include deployment of instant messaging/reporting tools, roll out assistive patient technology tools and Web access for Connecting Care.

Update 30/04/20 - Completed this week:

80+ additional laptops secured for BNSSG

Initial scoping of next digitial increment complete

Top priorities for next week:

- Complete roll out of E-consult and AA solutions

- Scope Social Care digtial requriements

- Initiate system benchmarking of existing remote monitoring/citizen enabling technology

- Undertake system review of clincian-clinician tools (including Careflow)"

02 Cancer To ensure the safe ongoing management of cancer patients during the crisis

* To monitor impact of crisis on cancer diagnosis and management

* To link with IS work to ensure maintained capacity for urgent cancer surgery

* To ensure national and local guidance is reviewed and discussed and plan implementation

* To link cancer leads with other work on outpatients, capacity and diagnostics and the impact on work.

Success will look like:

* Minimise the harm to patients as a result of delayed diagnosis or treatment of cancer during the COVID19 crisis.

* Clinicians in primary and secondary care are supported with information to inform decision making and processes

Being accelerated:

* To ensure the safe ongoing management of cancer patients during the crisis including move of urgent Cancer treatment to Emersons Green Treatment Centre (Care UK)

Update 27.4.20

* Significant drop in 2ww referrals – national campaign launched this weekend. Linking with Comms re local media campaign and messages.

* System endoscopy meeting being set up to co-ordinate use of available capacity, including PRIME, Care UK etc.

* Regional update – reviewing role of SWAG surgical hub

* Reviewing how we can restart the Dermatoscope project to support Teledermatology.

All BNSSG Endoscopy sites continue to only undertake emergency and urgent procedures. Further guidance form the Bristish Society of Gastronetologists is due imminently which will advise sites on how

they can resume other priority cases.

The cancer cell are working with independant sector providers to ensure we make best use of this capcity.

The Cancer cell are linking with the communications cell to align local and national media messages.

SWAG Alliance is developing proposals for a virtual cancer hub which will offer mutal aid if capacity is limited.

03 Children's

Services

Strengthening partnership to accelerate systemwide projects that keep vulnerable children, and those with complex needs well, in the

community, and out of acute care:

* Implementation of Connecting Care for voluntary sector providers

* Platform for sharing confidential data and information between providers

* Exploring all skill mix opportunities

* Establishing a system-wide list of prioritised vulnerable children (health)

* Regular cross-referencing the 'health' vulnerable list with social care and education vulnerable lists in each local authority

* Developing shared operational prioritisation arrangements

* Reviewing and improving transfer arrangements between providers

* Access to medications and shared drug chart

* Where appropriate, supporting educational access during COVID19

* Organising a centralised hub to provide advice for families

* Developing a 24/7 (on call) medical advice line

* Supporting the analysis of PPE need within all children's services, and tracking processes to facilitate mutual aid

Being accelerated:* Work in partnership with education and social care to ensure a co-ordinated response to Covid-19 for children and families

* Agreed list of prioritised vulnerable children with complex medical needs in order to enable resilience and stability of community care for prioritised vulnerable children by enabling workforce sharing between Sirona and commissioned

voluntary sector providers

* Established a restricted folder within the NHS Futures platform to provide a platform for sharing confidential data and information between providers

* 24/7 centralised hub has been rolled out to provide advice to families with on call medical advice available. The hub is based at Children’s Hospice South West, the advice line is available to all families of children from the agreed list of

prioritised vulnenerable children with complex medical needs

* Additional BRCH Discharge Information template developed with Children’s Social Care and Lifetime to improve quality of discharge into community

Update 30.4.20

Concerns with the decision to turn off routine referrals from GP's to all services have been escalated via UHBW,CCG primary care cell and CCG clinical cabinet.

Developing a proforma to be used to capture information from across the system to aid the recovery planning process, collated information to be provided to the cell 05/05.

Modifying the current Jessie May drug chart to make this suitable for use across organisations, address issues which have presented due to limited pharmacy capacity and multiple governance structures.

