When demand reaches the point that trusts are unable to care for patients in a safe and timely way, they will trigger an escalation plan to manage the enhanced risk.

The local system escalations plan should enable each area to take pre-determined actions to ensure that safety is maintained. Where the plan is not sufficient, e.g. the local system cannot manage the pressures internally, then escalation will take place to the regional tiers of NHS England and NHS Improvement where further support can be provided. These regional tiers will be able to draw down support nationally should that be needed. The approach this year is focused on continuous monitoring and supporting improvement with local teams linked to regional teams and the national infrastructure.

Trusts will also have a series of internal indicators which are closely monitored. Should the situation escalate, trusts have a number of different options available to them, for example:

  • Acute trusts use the operation pressures escalation levels (OPEL) alert system. As a trust escalates through the levels, it might need to initiate a ‘full capacity protocol’ which could include diverting ambulances, mixed sex accommodation breaches, opening escalation areas and outliers.
  • Ambulance trusts use a resource escalation action plan (REAP). There are four levels of escalation within the REAP which determine a trust’s response. It could include deploying ambulance staff to emergency departments to manage turnaround, providing alternative transport for less urgent patients or requesting support from another ambulance provider.
  • Community trusts also use the operation pressures escalation (OPEL) alert system. They will be maximising the use of re-ablement and intermediate care beds and expanding capacity wherever possible through additional staffing and services, including primary care.
  • Mental health trusts often use their own version of the OPEL system and participate in all system calls with acute, CCG, social care and community providers. Their focus is on patient flow, maintaining capacity in designated places of safety and reducing length of stay and delayed transfers of care, which will create additional capacity and contribute to resilience. 

Next Steps

As NHS England publishes its weekly sitrep data over winter, NHS Providers will be capturing some of the key figures each week alongside views from NHS trusts on how winter feels on the ground in our weekly winter watch live briefing, coming soon on our website.