Agenda item: 8

Paper no: 5

Title of Report: Covid Incident Response

Status: TO NOTE

Committee: Governing Body Date: 28/04/2021

Venue: Virtual meeting

Presented by: Elaine Newton, Director of Planning and EPRR/AEO Executive Lead sign Karen McDowell, ICS COO/ Deputy CCG AO Date: 19/04/2021 off: Stephen Haynes, Covid Transition Consultant Elaine Newton, Director of Planning and EPRR/AEO Author(s): Plus inputs from Subject Matter Experts, e.g. Covid testing and vaccination programme

Governance Conflict of Interest: None identified  The Author considers: Previous Reporting: A previous report on Covid Incident Response was presented to (relevant committees/ Governing Body in January 2021 forums this paper has previously been presented to) Freedom of Open – no exemption applies. Part I paper suitable for  Information: The publication. Author considers:

Executive Summary This report presents a high-level summary of the Covid Level 3 incident response, both across Surrey Heartlands Integrated Care System partners and with the Surrey Local Resilience Forum to reflect the multiagency effort.

It headlines the issues that have presented throughout the second wave, and the transition in March 2021 from a level 4 to a level 3 NHS incident. The paper also highlights how the response continues to be managed and any risks mitigated.

This paper also covers the headline updates for the Covid-19 testing and vaccination programme across Surrey Heartlands.

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Implications What is the health • Objective 1: Continue to work towards achieving sustainable impact/ outcome and systems. is this in line with the • Objective 2: Develop collaborative working and organisational CCGs’ strategic change, at both place and scale. objectives? What is the financial/ Costs attributable to Covid incident response have been logged resource required? and submitted for Covid reimbursement budget What legislation, • Civil Contingencies Act 2004; policy or other • NHS Act 2006 (Sec 252A) as amended in Health & Social guidance is relevant? Care Act 2012 sec 46; • The Health Protection (Coronavirus, Restrictions) () (No. 4) Regulations 2020 – grants the Government emergency powers; • NHS England EPRR Framework Is an Equality Not for this paper specifically but for programmes e.g. Covid Analysis required? Vaccination programme Any Patient and N/A Public Engagement/ consultation required? Potential risk(s)? A partnership risk log is being maintained for Incident (including Management Group (SHCCG) and Covid Management Group reputational) (LRF). Top line risks relate to ICU capacity (forward look), Mental Health provision (esp. CAMHS), staff welfare and wellbeing. There are notable risks to Public Health if this programme is not delivered effectively.

Recommendation(s) (1) TO NOTE the report and work underway.

Next Steps (1) Revised incident battle rhythm for Incident Management Group (IMG), Local Resilience Forum (LRF) and Strategic Coordinating Group (SCG) (2) Incident Coordination Centre (ICC) review of hours and operating model (3) Local and regional debrief process and lessons learned. (4) Preparations for potential future waves and Covid variants

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Covid Incident Response

1. Regional and Surrey Heartlands ICS perspective 1.1. The impact of the pandemic on hospital bed capacity and NHS services across the South East region and across Surrey Heartlands Integrated Care System (ICS) has continued on a downward trajectory over the last quarter of 2021. 1.2. Surrey Heartlands, in common with the NHS nationally, has moved into recovery and restoration phase of operations to manage the delivery of elective care and deal with the usual increases in demand over the winter period. 1.3. Attendance rates at A&E departments and subsequent admissions are now broadly in line with seasonally expected levels. A short spike in demand has been noted at some of our A&E departments from patients presenting with post vaccination concerns, this now appears to have eased. The numbers of patients in Surrey Heartlands hospitals with a Covid diagnosis has reduced to below 1% of our total bed base, with those in ITU accounting for low single figures.

