Integrated operational pressures escalation levels (OPEL) framework 2024 to 2026

Purpose of the OPEL framework

The NHS Constitution of England establishes the principles and values of the NHS, outlining the rights of patients, the public and staff. It sets out the rights to which patients, the public and staff are entitled. Patients always come first in everything we do, and the welfare of staff providing and supporting this care should also be prioritised. The OPEL framework supports this and ensures patients get the right treatment in a timely manner and support staff within organisations to respond consistently to operational demands.

This 2024 to 2026 framework for the management of operational pressures is for NHS acute trusts, community health service (CHS) providers, mental health (MH) service providers, NHS 111 providers, integrated care systems (ICSs), and NHS England regional and national teams. Throughout this document we collectively refer to NHS acute trusts, NHS CHS providers, NHS MH service providers and NHS 111 providers as ‘providers’, but differentiate specific types of provider where necessary.

This framework provides the core parameters that each of these types of provider must use to determine their OPEL. It also details the process for aggregating the OPEL scores for ICSs, NHS England regions and NHS England nationally. This ensures the operational pressures across all levels of the NHS in England are consistently and accurately represented.

The benefits of using a consistent and unified OPEL framework across all NHS acute trusts, CHS providers, MH service providers, NHS 111 providers and ICSs are:

  • enhanced oversight of patient safety and, patient-centred decision-making across the urgent and emergency care (UEC) pathway through clear and consistent identification of risk to access to care for patients
  • increased efficiency across the UEC pathway through optimising use of resources, and enabling clinical and operational teams to monitor operational pressure and, identify patterns and interdependencies between operational parameters
  • improved communication by providing a common structure for measuring operational pressures and standardised escalation processes, enhancing the speed of response
  • a consistent response to changes in operational pressure by giving parity of esteem across those NHS providers covered by this framework 
  • improved transparency across all levels of the NHS to promote engagement of and collaboration between all stakeholders in managing operational pressures effectively  

The Integrated OPEL framework 2024 to 2026 is the only recognised operational escalation framework for the provider types within its 4 pillars and ICSs to report UEC operational pressures in the NHS. All organisations listed must comply with this framework and the respective actions for external reporting.

This document and its appendices serve as an adjunct to and must be read alongside local full capacity protocols, surge policies or their equivalents. However, local policies should be updated to reflect the core parameters and actions in this document.

Background

NHS England introduced the national Operational pressure escalation Level (OPEL) framework in 2016 to standardise local and system escalation processes, encourage wider co-operation and improve regional and national oversight of operational pressure.

Measurement of operational pressures was further standardised for 2023/24 with the introduction of 9 acute hospital parameters. This approach provided greater consistency and objectivity but remained limited by its focus on NHS acute providers and their contribution to integrated care system (ICS) operational pressure. It was intended as an iterative step toward a clinically relevant, objective and digitally enabled framework to monitor operational pressure.

The integrated OPEL framework 2024 to 2026 now provides a unified, systematic and structured approach for a co-ordinated response to operational pressures at system, regional and national levels, one that has been expanded to the contribution of community, mental health and NHS 111 services to ICS pressures.

Changes from the 2023/24 OPEL framework

In developing this iteration, we have considered feedback and wider consultation on the previous framework, undertaken empirical testing and collaborated with a broad and expert range of system and provider representatives from across the NHS. We have also taken account of progression within the Urgent and emergency care (UEC) recovery plan and 2024/25 priorities and operational planning guidance.

