OFFICIAL SENSITIVE. 10 July 2017 NHS England LHRP Co-chairs

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1 Publications Gateway Reference Simon Weldon Director of NHS Operations and Delivery To: Provider Accountable Emergency Officers NHS England Skipton House CCG Accountable Emergency Officers 80 London Road NHS England Regional Directors London SE1 6LH NHS England Regional Directors of Assurance and Delivery NHS England Directors of Commissioning Operations 10 July 2017 NHS England LHRP Co-chairs Cc: NHS England Heads of EPRR NHS England Business Continuity team CCG Accountable Officers CCG Clinical Leads CSU Managing Directors Clara Swinson, Director General Public Health, Department of Health Helen Shirley-Quirk CB, Director Health Protection and Emergency Response, Department of Health Dr Kathy McLean, Executive Medical Director, NHS Improvement Dr Ruth May, Executive Director of Nursing, NHS Improvement Dear colleague Process for Emergency Preparedness, Resilience and Response (EPRR) Assurance The last few months have been busy for us all in relation to NHS resilience and response. These events make the annual NHS EPRR Assurance process even more important and this letter starts this process for As in previous years, NHS England will lead the process via Local Health Resilience Partnerships (LHRP) in order to seek assurance that both the NHS in England and NHS England are prepared to respond to emergencies, and are resilient in relation to continuing to provide safe patient care. The format and process this year will follow that of The purpose of this process is to assess the preparedness of the NHS, both commissioners and providers, against common NHS EPRR Core Standards which remain unchanged for this year. A task and finish group is currently reviewing the Core Standards ahead of the 2018/19 process and these will be published in the autumn. The EPRR Core Standards are available on the NHS England internet site Local Health Resilience Partnerships continue to play an integral part of the process and constituent members are asked to support NHS England in conducting the process. The NHS EPRR assurance process concludes with a submission to the NHS England Board in March Once this has been accepted by the Board, NHS England will be in a position to provide national EPRR assurance for 2017/18 to the Department of Health and the Secretary of State for Health. Page 1 of 7

2 In light of the current UK risks and threats, this year s process will include an additional element of assurance for NHS Strategic Assets. This additional element will include a site visit to meet with the relevant leaders within these organisations. This process is described in section 4 of this letter. 1. Timeframes The timelines for this year s process will be in line with those for the 2016/17 process. All organisations should commence their self-assessment immediately so as to give suitable time to undertake this in a measured and calculated manner. EPRR Core Standards selfassessment. Work planning and Board Sign Off LHRP confirm and challenge process. LHRP documentation submission to Regional team Regional confirm and challenge meetings with LHRP co-chairs. Document submission to the central team by 31 December 2017 National confirm and challenge meetings with Regions by 28 February 2018 NHS England Board submission by 1 April 2018 Once organisations have taken their self-assessment results to their Boards/Governing Bodies there will be Local Health Resilience Partnership confirm and challenge process to provide organisations with a peer review. Following this, Local Health Resilience Partnership Co-Chairs will submit their reports to the NHS Regional Teams where there will be a regional consolidation process, via confirm and challenge meetings. NHS England regions will determine the local arrangements and dates for submission. By the 31 December 2017, Regional Teams will submit their consolidated data to the Central Team where national consolidation will take place. This will be complete by Wednesday 28 February 2018 so that the national report can be prepared and considered by the NHS England Board by 1 April Actions 2.1 Providers of NHS funded care The following organisations are required to undertake the NHS EPRR assurance process: Acute hospital service providers Specialist hospital providers Ambulance service providers (including patient transport organisations) Community service providers (this includes NHS Trusts, Foundation Trusts and social enterprises) Mental health service providers NHS111 providers Local Health Resilience Partnerships may wish to include other organisations not mentioned above, at their discretion. Page 2 of 7

3 Provider organisations are asked to undertake a self-assessment against the relevant individual core standards and rate their compliance. These individual ratings will then inform the overall organisational rating of compliance and preparedness. Once this process has taken place, organisations are required to take a statement of compliance to a public Board meeting. Provider organisations are also required to publish their statement of compliance in their annual report. This Board report, along with the Core Standards assurance ratings and rectification plans, should then form the submission to the Clinical Commissioning Group and Local Health Resilience Partnership. The Local Health Resilience Partnership will undertake a formal review via a confirm and challenge meeting. Organisations which operate across Local Health Resilience Partnerships borders should present their self-assessment and supporting evidence to their lead commissioner and host Local Health Resilience Partnership. This documentation should also be shared with other relevant Local Health Resilience Partnerships /stakeholders as necessary. 2.2 Commissioners of NHS funded care The following organisations are required to undertake the EPRR assurance process: Clinical commissioning groups NHS England regional and central teams. Commissioning organisations (including NHS England) are required to undertake a selfassessment against the relevant individual NHS EPRR Core Standards and these individual ratings will then inform the overall organisational rating of compliance and preparedness. Once this process has taken place commissioners are expected to take a statement of compliance to their Governing Bodies/Senior Management Teams. This report along with the Core Standards assurance ratings and rectification plan should then form the submission to the Local Health Resilience Partnership. The Local Health Resilience Partnerships will undertake a confirm and challenge meeting. Commissioners which operate across Local Health Resilience Partnership borders should present their self-assessment and supporting evidence to their regular host Local Health Resilience Partnership. This documentation should also be shared with other relevant Local Health Resilience Partnerships s/stakeholders as necessary. Clinical Commissioning Groups are asked to support NHS England in the additional assurance of the UK NHS strategic asset (Section 4). 2.3 Local Health Resilience Partnerships (LHRPs) It is expected that Local Health Resilience Partnerships s will review and consider all relevant organisations self-assessments, Board or Governing Body papers (or equivalent) and rectification plans and provide a mechanism across their geography to facilitate confirm and challenge. Local Health Resilience Partnerships are expected to: Ensure that commissioners of services are actively involved Seek further evidence where an organisation considers itself less than Fully Compliant. Page 3 of 7