2. Surrey Heartlands – our local challenges and forward look Local Challenges: 2.1. To relieve staffing pressures and protect clinical safety for patients at the height of the pandemic impact, over 50 ITU patients were transferred out of area for intensive care. It is pleasing to report that all but 6 of those individuals have been repatriated into Surrey or have been discharged from hospital care. The remainder are awaiting clinical clearance for transfer due to their acuity. 2.2. Surge capacity for ITU in our 3 hospitals has been returned to normal configuration and total occupancy in the units is currently around 75% to 80% of capacity. 2.3. With an eye to the future potential for subsequent wave activity, our Urgent and Emergency Care team in conjunction with regional ICS colleagues are undertaking a statistical modelling process. The modelling provides three different scenarios based in epidemiological factors, adherence to and vaccination uptake/ programme effectiveness. Furthermore, each system (by provider) has been asked to set out their capacity plans for any future surge, in terms of Covid and non Covid bed configuration, mindful of the potential impact on recovery and the imperative to maintain throughput of electives alongside. 2.4. An additional workstream being undertaken led by the regional NHSE&I Adult Critical Care clinical lead is working to identify an increase in ICU bed numbers from the current 3 ICU beds per 100,000 population to 7 ICU beds per 100,000 (Surrey Heartlands continues to fall short of the 10 ICU beds per 100,000 required). This workstream project has not yet identified to Surrey Heartlands any proposals regarding this plan or the potential timeline, potentially this may affect the numbers

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of ICU beds in the SE plan and the mutual aid planning process within Surrey Heartlands for future wave(s). 2.5. The ICS is working to ensure the provision of timely and equitable access to Post Covid Syndrome (‘Long Covid’) assessment services. Learning to date has enabled us to have in place the necessary pathways for those individuals who have been found to have specific psychological or medical needs and increase capacity where the need is identified. In parallel, we continue to grow the SH communities’ programmes to support the social and emotional needs of post COVID 19 individuals to empower self-care. Post -COVID Outpatient Clinics are available, and Oximetry@Home is currently being delivered through 3 Virtual Wards at ASPH, RSFT and SASH, and through the Oximetry Monitoring at home by Primary Care (one service in each ICP geography). There are currently 201 patients (as at 25-Mar) within the service across Surrey Heartlands. Patients monitored over the past few weeks have been gradually reducing across all the ICPs. 2.6. Sickness levels and the wellbeing of our NHS staff remains challenged at this time given the prolonged and inherently stressful nature of the pandemic response. Covid related sickness has however, reduced across all our providers, including the ambulance service, community and social care partners, primary care and mental health services. As of the 15th of April, of 499 staff absences across the ICS, some 136 were noted as Covid related, equating to 27% of the total. For illustration the table below shows the position in the Surrey Acute hospitals.

2.7. To support our own staff in terms of their mental health and overall wellbeing several initiatives are underway. The Workforce Resilience Hub, delivered by Surrey and Borders Partnership supports teams and individuals via number of pathways to access help in dealing with stress, pressure, remote working and loss among other issues. More than 500 staff have reached out to these services since January 2021.

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2.8. The mental health system is continuing to experience significant pressures which have undoubtedly been exacerbated by the Covid 19 pandemic and the protracted periods of national lockdown. Factors such as employment and financial insecurities, isolation, disruption in routine, school closures and home working are likely to impact negatively on the emotional wellbeing of many Surrey residents. 2.9. We are continuing to experience adult mental health care demand and acuity challenges across the Surrey system many of which can be adjudged to relate to the constraints imposed by pandemic lockdown. The table below highlights the key pressure points.

There is significant collaborative work underway to manage sustained pressures in the mental health system at this current time. OPEL1 escalation calls are in place to review daily pressures and these have helped individual case discussions. Since the end of March 2021 additional support has been taken to focus on daily bed flow. From a Child and Adolescent (CAMHS) perspective the challenges are increasing exponentially with specific concern around eating disorders cases. Referrals into services are up by 28% (up 20 to 91) compared to same period last year (Jan-Mar), with urgent referrals up by 283% (up by 17 to 23) compared to same period last year (Jan-Mar). Substantive staff to support these patients remain below plan level by 25% (5wte’s) Currently these vacancies are backfilled with agency and seconded staff. The national picture is similar to the Surrey situation at this time. In response to this the ICS is part of 3 times weekly CAMHS tier 4 incident cell meetings led by NHSE&I regional clinical colleagues. Continuing to manage response, recovery, and risk.