The significant changes from the 2023/24 version are:

  • comprehensive revision of the existing acute OPEL parameters, including their definitions, scores and weighting, to ensure they continue to give an accurate and reflective representation of current needs  
  • updated proportional representation for acute OPEL using the latest emergency department (ED) attendance data (as detailed in appendix A) to accurately reflect the current proportionality 
  • introduction of 3 new pillars of OPEL, with new OPEL parameters for MH services, CHS and NHS 111 as well as the actions to be taken in response to changes in operational pressures within these pillars  
  • introduction of a process for OPEL score normalisation to provide consistent OPEL scoring across all pillars and organisations using OPEL 
  • implementation of an overall ICS OPEL score based on the parameter scores for the acute, CHS, MH and NHS 111 pillars. This provides an aggregated overview of the operational pressures across the ICS using a consistent scoring method, as well as an indication of the OPEL for each pillar 
  • updated actions for acute trusts, ICSs and NHS England regions to ensure they remain effective and aligned with the current and evolving operational requirements 

OPEL and EPRR

It is important to note that the incident definitions within the NHS emergency preparedness, resilience and response (EPRR) framework have not changed and there has been no variation to the requirement for systems and services to ensure effective arrangements are in place to deliver appropriate care to patients affected by an emergency or incident. The statutory requirements and underpinning principles of the EPRR Framework and associated legislation take precedence over the OPEL framework.

The system co-ordination centre (SCC) is the real-time forum for operational oversight at ICS level. The SCC specification describes the need for joint working across EPRR and SCC operations to ensure co-ordination of response using a shared framework of policies, which include OPEL and EPRR, to a:

  • business continuity incident
  • critical incident
  • major incident

There is no continuum of definitions between the OPEL and EPRR Frameworks. It is therefore possible for an organisation to be at OPEL 1 and to have declared an (EPRR) incident. Similarly, the declaration of a critical incident due to ‘operational pressures’ is not an automatic expectation where OPEL 4 is sustained as the OPEL 4 actions have not achieved de-escalation. The declaration of an incident is a decision for the NHS provider based on the EPRR Framework and trust incident response policies and procedures.

Components of the Integrated OPEL framework 2024 to 2026

Integrated OPEL framework scores

The Integrated OPEL framework 2024 to 2026 assesses operational pressure for the 4 pillars of the UEC pathway using a set of parameters for each. This produces a numerical OPEL score and corresponding ‘escalation level’ from 1 to 4.

Compared to the OPEL framework 2023/24, this updated framework is an iterative step towards a whole ICS representation of system pressure and will produce the following scores:

Acute OPEL scores

Every NHS acute trust is required to use the OPEL parameters to derive its OPEL score.

  • acute OPEL score for each hospital site with a Type 1 ED, calculated from the sum of scores for each of the acute OPEL parameters.
  • acute OPEL score for each acute trust based on proportional representation of each site within that trust. Proportional representation is based on all-type ED attendances.
  • acute OPEL scores for each ICS. Proportional representation is based on all-type ED attendances.
  • acute OPEL scores for each NHS England region and NHS England nationally. Proportional representation is based on all-type ED attendances.

Community health services OPEL score

Every NHS community health services (CHS) provider is required to use the OPEL parameters to derive its OPEL score.

  • CHS OPEL score for each CHS provider, calculated from the sum of the scores for each of the CHS OPEL parameters.
  • CHS OPEL score for each ICS. Every ICS is required to define the contribution of each NHS CHS provider within its footprint to provide an aggregated ICS CHS OPEL score.
  • CHS OPEL score for NHS England regions and NHS England nationally, calculated from each ICS’s CHS OPEL score and aggregation based on proportional representation using Office for National Statistics (ONS) population data by ICS.

Mental health OPEL scores

Every NHS mental health service (MH) provider is required to use the OPEL parameters to derive its OPEL score.

  • MH partnership provider OPEL score, calculated from the sum of the scores for each of the MH OPEL parameters.
  • ICS MH OPEL score for each ICS. Every ICS is required to define the contribution of each NHS MH service provider within its footprint to provide an aggregated ICS MH OPEL score.
  • MH OPEL score for NHS England regions and NHS England nationally, calculated from each ICS’s MH OPEL score and aggregation based on proportional representation using ONS population data by ICS.

NHS 111 OPEL scores

Every NHS 111 provider is required to use the OPEL parameters to derive its OPEL score.