* DCO letter and distribution process agreed with LAs for parent carers who need to take children out of immediate local area for health reasons. BNSSG SEND Boards have re-formed and begun to address the impact

of Covid on SEND provision.

* Exploring risk and implications of different organisations interpreting the PPE guidance in dfifferent ways. Lifetime workforce facing cahllenges but managing successfully. Other health providers in good workforce

position.

* BNSSG children's settings PPE data collated and submitted to PPE modelling and mutual aid team

* BRCH additional Covid discharge information template agreed by all partners and operational from 27.04.20


04 Maternity Supporting the maintenance of current maternity services through their COVID19 response and, where possible, accelerating the aims of

our Maternity Transformation Programme:

* Escalation of operational issues through the system silver command structure, helping to ensure a system wide approach to new

guidance/process which are being implemented very quickly.

* Sharing communications with the maternity voices partnership social media channels.

* Facilitating shared learning across the system

* Sharing information from, and reporting to, the

regional and national teams

* Supporting the development of IT bid for laptops and other innovative equipment (e.g. home blood pressure monitors) that will aid staff

and patient safety

* Exploring opportunities for workforce sharing and skill mix between maternity and health visiting teams

Update 30.4.20

- Sandra Reading continues to progress work to identify the possibility for honorary contracts to be established for midwifery staff across the system.

- Communications are in place on both NBT and UHBW website's and patient information applications, establish a communications sub group which meet on a weekly basis to manage communication

issues effectively moving forward. Plan to begin using the maternity voices social media from w/c 04/05.

- NBT obstetric team are reviewing guidance and producing a proposal for which scans will be stood down in which order should this be required if the situation worsens, this proposal will be shared with

UHBW.

- A UHBW midwife is producing a digital antenatal education package for use across BNSSG, estimated to be shared with the cell w/c 04/01.

- Ongoing work to establish agreement from NBT and UHBW to progress with blood pressure Hamptom app for a 3 month free trial.

- Continue to report operational changes to NHS England every Tuesday alongside twice weekly reports of the number of COVID positive cases within both Maternity units.

- NBT and UHBW are reviewing previous risk assessments, UHBW are anticipating to restart the homebirth service from w/c 11/05.

05 CVD * To accelerate the development of Heart Failure services in BNSSG and implement an approach to Cardiac

* Rehab that does not require face-to-face contact.


* Development of a heart failure service that moves people out of hospital more quickly.

* Heart Failure sub-group met and defined what a good HF service would look like. There was clear buy-in from all parts of the system and a way forward is becoming clearer

* NBT have progressed the delivery of remote monitoring and UHBW are working towards it. These steps will reduce the need for AF patients to come into hospital for monitoring and means they can

have their arrhythmia monitored without any face-to-face interaction.

Update 30.4.20

There haven’t been any meetings this week, no set plans to update yet.

Introduction of remote monitoring for AF patients at NBT completed and working to roll out at UHBW.

06 Dianostics * Review what strategic changes might be made to the delivery of diagnostics that both supports the delivery of the 5 Year Plan and the

provision of diagnostics during COVID19

* Coordinate the responses of the different diagnostic modalities to the COVID19 pandemic

* Respond to requests and diagnostics requirements to support the wider system

* Explore options delivery of diagnostics in BNSSG that maintains safe access for as long as possible

* Evaluate the risks associated with different models of delivery and ensure they are properly assessed and mitigated

* Manage issues around the implementation of new diagnostic referral guidance

* Maintain oversight of the DMO1 performance issues and manage the diagnostic recovery after the pandemic

The scope of the group has been clarified and the Cell will proactively focus on the following modalities:

o MRI

o CT

o Plain film X-Ray

o Endoscopy

This will maintain the strategic shape of the diagnostic programme in the 5 year

plan, however the Cell will reactively respond to issues raised in other modalities as the system requires.

* On 8th April, Clinical Cabinet approved the approach to diagnostic imaging,

subject to amendments.

