10 - 2025-06-18 IJB - NHSL Winter Planning 2024-25 Debrief - Appendix 1

North Lanarkshire Council · 18 June 2025
Back to Health and Social Care Integration Joint Board — 18 June 2025 and its agenda

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Meeting: NHS Lanarkshire Board     
Meeting date: 30 January 2025
Title: Urgent and Unscheduled Care Festive Period and Actions
Going Forward 
Responsible Executive/Non-Executive:  Colin Lauder 
Report Author: Kirsty Orr 
1 Purpose 
This report is presented to the NHS Lanarkshire Board for: 
This report is presented to the Board for: 
(please tick all appropriate) 
Discussion ☒
Decision ☐
Assurance ☒ 
This report relates to a:
(please tick all appropriate) 
Local Policy ☒
Government Policy ☒
Urgent Operational Issue ☒ 
This report aligns to the following NHS Scotland quality ambition(s):
(please tick all appropriate) 
Safe ☒
Effective ☒
Person Centred ☒ 
This report relates to the following Corporate Objectives: 
(please tick all appropriate) 
Better Health ☒
Better Care ☒
Better Value ☒
NHS Lanarkshire

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Better Workforce ☒
2 Report Summary
2.1 Situation
NHS Lanarkshire’s Board is asked to note the content of this report which outlines the performance,
experiences and whole system learning from the operational, clinical and managerial teams during the festive
fortnight. Performance against the Emergency Access Standard (EAS) has been significantly challenged over
this period and therefore intensive focus on the implementation of the key principles agreed as part of our
Target Operating Models, along with maximising virtual bed capacity, increasing call before you convey and
redirection through FNC + Plus is required to support recovery.
Whilst the situation in NHS Lanarkshire has been challenging our data and reports indicate that we have not
seen the same extreme SAS queues and patient waits as has been the case in other parts of Scotland and the
wider UK, we are confident that be contributed to the extensive collaborative working with SAS colleagues
during this period. The detail of the joint working is described in the Section 2.2 of this report.
The paper describes the learning we have taken from the last month and how this will influence Operation
FLOW into 2025.
2.2 Background
NHS Lanarkshire Unscheduled Care Performance – December 2024
For end of December 2024 NHS Lanarkshire reported an end of month performance against the 4-hour
standard as 47% compared to the revised target trajectory of 78%. This is our lowest reported performance
since December 2022 and the first time we have been below our lower control limit since then. For the week
commencing 23 December 2024 there was a 1.3% drop in attendances in comparison to 2023. An overview
of 4-hour monthly performance against trajectory is shown in Appendix 1. NHS Lanarkshire to date
performance from 1 January 2025 to 21 January 2025 is 50%, which indicates an improved position at the time
of writing.
Acute hospital occupancy levels remained high at 99%, calculated from our funded bed base. Reducing
occupancy levels remains a key action to ensure safe flow to our off site areas, to create capacity for our new
emergency admissions and is a crucial element of our improvement plan.
We have seen an increase in both the number of patients waiting 8 hours (Appendix 2) and 12 hours
(Appendix 3) in our Emergency Departments which compromises positive patient experiences and safety in
care. The data shows that 1937 patients waited over 12 hours which is an increase of circa 800 patients from
December 2023 (34% increase) and 2174 patients waited over 8 hours which is over 700 patients (9%
increase) from 2023.
Our delayed discharge performance demonstrates random variation but within our control limits and above
our trajectories as shown in Appendix 4. The number of delays showed minimal change between the months.
Appendix 5 shows our delayed discharge occupied bed days.
To further understand our unscheduled care pathways, we analysed our weekly unscheduled care journeys.
An Unscheduled Care Journey is defined as the time a person spends in a series of emergency/urgent care