  • NHS 111 OPEL score for each provider, calculated from the sum of the scores for each of the NHS 111 parameters.
  • NHS 111 OPEL score for each ICS. Every ICS is required to define the contribution of each NHS 111 provider within its footprint to provide an aggregated ICS MH OPEL score.
  • NHS 111 OPEL score for NHS England regions and NHS England nationally, calculated from each ICS’s NHS 111 OPEL score and aggregation based on proportional representation using data on call distribution.

ICS overall OPEL score

This is derived from parameters across the acute, mental health, and community health service OPEL pillars and is based on proportional representation of each ICS using ONS population data. NHS111 is a standalone pillar and does not contribute to the integrated OPEL score.

NHS England regions and NHS England national overall OPEL score

This is derived from parameters across the Acute, Mental Health, and Community Health Service OPEL pillars and is based on proportional representation of each ICS using ONS population data. NHS111 is a stand-alone pillar and does not contribute to the integrated OPEL score.

Once OPEL scores are calculated the actions from the corresponding level of escalation should be enacted by the relevant organisations (see Appendices F to J).

OPEL data submission and aggregation

Acute NHS trusts, NHS CHS providers, NHS MH service providers and NHS 111 providers must submit data pertaining to each OPEL parameter to their respective ICS. This data must be made available to NHS England for the purpose of OPEL oversight across all pillars and levels.

ICSs must submit the data for each parameter to NHS England via a digital solution and at the same frequency with which they receive it, ensuring accurate NHS England regional and national OPEL scores for each pillar and for the NHS can be derived.

Assessment cadence and submission

As a minimum, every provider (acute, CHS, MH, NHS 111) must complete an OPEL assessment once every 24 hours or more frequently in response to changes in assessments. These assessments must be completed by 10:00am, 7 days a week to maintain continued ICS oversight in line with the SCC specification. Subsequent frequency of OPEL assessments is directed by the OPEL score and corresponding escalation level as detailed in the OPEL actions in response to changes in operational pressure.

We recognise that on occasions specific data may not be available or updated for certain OPEL parameters: for example, due to failure of automated data flows, or the inability to collect or submit data by the required time. Where this is the care for any parameter within any pillar, the last known data submission for that parameter should be resubmitted to ensure a complete submission for the pillar and onward aggregation of OPEL score. Nil returns are not to be submitted under any circumstance as they risk underrepresenting the OPEL score.

Digital automation

The data submission for each OPEL parameter and pillar should be digitally automated where possible and any analogue collection of data avoided. This provides continuous, or scheduled reviews, of the OPEL score, ensuring timely and accurate information flow across all levels of the NHS. Digital automation also reduces administrative burden, efficiency and accuracy through streamline data collection, reporting and aggregation.

It is strongly recommended that ICSs reduce any potential for analogous measurement and use digital dashboard platforms to receive OPEL submission and to aggregate and formulate the various OPEL scores. Such platforms must then be made available to the national dashboard solution. Where digital solutions are not available locally, NHS England will plan with the digital dashboard provider for submission directly to the national dashboard provider.

Proportional representation

The notion of proportional representation within each OPEL pillar is fundamental to the OPEL framework as it ensures the accurate and consistent aggregation of NHS provider OPEL scores. It must be applied consistently from provider through to NHS England.

Due to nuances between provider types, organisational footprint and governance, different methods of proportional representation are applied to OPEL scores. The details of these can be found in appendix A.

Normalised OPEL score and escalation level

Normalising OPEL scores is also crucial to ensure that operational pressures across different NHS pillars are evaluated fairly, allowing for a balanced representation of operational pressures. This approach supports the accurate and consistent application of the framework, helping stakeholders effectively measure and respond to pressures within the NHS.

Normalisation is the process of converting raw scores from various parameters into a standardised format. This is essential for OPEL because each pillar has different numbers of parameters, making direct comparisons challenging. By normalising the scores, the data is comparable across different pillars and providers, regardless of the number of parameters involved.

The normalisation process and the rationale behind the methodologies are described in appendix A.