1 OPEL – operational pressures escalation levels framework

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Forward Look: 2.10. NHS Chief Executive Sir announced on the 25th of March that the national incident level for the NHS COVID-19 response was to be reduced from level 4 to level 3, effective immediately. 2.11. The ICS continues to operate within a level 3 framework to help manage the pandemic response in line with the change declared by the NHS nationally. This includes weekly gold level Incident Management Group (IMG) chaired by the ICS Accountable Officer or Accountable Emergency Officer. 2.12. The ICS also participates in weekly NHSE/I regional calls at senior level. This ensures that Surrey Heartlands keeps pace with all national policy, reporting requirements, recovery planning and management developments in the pandemic response and transition to business as usual. 2.13. The Surrey Heartlands Incident Coordination Centre (ICC) has been in operation for over a year now and has dealt with more than 30,000 emails during this time. Whilst demand is currently reducing, the ICC was dealing with an average of 160+ emails per day during April 2020 and an average of 100+ emails a day during November and December 2020. As the pandemic response continues, in accordance with NHSE/I direction, resources have been secured to continue staffing the virtual ICC 7 days a week until the end of September 2021. 2.14. The Incident Management Group continues to have access to a daily situation report (SitRep) prepared by the Surrey Heartlands Urgent Care team. This presents an update on the position at each of our acute hospitals in terms of ITU capacity, patient repatriation progress, A&E performance and any immediate risks. Debrief and Emerging Local Themes: It is good practice to learn from any incident and an iterative approach to this has been in place for the Covid-19 response from the outset. NHSE/I SE have issued a debrief strategy to formally capture learning across the region, to ‘systematically and consistently identify the learning from the NHS response to the 2020/2021 COVID-19 pandemic so that improvement can be embedded into practice. This strategy will collate feedback from health partners (providers), ICSs, Networks (such as adult critical care and pathology) and regional arrangements to create a final report by mid-June 2021. In support of this a debrief of the Surrey Heartlands Integrated Care System (ICS) Incident Management Group (IMG) was held on 23rd March 2021 and a report is currently being compiled for submission to region by the end of April. Further debrief activities, such as an electronic questionnaire for CCG staff, will also be completed for submission by mid-May. Action plans will then be developed to try to embed the learning into business-as-usual activities and incident response plans. Whilst not yet fully aggregated, emerging themes from the local event have identified positive responses to the way the ICS communicated and engaged with its constituent partners and worked well across regional and geographical

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boundaries, for example mutual aid. Also identified were challenges around multiple and duplicate information requests from national and regional sources within unrealistic timescales. 2.15. In anticipation of a potential third wave the ICS is engaged with Surrey County Council public health colleagues in joint work to proactively model the likely impact of the pandemic in terms of pressure on resources in the coming months. 2.16. In terms of demands from the pandemic on primary care, Practices have been RAG rated based on the following factors to indicate whether the practice is high risk: • Number of FTE GPs in General Practice • Staff over 60 in General Practice • Current GP absences in the general practice workforce • Clinical Offer to List Size Ratio • Lead Practices Supporting COVID-19 The Primary Care Team is support general practice on a case-by-case basis by seeking support from neighbouring practices, PCNs, GP Federations and the LMC. The figure below shows the position of the RAG rated practices this week, any practices flagged as Red have been contacted by the ICS Primary Care team and supported appropriately.

2.17. The redeployment of CCG staff in response to the pandemic is under active review with the intention of allowing a return to usual duties as soon as is practicable where such a move is sufficiently mitigated from a risk perspective. 2.18. Given the complexity and wide-ranging nature of the Covid response, the need to manage risk actively and effectively has been a significant challenge over the past few months. Significant work has taken place to consolidate individual risk registers into a partnership document that Strategic Coordinating Group, (SCG), Covid Management Group (CMG) and Incident Management Group (IMG) can use to maintain an assurance overview.