* On the 14th April, BNSSG Gold Command signed off the unified approach to Diagnostic imaging in BNSSG

* That guidance on imaging is now on Remedy (appended below), with a

more detailed version on TeamNet. There has also been a communication

sent to Primary Care colleagues to make them aware of the new referral

guidance.

* The Diagnostic Cell is meeting formally for the first time on Wednesday 22nd,

having just been an informal catch-up to this point.

* Gemma Artz has made significant progress in working with the Independent Sector on utilising their diagnostic capacity.

27/04/20 - We need to understand the workforce and equipment

implications of Nightingale UWE on our Acute Radiology departments ASAP

to allow them to plan.

As a result of the changes in Radiology to address COVID, the departments

are conducting more chest x-ray than usual. Normally, these chest x-rays

would be conducted by 1 Radiographer, but they must now be conducted by

2 Radiographers to maintain infection control. This has had a major impact

on the capacity in Radiology. To address this, Radiographers have been

moved off CT/MRI onto X-Ray and shift patterns have been changed,

reducing capacity on other modalities.

07 End of Life

Care

* To coordinate end of life planning across a wide range of organisations, including Sirona, the three local acute trusts, the two Hospices,

primary care, residential and nursing care homes, domiciliary care and the CCG;

* To ensure all the key people are involved in producing end of life guidance

* To ensure information is shared across all the main providers so everyone is aware of the guidance being developed, modelling data

being produced etc.

* To support organisations to implement new pathways and guidance within their organisations

* To share good practice to save people starting from scratch

* To provide a mechanism for organisations to escalate issues up through the COVID19 governance structures for them to be resolved

* Guidance has been produced on anticipatory prescribing and protocols for EMIS have been agreed and are being rolled out to all practices with support from One Care

* Guidance on how to enable carers to administer subcutaneous injections in community settings is being rolled out. District Nurses are assessing carers competence and providing Carers authorisation

charts, training for carers and information sheets for carers

* Training is being provided to enable community staff to verify a death in the community. Alternatively clinicians can support verification remotely if the patient is with someone a health care

professional who is not trained in death verification

* A new Standard Operating Procedure is being written on post end of life care

* More senior clinicians are now supportingthe Hospice end of life 24/7

advice lines out of hours to manage the increase in demand and complexity

* St Peters Hospice have produced two webpages, one for clinicians and one for carers to explain the new end of life guidance and other organisations are signposting staff and carers to them - now live

* Support is being provided to Care Homes on end of life care as Sirona

staff are providing wrap around Multidisciplinary Team meetings with

Care home staff, where care homes are offered an hour with a clinician

virtually to discuss any issues.

* Sirona have run webinars on the end of life guidance for their staff

* End of Life Frequently asked questions have been produced and will be on the Futures NHS Collaborative Platform

08 Frailty * Delivery of integrated frailty service and acceleration of components of model of care to support C-19 response.


* System-wide agreement on revisions to model of care (MoC) to support C-19 response:

o Virtual practice MDTs

o Acute specialist support to care providers

o Clarity on any revisions to timescale for mobilisation of full IFS in light of C-19 recovery planning.

Update 24.04.20

* Virtual Frailty MDTs: the Model of Care Group has signed off the approach to

implementing the virtual model. Work has already commence to accelerate

virtual MDTs in localities using MS teams;

* Revised SOP to be completed w/c 27.04.2020.

* Ongoing work is taking place in respect of care homes wrap around teams with

the Care Provider cell to define the specialist medical input that is required;

* It has been confirmed that the reprioritised Sirona transformation plan is

going to the next Recovery Cell for decision about the Frailty Hub mobilisation

Update 30/04/20 - Priorities for next week:

Circulate latest version of Frailty MDT SOP to clinincal reference group and MDT working group members for feedback


09 Outpatients * Ensure a centralised and coordinated response that enables effective social distancing for staff and patients, minimises pressures on

acute services, whilst providing sufficient access to specialist knowledge to support primary care management of patients

* Ensure alignment to national guidance as it emerges

* Keep as much high value OP activity going as possible (cancer, urgent, high risk groups)

* Free up clinician capacity to focus on acute inpatients

* Accelerate shared care between primary, community & secondary

* Accelerate non-F2F contacts with patients

* Safely manage clinical risk

* Provide clear & rapidly evolving communication to all parts of system (e.g. REMEDY, messages to patients, clinical teams etc.)