Normalisation of OPEL score ensures:

  • comparability: enables comparison across different pillars and providers as operational pressures are assessed on a like-for-like basis
  • standardisation: by providing consistency in scoring, making it easier for all those utilising OPEL to interpret and act on the data
  • transparency: by providing a clear and understandable metric that stakeholders can use to make informed decisions

The table below shows the normalised OPEL score ranges, their corresponding operational pressure escalation level and an indication of the clinical risk for each level. The ranges and corresponding escalation levels are standard across every pillar of OPEL, ICSs and NHS England, both regional and national.

(Normalised) OPEL scoreCorresponding escalation levelClinical risk
0–15OPEL 1Low
>15–40OPEL 2Medium
>40–70OPEL 3High
>70–100OPEL 4Very high

Integrated trusts

Where an NHS trust provides services across multiple pillars, it should generate separate OPEL scores for each pillar by applying the relevant parameters. For example, if an NHS trust provides both acute services and CHS, it should produce 2 OPEL scores: one for the acute OPEL and one for the CHS OPEL, allowing both services to be accurately reflected in the respective ICS’s scores.

Acute OPEL

Each NHS acute site with a Type 1 ED must complete an OPEL assessment using the 10 acute OPEL parameters and normalisation process, to derive a normalised OPEL score out of 100. This score also denotes the escalation level. The values and data on which this assessment is based must be made available to the ICS and shared with NHS England, to derive the ICS, NHS England regional and the NHS England national acute OPEL scores.

The acute OPEL now has 10 parameters:

  1. average ambulance handover since midnight (minutes)
  2. current 4-hour ED performance (percentage)
  3. current ED Majors and Resus occupancy (percentage)
  4. current median time to treatment since midnight (minutes)
  5. patients in ED over 12 hours (percentage)
  6. patients in ED referred to service (percentage)
  7. bed occupancy (percentage)
  8. patients no longer meeting criteria to reside (percentage)
  9. patients discharged (percentage)
  10. beds closed for infection prevention and control (percentage)

The definitions and thresholds for the acute hospital parameters, and the scores attributed to each threshold can be found in appendix B.

NHS community health service OPEL

All NHS CHS providers must use the 8 CHS OPEL parameters and normalisation process to derive a normalised OPEL score out of 100. This score also denotes the escalation level. The values and data on which this assessment is based must be made available to the ICS and shared with NHS England, to derive the ICS and NHS England CHS OPEL scores.

The CHS OPEL parameters assess and monitor the operational pressures within CHS. The 7 are:

  • community bed occupancy (percentage) 
  • no longer meeting criteria to reside (percentage) 
  • virtual ward occupancy (percentage) 
  • pathway 2 capacity and flow (percentage) 
  • community nursing caseload versus scheduled (percentage) 
  • intermediate care contacts versus scheduled (percentage) 
  • UCR (urgent community response) 2-hour response (percentage) 

The definitions and thresholds for the CHS OPEL parameters and the scores attributed to each threshold can be found in appendix C.

Due to the complexities of CHS provider boundaries and the variable number of CHS providers within ICS footprints, the lowest quantum of measurement for CHS OPEL is at ICS level. ICSs are required to self-define the contribution from each NHS CHS provider within their footprint. This can be achieved by consistently assessing an appropriate metric such as proportion of funding allocation to various CHS providers, number of community beds or number of community visits.

Mental health service OPEL

All MH service providers must use the 8 MH OPEL parameters to derive its OPEL score and normalisation process to derive a normalised OPEL score out of 100. The values and data on which this assessment is based must be made available to the ICS and shared with NHS England, to derive the ICS and NHS England MH OPEL scores.

The MH OPEL parameters assess and monitor the operational pressures within MH services. The 8 are:

  • bed occupancy – adult mental health (percentage) 
  • bed occupancy – older adult mental health (percentage) 
  • patients clinically ready for discharge (percentage) 
  • inappropriate out of area placements (number) 
  • planned mental health discharges (percentage) 
  • achieved mental health discharges (percentage) 
  • mental health beds closed to admission (percentage) 
  • patients waiting for mental health inpatient admission (percentage) 

The definitions and thresholds for the MH OPEL parameters and the scores attributed to each threshold can be found in appendix D.