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services which occur within 24 hours of each other. The services covered in the Unscheduled Care Pathways
are Acute Hospital Emergency Stays, Emergency Department Attendances, Mental Health - non respite stay,
NHS 24 contact, GP OOH contact and emergency SAS contacts. This revealed that in October to December
2024 the weekly average number of Unscheduled Care Journeys was 6,101 which is an 0.5% increase from
2023 for the same time period. A weekly average of 3,976 (65.2%) journeys resulted in
attendance/admission to hospital, 0.7% increase from 2023. A weekly average of 2,482 (62.4%) journeys
have no contact with other services before attending hospital, this is a 1.3% increase from 2023. This
suggests more patients are going direct to hospital with no previous contact with other services. As a
consequence, we know that we have further work to undertake in relation to our public facing
communication and engagement approaches to maximise the management of our unscheduled care
demand.
Clearly, our performance against the key metrics for the programme continue to be below our
performance milestones and this has implications from both a patient and staff safety and experience
perspective. The unrelenting pressure on our system has been exacerbated increasing flu rates with a peak
of 147 patients admitted across our acute sites with flu. Appendix 6 provides a seasonal yearly comparison
for test positivity influenza in Scotland and Appendix 7 illustrates the direct impact this year for NHS
Lanarkshire.
However, regardless of the challenges and extreme system pressures we remain committed to operational
delivery and implementation of the actions outlined in our Operation FLOW Improvement Plans.
Learning and Reflections from the Festive Period
We have sought to understand the learning and reflections from our clinical, operational and managerial teams
during this intense and highly pressured period across our system. Colleagues from all parts of the system
recognised the continued commitment to whole system working and the importance of collaborative working
to resolve issues. The key activity and reflections for Interface Division, Acute Division and Health and Social
Care Partnerships (HSCPs) is captured below.
Interface Division
As part of the development of Interface Division and FNC+Plus the first beds within the new virtual wards
became available from the end of November 2024. Five patient pathways have been developed and are
being developed over the coming weeks and months. The virtual beds will support both primary care services
(and so reduce hospital attendances) and also acute services (reduction in occupancy and lengths of stay,
however at this is the first such service in NHS Scotland this this will take time to embed the change and shift
our performance.
To support the reduction of bed occupancy across our physical estates our virtual beds with Doccla for frailty
and discharge support pathways including diagnostic virtual wards (Appendix 8) have been established. We
plan to expand to OPAT, orthopaedic and surgical wards from end January 2025.
Increased multidisciplinary staff presence within the FNC + Plus has been essential to manage our demand.
This includes MSK physios to provide assessment of MSK presentations which equates to 40% of all calls from
NHS 24 meeting that criteria. In addition, during the week commencing 6 January 2025 the teams introduced
primary care colleagues working with SAS to identify patients that community staff could respond to, which
allowed the original SAS request to be cancelled. They also identified cases where people have had
exceptionally long waits for ambulances and have passed these to community staff to undertake welfare

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visits/ check clinical stability to reduce risk, maintain patient safety and also to remain in community care
rather than travel to an Emergency Department.
To further support peak activity periods increased evening, weekend and overnight FNC + nursing staff
availability was implemented, which has helped to ensure that calls are answered timely and ability to apply
pathways to ambulatory care during peak periods in particular.
Importantly, increased SAS presence within FNC + Plus, funded jointly by NHS Lanarkshire and SAS, has been a
key learning for both organisations during the festive period. This facilitated collaborative management of the
SAS Stack along with NHS L demand to maximise call before you convey opportunities and Appendix 9
illustrates our data. Interestingly, there are SAS 1,572 contacts per week and this is up 10.5% up from 2023.
Each week 977 contacts are conveyed to hospital which is 2.3% down from 2023. This suggests that whilst SAS
is involved in more journeys they are conveying fewer to hospital. A further breakdown reveals that 45 (2.9%)
of all SAS contacts were referred to FNC and 27 (60.0%) of these referrals were not conveyed to hospital. We
know that there are some further opportunities here. For NHS Lanarkshire to witness a reduction of 1% in the
overall number of attendances/admissions to hospital the FNC+ Plus will require to see a 37% increase in
patients not conveyed to hospital. It is important to note that a 1% reduction in attendances would see
approximately 1.3% - 1.9% improvement in ED performance depending on the mix of patients not conveyed to
Emergency Departments. From an NHS 24 perspective there are 2,352 contacts per week, 5.0% down from
2023. 735 (31.3%) of these contacts were transferred to hospital which is 2.0% down from 2023. This
suggests that whilst fewer patients are contacting NHS 24 in 2024 a higher proportion are being sent to
hospital (Appendix 10). There were 499 (21.2%) referrals to FNC from NHS 24 with 184 (36.9%) of referrals
to FNC from NHS 24 requiring a clinical call back this equates to 7.4% of all NHS 24 contacts. 80 (43.5%) of
referrals with a clinical call back were not conveyed to hospital which we assume has reduced ED
presentations for that patient cohort (Appendix 11).
To support and facilitate hospital flow ABC ambulances assisted with discharges, inter hospital transfers and to
transport patients to hospital that are “fit to sit”. This was made possible by the collaboration between NHS L
and SAS on deployment of vehicles to support patients getting the help they need at the right time and by the
right service. Additionally, members of the Interface Division have supported board rounds at UHW to assist in
the identification of patients for virtual beds to create physical bed capacity and enhance safe flow. Prior to
the festive period a Children and Young People Test of Change was undertaken. The clinical team
(compromising of a doctor and nurse) utilised the minor’s area overnight at UHW to reduce pressure and
overcrowding in ED and long waits for children and young people. The testing is complete and rotas are being
prepared to support the model for a further 12 weeks.
Acute Division
The Acute Division continues to progress with the implementation of winter plans across all 3 acute hospital
sites in preparedness for winter. The winter plans across the acute sites focus on actions, primarily to reduce
hospital occupancy through admission avoidance, early decision making and reducing length of stay through
greater clinical cover particularly within frailty and where patients are boarded out of specialty.
Sites have included the following initiatives within the winter plans:
• Increase Junior Medical and Consultant cover for boarded patients
• Increase in Medical and Nursing cover within Frailty areas
• Increased Pharmacy cover
• Increased discharge facilitators