3. Covid-19 PPE and Testing Update 3.1. The PPE strategy across Surrey Heartlands is governed by the guidance set out by DHSC for Covid-19 response. The current PPE Scheme has operated since the start of the Covid-19 Pandemic and provides free PPE Provisions to Health &

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Social Care obtained via daily pallet deliveries (for NHS and Foundation Trusts) or through the PPE Portal (for Primary & Social Care). The scheme is extended until March 2022, to covers all core PPE products for managing and treating patients with Covid-19 (e.g., facemasks, aprons, gloves, gowns, eye protection & hand sanitiser). As a contingency measure, the National Supply Distribution (NSDR) service is a 24-hour emergency PPE responding to orders if a shortage of PPE occurs. 3.2. The Surrey Testing Cell is an integrated team between Surrey Public Health (Surrey County Council) and Surrey Heartlands. It currently aligns with existing governance arrangements for system-wide COVID-19 response initiatives. The Testing Cell provides a number of COVID-19 Testing workstreams: • Settings Testing – this programme currently provides COVID-19 PCR outbreak testing within complex settings (including swabbing assistance if required). In addition, this programme also provides testing for individuals moving settings e.g. admission into care homes, and individuals with symptoms who are unable to access national testing programmes. • To date testing has taken place in over 200 settings and has carried out more than 9,000 PCR swab tests. • Targeted Community Testing in Surrey provides symptom free testing to people living or working in Surrey delivered via Local Authority-run sites and pharmacies, offering either assisted testing, community collections or both. The landscape of symptom free testing rapidly changing in-line with ongoing expansion of Department of Health and Social Care (DHSC) led models (i.e., schools and education settings, workplace testing, pharmacy collection). • Mobile Testing Units (MTUs) are deployed across the Surrey, both in routine, planned geographically spread deployments and more reactive, focused sites, based upon outbreaks and increase in cases. 3.3. Current priorities for Testing include: • Continuous review of activity and assessment of demand for symptom free testing, and flexing the offer accordingly, scoping and engaging parts of the population who are under-represented in Covid-19 testing, and sourcing new MTU sites throughout Surrey as lockdown eases and some sites are no longer available. • If the Testing Cell is required to continue beyond the end of September 2021, further funding and staffing will need to be identified to continue the programme. To support this, we will carry out regular review of the work programmes throughout April and May, so that early discussions can take place with Surrey Heartlands (if required) to ensure continuity from September onwards.

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• Regular discussions take place with partners in the SLRF to identify how to access system support for urgent testing requirements once major incident has been stood down. Additionally we are clarifying governance arrangements for the Testing Cell going forwards, to ensure clear process for requesting additional resource if new programmes are required by DHSC/NHS Test and Trace.

4. Covid-19 Vaccinations Programme Update Administration of Covid-19 vaccinations commenced on Wednesday 16 December 2020. Capacity has increased incrementally as more sites have come online and vaccine supply has improved. 4.1. Types of Delivery Model There are four models in use for vaccine delivery in Surrey Heartlands; • 1 Vaccination Centre at Epsom Racecourse, moving to Sandown w/c 10 May • 3 Hospital Hubs • 16 Local Vaccination Sites and • 11 Community Pharmacies In addition to 'fixed' sites, local Primary Care and Community based colleagues have also been visiting care homes and those who are housebound to ensure they receive their vaccination. 4.2. Priority Cohorts 1 to 9 Between 16 December 2020 and 17 January 2021, in accordance with Joint Committee of Vaccines and Immunisation (JCVI), guidance the focus was on vaccinating priority cohorts 1 and 2 - Older Adult Care Home Residents and Staff and over 80s and Health and Social Care workers. Since 18 January 2021, the eligibility for vaccination has been extended to priority cohorts 3 and 4 - those aged 70 to 79 and the clinically extremely vulnerable. Since the 15 of February 2021, the eligibility for vaccination extended to cohorts 5 and 6 which includes a wider group of people at clinical risk including young adults in Residential Setting, Carers and those aged 65 to 69. Since March 2, the eligibility for vaccination has been extended to cohorts 7,8 and 9 which includes those aged 60 to 64, 55 to 59 and 50 to 54. On the 13 of April 2021, JCVI guidance published its next set of guidance on cohorts 10 to 12 (people aged in their 40s, 30s, 18, 19 and 20s); applying a phased approach extending the vaccination offer to people aged 45 to 49 in the first instance.