As for CHS, due to the complexities of MH provider boundaries and the variable number of MH providers within each ICS footprint, the lowest quantum of measurement for MH OPEL is at ICS level. ICSs are required to self-define the contribution from each NHS MH provider within their footprint. This can be achieved by consistently assessing an appropriate metric such as proportion of funding allocation to various MH providers or number of MH beds.

The MH pillar is specifically designed for adult and older adult MH services. The MH OPEL parameters do not currently cover children and young people services, due to the intricate commissioning arrangements for these services and the overlap with social and local authority services. We are committed to exploring ways to address these complexities in the future.

NHS 111 OPEL

Each NHS 111 provider must use the 6 NHS 111 OPEL parameters to derive an OPEL score and normalisation process to derive a normalised OPEL score out of 100. The values and data on which this assessment is based must be made available to the ICS SCC and shared with NHS England, to derive the ICS and NHS England NHS 111 OPEL scores.

The NHS 111 OPEL parameters assess and monitor the operational pressures within NHS 111 services. The 5 are:

  • average speed to answer previous hour (minutes)
  • average speed to answer from midnight (minutes)
  • calls abandoned since midnight (percentage)
  • outstanding clinical cases per currently scheduled 111 clinician (number)
  • clinical call backs offered in 20 minutes from midnight (percentage)
  • average wait for a clinical call back from midnight (minutes)
  • average speed to answer in the previous hour (minutes)
  • calls abandoned from midnight (percentage)
  • outstanding clinical cases per currently scheduled NHS 111 clinician
  • clinical call backs offered in 20 minutes from midnight (percentage)
  • average wait for a clinical call back from midnight (hours)

As for CHS and MH services, due to the complexities of NHS 111 service provider boundaries and the wide variation in the number of NHS 111 contracts in each ICS footprint, the lowest quantum of measurement for NHS 111 OPEL is at ICS level. ICSs are required to self-define the contribution from each NHS 111 provider within their footprint. This can be achieved by assessment of a consistent metric such as proportion of funding allocation to various NHS 111 providers.

Escalation and actions in response to operational risks and pressures

OPEL response overview

The OPEL framework recognises operational pressures in a consistent way. It also supports organisations’ responses to stabilise and recover by providing actions for each OPEL and identifying the responsibilities for NHS acute trusts, MH service providers, CHS providers, NHS 111 providers ICSs and NHS England regions.

OPEL actions should be implemented in conjunction with local surge and escalation policies and procedures. Local policies and procedures must be updated to reflect the OPEL 2024 to 2026 action cards in Appendices F to J and escalation algorithms in appendix K. Particular attention should be given to multi-agency actions, which are considered higher risk and require joint ICS and NHS England regional awareness and response to support rising pressure in UEC.

Dynamic risk assessment in response to changes in OPEL

Dynamic risk assessment (DRA) is a proactive, real-time process for assessing and responding to risks in complex, unpredictable and/or rapidly changing environments. It involves continuous monitoring and adapting to potential hazards, changing conditions and the needs of people using services and the staff delivering them. DRA also recognises that in complex and rapidly changing scenarios, failures of measures to mitigate patient safety often result from several risk events occurring simultaneously or within a short space of time, so that single risk mitigation strategies cannot be relied on. It supports consideration of the connectivity, or contagion, between the different risks across a provider, pathway or system and hence a risk sharing approach.