* Enable rapid recovery post-COVID by adopting new transformed models of care

Update 30/04/20

Response to NHSE Guidance - A paper has been drafted to go to System Silver on 04/05. This sets out a proposal to pause re-opening referrals for approx 2 weeks while the system agrees some key

principles for outpatients, and providers have time to assess readiness.

A&G Implementation - Uptake seems to be pretty good. Providers seeking qualitative feedback from clinicians. E-RS is a bit clunky, but thought to be best option for now. NG will seek feedback on

neurology pilot. JD to escalate reporting issue to digital cell, as well as development to link Medway pulling data through from ERS.

Attend Anywhere and AccuRX Implementation - Feedback is being gathered from patients and clinicians. Early indication are that it is really well recevied.

Clinical Triage - MSK is a really good example of effective traige. JD to find model and see what can be learnt for other services. RSS can support with pending patients triage. Service should think about

the clinical guidance that can help to inform this.

South Gloc onto RSS - No further practices have joined this week. JD, HC, RA and DP to meet to understand Bath referral issue and to frame option into system principles for mandatroy use.

10 Respiratory * Appropriate cessation of activities as the pandemic progresses

* Implementing the agreed tiered model for urgent advice and guidance

* Implementing the agreed model for facilitated discharge or prevention of admission (respiratory patients – chronic lung disease or new

symptoms)

* Implementing a pathway for patients requiring oxygen weaning/ breathlessness management: discharge from acute care (any hospital)

or via the SPA

* Delivery of training to community based staff

* Face to face Pulmonary Rehab stopped on 16th March (digital alternatives are being made available) and Home oxygen assessment reviews will be paused from 27th April.

* Model of care signed off by Clinical Cabinet on 23rd April 20

* Provision of advice and guidance to colleagues commences its phased launch from 27th April 20

* Maximising opportunities for prevention of admission and facilitated discharge

commences 27th April 20

* Training has commenced

Update from 30/04/20

* Model of care - After being approved by Clinical Cabinet on 23 April 20, the paper was passed to Bronze Control and the System Change cell on 28 April 20 for their information.

* Communication plan has been developed and shared with partner organisations.

* HR processes ave been completed for GPs providing support to the advice and guidance service

* Community partners have continued to implement their training programme for non-specialist community staff

* SOP circulated for consultant advice and guidance service

* Checks have been made that stakeholders are happy to go ahead with new service and final call scheduled for 0900 Friday 30th April to ensure comms can go out.

Top priorities for next week:

* Prepare update for Silver regarding communications and next steps

*Ensure phone line is secured

* MOnitor implementation and support as required

11 Stroke * Establish stroke discharges through community ICB pathways

* BIRU Discharge Pathway

* System Advice and Guidance

* Centralised HASU (detail TBC)

What success looks like:

* Stroke discharges to be incorporated in to community ICB processes.

* Strong links with the voluntary sector for support to ensure that where discharges may be quicker than usual

* A clinically agreed pathway in place to support stroke discharges requiring more complex interventions.

* A robust discharge process in place for patients leaving BIRU and returning to the community via Sirona.

* An agreed contractual mechanism in place to support moving the sub-acute rehab provision in NBT to enable more acute based capacity

be available to support covid-19 pressures.

* A centralised point for system advice and guidance based on levels of clinical and operational priority.

* A rota supported by colleagues across the system, hosted by NBT.

* A centralised specialist acute / hyper acute facility for all stroke patients.