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• Additional Medicine for Older Adults consultant cover in Orthopaedics
• Extending Ambulatory Care hours
• Increased ED nursing cover
As in recent years staffing challenges and availability of physical space on the sites has meant that the ability
to open additional winter beds has not been possible. Given the baseline occupancy leading into festive period
and significant spike in Flu cases this has placed significant pressure on the acute sites, particularly through the
Emergency Departments and admission units, impacting on waiting times, ambulance offload times, safety
and performance.
Acute sites began to see a steady increase in Flu cases from week commencing 9 December 2024. At this point
occupancy in UHW was already above 100% with UHM & UHH occupancy between 97% and 100%. Reported
cases rose to 147 inpatients across the acute sites on 28 December 2024 but at time of writing has reduced to
circa 60 patients. Access to side room capacity and the requirement to cohort appropriate patients impacted
further on flow. A reduction in site occupancy remains critical in maintaining flow and safety however as in
2022 when sites were impacted by a high volume of Flu/ Covid cases there are occasions when access to
further surge capacity is required to manage specific events where acuity and length of stay increase.
Consideration for how we flex capacity in the future in line with a flu/ covid plan is required to ensure we can
maintain flow through future winters when there is a significant rise in respiratory conditions.
The increase in acuity saw a rise in patients with a length of stay (LOS) greater than 14 days. This increased
through December to a high of 415 (against a trajectory of 311). The high volume of patients correlated to the
highest number of bed days recorded for this patient group, since we started monitoring in July 2024, at 7188
bed days compared to approximately 5500 bed days through September. There was a significant rise in
patients in delay with a LoS > 14 days in delay at both UHH and UHM leading up to the festive period and all
sites showed an increase in patients not in delay. There have been challenges with locality capacity and HAT
capacity that have impacted sites at different times and we have not yet moved to home assessment as the
norm for all appropriate patients.
Alongside the internal actions sites have continued to engage with teams to focus on the use of virtual
capacity. UHW have had support from the interface division to work with teams through ward board rounds
to identify appropriate patients. All sites have adopted a daily review of inpatient radiology requests to ensure
patients are identified who could be discharged to the virtual diagnostic pathway. Sites have also
implemented processes to ensure any patient awaiting a package of care whose discharge is cancelled on the
day are reviewed and a determination is made as to whether ongoing care can be provided through the virtual
ward.
Tests have been undertaken within ED at UHW linking with the FNC to redirect patients into alternative
pathways through an early triage process. In response to increased pressure in early January implementation
of redirection back to GP OOH to reduce pressure within ED has been implemented and additional support
from GPs has been provided at UHW.
Further work is required to fully implement the Optimal Discharge Planning TOM and the Front Door TOM as
there is recognition this will support flow, improve processes and allow us to maximise opportunity to reduce
LOS and occupancy.