OPEL provides a consistent framework for the DRA that should be undertaken when making decisions in response to operational pressure, regardless of organisation. In the same way that OPEL augments and is used in conjunction with local surge and escalation policies and procedures, OPEL must be used as a consistent measure alongside the National Quality Board DRA framework, to augment local information when undertaking DRA and enacting actions. As an overview:

  • organisations should undertake continuous DRA: when responding to changes in OPEL, and use the parameters within each pillar of the OPEL framework to consistently monitor changes in OPEL and the impact of any actions taken  
  • dynamic risk perception: risk can be viewed differently by different stakeholders, and it is important to gain a comprehensive understanding about the risks and potential actions by listening to different staff groups, professions and patients.
  • actions are grounded by providers’ OPEL assessments and DRA: we expect ICSs and NHS England regions to implement all OPEL 3 or 4 actions if any provider within their region is assessed as OPEL 3 or 4, regardless of the aggregated OPEL score for that ICS or region 
  • decision-making in extremis: the actions in the OPEL framework are not routine actions and the focus of decisions made in extreme situations – for example, in response to overcrowding and delays – may be the mitigation of more substantial patient risks elsewhere in the pathway. To enable this, risk sharing across system partners – for example, across multiple providers – may be necessary and should be supported by integrated care boards (ICBs) 
  • documentation of actions: all decisions should be recorded, including those to mitigate anticipated risks, as well information on how a risk has been identified and measured to determine its potential for harm. This documentation will be a useful resource for learning and evaluation 
  • consideration of external factors: all decisions must consider the wider external factors that could affect the desired outcomes: for example, decisions made by other providers or neighbouring systems, regional functions or any external issue impacting on the UEC pathway 

Enacting OPEL actions

The action cards do not specify the circumstances in which an action should not be taken; that is left to local discretion based on the DRA. However, if the organisation decides an action will not be implemented or circumstances prevent its delivery, this should be reported to the ICS (via the SCC) and NHS England region by exception and regardless of escalation level.

Enacting and de-escalating any OPEL action(s) is discretionary to local operational management based on local assessment of risk. Organisations may implement actions for an OPEL higher than the one they are at if they can justify that the perceived risk warrants the implementation of such actions. The governance for these decisions should be clearly defined in updated local policies.

Similarly, the actions for an OPEL may remain in place beyond when an organisation’s OPEL drops, to allow time for the original OPEL’s actions to be implemented and their effectiveness assessed.

Each provider is required to monitor and measure the OPEL parameters and calculate its corresponding OPEL score. Actions should be implemented when OPEL thresholds are breached. For example, we expect that an acute trust achieving OPEL 3 will respond by implementing all OPEL 3 actions.

ICSs should monitor individual provider OPEL scores and its overall OPEL score. Similarly, NHS England and NHS England regions should monitor ICS OPEL scores. When a provider escalates, the relevant ICS and NHS England region are required to:

  • enact the provider-specific actions for the corresponding operational level 
  • review their own organisational operational level actions 
  • enact the provider-specific actions for the corresponding operational level
  • review their own organisational operational level actions

For example, if a CHS provider enters OPEL 4, the ICS should enact the specific ICS MH OPEL actions, review all other ICS OPEL 4 actions and consider enacting them as appropriate.

Additionally, if an ICS’s overall OPEL score reaches OPEL 3, it should implement all OPEL 3 actions, and the relevant NHS England region should also review and enact its OPEL 3 actions accordingly. Providers should continue to implement actions at their corresponding escalation level based on their OPEL scores.

NHS 111 actions: clinical safety plan and national contingency

NHS 111 OPEL actions must be considered alongside the more dynamic approach to NHS 111 clinical safety planning (CSP), further details of which can be found in clinical and operational monitoring section of appendix I. CSP is the approach NHS 111 providers take to review their call taking capacity and clinical management capacity collectively. It enables ICBs and the relevant region to manage the safe delivery of the front end (call taking) and the back end (clinical queue management) within NHS 111 providers.

Furthermore, where an NHS 111 provider triggers a score of OPEL 4, it is important to note that this will not automatically invoke national contingency. The NHS England national IUC (integrated urgent care) and UEC teams will consider any requests for national contingency in relation to performance levels and system pressures across the country and use real-time telephony data as part of their consideration of the suitability of any request for contingency.

Contact

For queries relating to this document please contact the iUEC national team at NHS England: England.uec-operations@nhs.net

Publication reference: PRN01379