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4.3. Current Performance In total and to date, the system has provided more than 585k vaccinations via the Surrey Heartlands vaccine sites. This consists of 473k first doses and 112k second doses (as set out in the table below).

The greatest increase in second doses can be seen in the 75-79 cohort (+14%). Priority Cohorts 1 to 9 The programme has achieved vaccination rates more than 90% for all cohorts 1-4 which is an excellent achievement. We have also achieved over 90% for Carer’s uptake of first doses. For cohorts 5-9 we continue to deliver over 80% for second doses. We are continuing to work with SMI (80%) and those with Learning Disabilities (83%) to increase vaccination uptake. We continue to drive vaccination uptake for cohorts 1 to 9. 4.4. Health Equalities An equality impact assessment was completed in January 2021 and the actions and recommendations arising from that are now being taken forward. We have subsequently established a Covid-19 Vaccination Equalities and Engagement Cell and have secured £100k of regional monies to support Surrey Heartlands to address health inequalities. The Primary Care Networks have developed a roving model and the model is now supporting care homes for the elderly, non-older people care homes, GRT Communities, Homeless, Asylum Seekers, Domestic Abuse Hostel, Sex Workers, BAME outreach models to mosques to name but a few of the cohorts we have focussed on. This work continues to be ongoing for both first and second vaccinations. 4.5. Future Planning To ensure sustainability of the delivery models, work has commenced to understand the requirements of the future vaccination model longer term in line with NHSE 2021/22 priorities and operational planning guidance. Vaccination

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programme planning will need to take into consideration any updated advice from the Joint Committee on Vaccination and Immunisation (JCVI) regarding: • Preparation for a Covid-19 re-vaccination programmed from autumn and, • the possibility of Covid 19 vaccination of children, should vaccines be authorised for use in under 18s and recommended by the JCVI

5. Partnership Support 5.1. In terms of Local Resilience Forum partners involvement, the ICS receives weekly updates from cells formed within the Covid Management Group, which continues to meet at a reduced frequency at this time. The meetings are timed to link to the national Government steps timetable for the easing of lockdown. 5.2. Given the reduction in pandemic related activity, the Surrey LRF Strategic Co- ordination Group has completed a review of the actions required to return to a business-as-usual status. On the 19th of March, the SCG held a peer challenge event to confirm the steps required to stand down the major incident status which had been in place since March 2020. The three joint SCG chairs and the joint chairs of the CMG agreed that subject to a number of tests being met for de- escalation and appropriate mitigations being in place, the major incident and SCG meeting would cease. 5.3. The tests included; (a) the immediate, significant threat to life is minimised and reducing; (b) the mechanisms are in place to ensure effective surveillance and oversight of the risk of resurgence, (c) all response activity has effective governance in place and/or a BAU ‘home’ (d) there is a way of coordinating residual response activity without the SCG/major incident being in place and e) there are clear, simple and effective procedures for standing the SCG back up again, as required. It was subsequently agreed at the SCG on the 14th of April that the incident and the SCG will stand down at the end of April. 5.4. In terms of (the military operation to support the NHS pandemic response), the MOD has begun to wind down operations in the region. Military personnel have withdrawn from the ICS footprint at both acute and vaccination sites and in support of the ambulance service. Military liaison officers remain in place at a regional level currently. 5.5. The ICS is maintaining a watching brief via liaison with NHE&I over the hotels being used as Managed Quarantine Service locations that may impact on NHS services in our footprint. These hotels are used to house arrivals in the UK from ‘red list’ countries for a period of 10 days. Whilst none of the hotels are within the county boundaries (currently Gatwick and Heathrow airports) they have the potential to create demand at both East Surrey and Ashford hospitals if the guests require emergency medical treatment.

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