Update 30.4.20

The BNSSG Stroke programme has agreed an aspect of the Covid-19 response that focusses on ensuring that discharges are progressed as soon as medically possible to support the system pressure on

acute beds.

-Southmead and BRI therapies have seen a reduction in stroke admissions and presentation at HOT clinic / ED. ESD teams are operational but providing support through telephone contacts and home

programmes. Therapists at WGH report fewer stroke admissions but an increase in admissions of complex medical patients onto the unit. Concerns have been raised about the lack of P2 beds

appropriate for stroke rehab in North Somerset and the impact of flow on acute beds. Stroke rehab at SBCH is continuing as normal. Sirona are continuing to model a community stroke resource that will

be able to triage all community stroke referrals and provide specialist advice and guidance to colleagues working in P1 and P2 pathways across BNSSG if required. The service will also provide direct

support to service users with on-going rehab needs who are discharged from services with on-going rehab needs if community teams are unable to do this. Community referrals will be sent to the

CICB’s, triaged and copied to the community stroke team email account. This process is currently being trialled in South Glos. Once fully operational the service will facilitate a system wide MDT meeting

to include the Stroke Association and Bristol After Stroke.

- BIRU discharge pathway paused

- Conversations took place this week to confirm the requirements of centralised HASU

- Conversations ongoing re system advice and guidance

12 Mental

Health

Delivering short, medium and long term actions to support mental health and wellbeing.

Taking decisions to enable the mental health system to operate effectively. This includes acting upon any blocks or gaps in mental health

services, and ensuring that mental health capacity is supported, maintained and coordinated across BNSSG in response to this incident.

This includes: - Supporting preparations for the increased demand for mental health services.

- Having oversight of significant mental health operational changes within each organisation (which may impact on the wider system), and

offering direction and support for contingency plans for mitigation.

- Leading on the coordination of key support, e.g. bereavement training and services.

Understanding changes in our population’s mental health needs (e.g. assessing real-time indicators from partners, which may include NHS,

local authorities, education providers, police, employers and voluntary sector organisations), and using this to determine the Cell’s

priorities.

Consistently seeking to reduce health inequalities.

Agreeing priority groups to focus upon, and coordinating system-wide actions. This will include both immediate service needs, as well as

supporting a psychologically informed population-wide response. This may also include accelerating suicide prevention strategies to

reduce the number of suicides at a time when more people might be in or reach a crisis.

Sharing intelligence and feedback with the Strategic Change Command and its other cells, and escalating risks.

Ensuring that information about available mental health support is widely and accessibly communicated, to both professionals and the

public (working closely with VCSE and Communications Cells, and the sign-posted providers to ensure that they have capacity).

Prioritising key issues, and identifying additional resourcing requirements and sources of funding / resource to support the response

(including from other cells).

Communicating regularly between: cells and related groups (e.g. domestic abuse, homelessness); multi-agency and community fora

(including suicide prevention and social prescribing groups) within each locality; regional partners, such as the West of England Combined

Authority; and national partners, including NHSE/I and Public Health England.

27.04.20:

Actions undertaken:

New Mental Health and Wellbeing Sub Groups have been established (led by the CCG, public health, NHS providers and the voluntary sector). These aim to offer robust oversight of different levels of mental health need

(all age) to coordinate support and quickly escalate risks and issues. Their reporting mechanisms to the MH and Wellbeing cell are in place.

Self-Harm - Initial Plan to be agreed

Update on agreed whole-system metrics

Update on MH Helpline Partnership Agreement

Suicide Prevention plan (COVID-19) - agree process

Health Inequalities and Equalities Framework (Mental Health and Wellbeing)

System Recovery – to establish links with Recovery/Restoration Cell.

Agree with wider Cells remit for Bereavement Support.

Agree scope of new Learning Disability and Autism Sub Group

New Mental Health Out of Hospital Response Task and Finish Group agreed – to be set up

Liaison Psychiatry and AWP COVID-19: Joint MH Escalation Plan has been developed.