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Health and Social Care Partnerships 
NHS Lanarkshire, as in previous years, has offered a winter additional hours Local Enhanced Service (LES) to GP
practices in Lanarkshire. Two-thirds of practices agreed to participate in the LES this year, which involved
opening on one or more of seven days across the festive and January period. Of these practices, 90% opened
on days on which they would normally be closed across the festive period; the remainder will open on one or
more Saturdays in January. Data on the number of consultations offered will be collected at the end of
January, however in 23-24, an average of 499 patients per day were seen through this service across the
festive period. This ensures access to general practice care urgent care across the festive period and gives
opportunities for diversion from emergency departments and the Primary Care Out-of-Hours Service
(PCOOH). 
The PCOOH service was fully operational across the festive period, with only one period of safety netting due
to long waits as a result of exceptional volumes on 29 December 2024. Five patients presented to our
Emergency Departments during this period. Conversely, service resilience has been sufficient to offer diversion
of appropriate patients from all three Emergency Departments during week beginning 6 January 2024. The
service was also able to recruit additional GPs to work within the service to backfill the release of 2 GPs from
the PCOOH clinical management team on the evenings of 6 & 7 January 2025 to assist colleagues with in UHW
ED. 
From a community nursing perspective our arrangements have been robust and responsive: including
continued support and promotion of timeous discharge for End of Life Care patients from all sites; continued
phasing of IV antibiotic therapy at home with District Nursing (DN) / OPAT services; and specialist palliative
care nurse specialists providing specialist care at weekend to support winter pressures and responsive
specialist care at home. The teams also stepped-up to provide short-term, additive support given the New
year pressures, notably criteria reside audits undertaken by MDT in both community hospitals; urgent care
team supported the FNC+ ,as described above, to facilitate review and where appropriate reprioritise care for
patients waiting conveyance to hospital who were still at home; and in conjunction with above, same day
stand of additional support within each of the locality DN teams to support above, but also undertake safety,
care and comfort checks on designated people. 
Uptake levels of flu vaccination amongst staff has been very concerning in practice despite local vaccination
programme having been informed by the feedback from the PHS-led national staff survey on vaccinations
from earlier in 2024, a strong communications campaign (albeit local) and a range of options provided for staff
vaccination (notably mass vaccination centres and local clinics undertaken in hospital outpatient departments
at weekends, local health centres and council-owned community centres) plus bookable and drop-in clinics for
staff in each of the three main acute sites. Through the latter half of December, we also increased our
presence in the acute sites with vaccination staff ‘walking-the-wards’ and attending departments and this did
contribute to a continued uptake amongst the workforce, with almost additional 500 vaccines delivered to
staff in the last three weeks. Given the levels of vaccination uptake particularly amongst health and social care
staff we are already planning a “deeper dive” assessment of the drivers and barriers locally across the
workforce as we look ahead to next year, and would supportive of a similarly detailed assessment nationally. 
It is also notable that to-date there has been low levels of interest amongst staff to take up the role of peer
vaccinators within our system. An investigation has been commissioned by South HSCP Chief Officer to inform
our understanding for the reasons for this across different areas and staff groups. This will then inform
actions: for the programme; different directorates going forward. The recommendations from the review will
then go to EDG for consideration and CMT for approval.