Infrastructures around sub-cell - to ensure all providers understand escalation levels - developed.

MH and Wellbeing helpline infrastructure for BNSSG agreed.

New Trauma Informed Approach Working Group established to offer training and support for BNSSG workforce.

New Perinatal Mental Health Task and Finish Group agreed - to be set up.

Work for next week:

• Self-Harm - Initial Plan to be agreed

• Update on agreed whole-system metrics

• Update on MH Helpline Partnership Agreement

• Suicide Prevention plan (COVID-19) - agree process

• Health Inequalities and Equalities Framework (Mental Health and Wellbeing)

• System Recovery – to establish links with Recovery/Restoration Cell.


13 Locality

Working

* Support the mutual resilience and effectiveness of providers’ responses to COVID19 at locality and PCN level

* Clearly establish model of care from responsible Cell, covering the priority areas identified:

o Joint approach to primary and community home visiting (incl. remote monitoring)

o EOL community care

o Support to care providers (incl. Respect process)

o Supporting complex discharges Urgent care for minor ailments

o Develop first draft of locality plans for implementation of the above, via locality

o partnership boards.

Being accelerated:

* Virtual MDTs for frailty established in all localities

* Joint approach to home visiting between primary and community care

* Improved support for complex discharges and to care homes - Respect forms in place for all residents.

* Locality model has been developed, next will be working on care home support team and the Home Visiting model.

14. Diabetes * Peer communication/training

* Patient facing communication/education

* Supporting early discharge/clinical pathways


* Health professionals having timely succinct information to support clinical decision making; Diabetes specialist nurses have access to

support, advice and guidance from consultants; Primary care colleagues have access to diabetes specialist nurses.

* Patients can easily access and understand reliable information and advice and Patients normally receiving face to face structured

education have access to suite of resources to support their learning and understanding.

* Secondary care clinicians can confidently discharge patients with diabetes and refer to diabetes specialist nurses for ongoing support in

the community; Clinicians are supported to start Insulin where required.

Two work streams in place:

*Patient Facing comms/resources/pathways

* Health Professionals and Peer Support

Appropriate cessation of face to face structured education approved at Clinical

Cabinet 18/3/20. Comprehensive resource pack developed for patients. Changes to the existing footcare pathway approved at Clinical Cabinet 1/4/20. Communication to raise awareness of symptoms

associated with undiagnosed Type 1 diabetes in children and adults in progress

Being accelerated:

* Secondary care referral process to community DSNs to support early

discharge

* Availability of key patient resources in a range of languages

* Communication and support for care homes

* Collaboration with DM UK to develop online patient platform

* Provision of advice and guidance

15. Primary

Care

* To support the identification of vulnerable individuals and oversee the most effective deployment of available resources in collaboration

with partner organisations to meet needs

* To co-ordinate measures to support the resilience of primary care workforce and care delivery and to adapt these measures to reflect

the evolving situation

* To oversee and coordinate the primary care commissioning and provider response to the current and predicted impact

* To ensure practices and partners are kept appraised of the evolving situation

* To act as a central point of contact for stakeholders and partners regarding the primary care response

* To report to and disseminate from the BNSSG Health and Care Silver Command

One Care colleagues will be attending System Change Command to provide voice of primary care & make connections on behalf of primary care cell. The formal reporting line for the primary care cell,

however, will remain with operational

bronze.

Being accelerated:

* Six branch practices closed across the CCG area to concentrate resources in

main practices

* Rapidly rolling out online consultation capability to all practices

* Following RGCP guidelines and national NHSE guidance about routine work which could be paused as COVID19 pandemic escalates

* Practices are operating a triage first approach and zoning as per the national SOP for primary care

27/04/20 - Homeless services - part of vulnerable groups piece of work, but

needs escalating to Silver as requires wider support than Primary Care Cell

can offer.

Suggested group members: Local Authority, VCSE, Hostels etc.

covid -19: silver operational command: terms of reference · 2020. 5. 4. · the three cells within...

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