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We know that there been some challenges with managing the impact of the Optimal Discharge Planning TOM
with it not appearing to have been consistently applied in the lead in to the festive period, notably in terms of
pre-noon discharges and earlier engagement of social work where required as per the TOM. There is a
potential that delays would be avoided with early discharge planning involvement from social work, which
would support flow and safety improvement across our sites.
We recognise that the numbers of delayed discharges have increased across the system. Proactive and
responsive work continues across both HSCPs to respond to this pressure. However, a key learning point is
that there is a need to improve our proactive plans for increased social care capacity for next
winter. Increased sickness absence on top of planned leave is anticipated at this time of year and we should
therefore engage with external social care providers, well in advance, to explore opportunities to increase
capacity for this period to facilitate increased responsiveness during the annual significant system pressures.
As an organisation we also need to revisit AL provision for over this period.
2.3 Assessment
Improving performance against the 4-hour Emergency Access Standard remains a commitment for NHS
Lanarkshire. We are witnessing sustained performance improvement against Flow Group 1, Category 6 – See
and Treat, however that is not the case for the other flow groups. In response to this we are monitoring our
status and track our performance against all of our trajectories for each flow group on a weekly basis via
our site level and whole system Flow Oversight Boards and Executive Flow Oversight Board. We are
continuing to agree actions to support performance improvement though this process.
The Chief Executive established a Gold Command structure to provide decision making support to teams
across the system during the immediate post festive period. Importantly, we did not declare a critical incident
during this period of significant system pressures. Executive Directors have asked for a redoubling of effort by
the operational management teams, including more use of data, to allow focus on those parts of the patient
pathway require most effort and focus.
2.3.1 Quality/ Patient Care Assessment
There are no Quality or Patient Care implications to be noted. Quality and Patient Care should be
enhanced with the implementation of increased Virtual Capacity, Front Door and the Optimal
Discharge Planning TOMs.
2.3.2 Workforce Assessment
The workforce implications to be noted are:
• Changes to current ways of working with the implementation digital front door and virtual
capacity
• Increased clarity around roles and responsibilities in relation to flow and discharge planning
2.3.3 Financial Assessment
There are no financial resource implications to be noted.

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2.3.4 Risk Assessment/Management
A Risk Management Framework has been developed to underpin this work. A significant risk for
successful delivery of Operation FLOW 3 is the successful recruitment and retention of the workforce
to ensure the delivery of the new Target Operating Models.   
2.3.5 Equality and Diversity / Fairer Scotland Duty Impact Assessment (including health inequalities)   
Has an E&D /FSD Impact Assessment been completed? 
Yes ☒
No ☐ 
There are no Equality and Diversity implications to be noted. 
2.3.6 Other Issues 
No other issues require to be noted. 
2.3.7 Communication, Involvement, Engagement and Consultation 
The work progressed through Operation FLOW 3 has been reviewed and endorsed by colleagues who
support our governance structures across the programme of work.    All our work is underpinned
through an internal and external facing communication plan.   
2.3.8 Route to the Meeting 
All work being progressed through Operation FLOW 3 has been reported via our Executive Flow
Oversight Board prior to submission to NHS Lanarkshire’s Planning, Performance and Resources
Committee. 
2.4 Recommendation 
Decision 
• NHS Lanarkshire’s Board is asked to note the content of the report. 
3 List of Appendices 
The following appendices are included with this paper:
• Appendix 1: NHS Lanarkshire Current System 4-hour weekly performance 
• Appendix 2: NHS Lanarkshire 8 hour plus waits / month 
• Appendix 3: NHS Lanarkshire 12 Hour plus waits / month 
• Appendix 4: NHS Lanarkshire Monthly Delayed Discharges / Month 
• Appendix 5: NHS Lanarkshire Monthly Bed Days Delayed
• Appendix 6: Seasonal yearly comparison for test positivity influenza in Scotland
• Appendix 7: NHS Lanarkshire Influenza Hospitalisation

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• Appendix 8: Diagnostic Virtual Wards
• Appendix 9: Percentage of SAS Call Non Conveyed 
• Appendix 10: Percentage of NHS 24 Clinical Call Backs Non Conveyed
• Appendix 11: Call Before You Convey Calls to FNC

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Appendix 1 – NHS Lanarkshire Current System 4 - hour weekly compliance   
Appendix 2 – NHS Lanarkshire 8 hour plus waits / month

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Appendix 3 – NHS Lanarkshire 12 Hour plus waits / month 
Appendix 4 – NHS Lanarkshire Monthly Delayed Discharges / Month

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Appendix 5 – NHS Lanarkshire Monthly Bed Days Delayed 
Appendix 6: Seasonal yearly comparison for test positivity influenza in Scotland

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Appendix 7: NHS Lanarkshire Influenza Hospitalisation 
Appendix 8: Diagnostic Virtual Wards

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Appendix 9: Percentage of SAS Call Non Conveyed 
Appendix 10: Percentage of NHS 24 Clinical Call Backs Non Conveyed

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Appendix 11: Call Before You Convey Calls to FNC