4 Conduct a deep dive into core EPRR Governance in all organisations included in the assurance process Provide the NHS England Regional Director of Operations and Delivery with a report on the preparedness of all organisations in their Partnership. Actively monitor progress of those organisations reporting an overall rating of Non- Compliant until the Partnership is content that the organisation has attained an agreed level of compliance Actively engage with local NHS Improvement colleagues to support this process Records should be kept of the reviews undertaken and include any evidence requested. 2.4 NHS England Regional Teams NHS England Regional Teams will coordinate a submission to evidence their level of assurance and to help inform the national assurance assessment. Regional Teams will be asked to complete template(s) which will follow this letter and: Request any evidence of the work completed and/or plans put in place that they feel is necessary to support and/or challenge organisation(s) Be able to distinguish between the preparedness of NHS England and the preparedness of other organisations. Demonstrate where improvement is needed and the mitigation in hand at individual organisational/team level. Be able to identify and set out instances of good practice against the core standards so that this can be shared across regions to improve the overall preparedness and resilience of NHS England and the NHS in England. Actively engage with NHS Improvement colleagues to support this process Undertake the strategic asses assurance process (Section 4.) Records should be kept of the reviews undertaken and include any evidence requested. It is expected that all actions in section 2 above will be completed by 31st December NHS England Business Continuity Assurance NHS England business continuity assurance will be undertaken once and in conjunction with the NHS England Business Continuity Team, via the NHS EPRR Core Standards template. The NHS England Business Continuity Team will liaise directly with NHS England Regional Teams alongside the NHS England central EPRR team to gain assurance of NHS England arrangements. The NHS England Business Continuity Team will liaise directly with each Commissioning Support Unit (CSU) to gain their business continuity assurance, which will then be incorporated into the NHS England Board paper. 3. Assurance Deep dive This year s EPRR assurance deep dive topic is core EPRR organisational governance. There has been a significant amount of organisational change over recent years and there is a need to ensure that EPRR is secured appropriately, within all our organisations. This deep dive will include Page 4 of 7

5 assurance of areas such as internal organisational EPRR accountability, regular reports to public Board meetings, a realistic work program and a solid training and exercise program. Following on from the CBRN deep-dive carried out during the , the HAZMAT/ CBRN assessment remains incorporated into the NHS EPRR Core Standards. Acute hospitals should expect ambulance service providers to work with them to assess and challenge their level of HAZMAT/CBRN preparedness (using the NHS EPRR Core Standards). NHS England continues to fund ambulance service providers, via the National Ambulance Resilience Unit (NARU), to undertake this. In addition to this assessment, ambulance service providers are funded to provide training to support the acute hospital response. Specialist, community and mental health service providers should note that some HAZMAT/ CBRN core standards are relevant and pertinent to their organisations, and they also have a duty of care towards self-presenting patients who have been exposed to a HAZMAT or CBRN incident. 4. NHS Strategic Asset Assurance In light of recent incidents, this year s assurance process will include an emphasis on NHS Strategic Assets. These are organisations that are considered to provide vital services and will this year receive a greater level of scrutiny. The organisations covered within the NHS Strategic Asset assurance process for 2017/18 are: Ambulance services Major Trauma Centres Burns Centres High level Isolation Units (infectious disease units) High Security Mental Health Facilities Geographically remote organisations Ambulance services are receiving an enhanced assurance process which is being led by the National Ambulance Resilience unit and this program is well under way. NHS England will lead the enhanced assurance process for all other strategic organisations. This will include a site visit to each organisation and the key lines of enquiry for these visits will be shared with the respective organisations, in advance. The visits will consist of representation from NHS England, NHS Improvement and the lead Clinical Commissioner. This team will expect to meet with the organisation s Accountable Emergency Officer and Emergency Preparedness Manager/Lead. NHS England will work with these organisations to schedule these events. 5. Organisational Assurance Ratings Organisations will be expected to state an overall assurance rating as to whether they are Fully, Substantially, Partially or Non-Compliant with the NHS EPRR Core Standards. 1. Acute, specialist, Community and mental health providers should calculate their overall organisation compliance level by using the EPRR Core Standards and HAZMAT CBRN Core Standards tabs together (therefore standards 1-66 as a single rating). Page 5 of 7

6 2. Patent Transport, 111, NHS England (regional and national), CCGs, CSUs and other NHS funded providers should calculate their overall organisation compliance level by using the EPRR Core Standards tab only (therefore standards 1-52 only). 3. Ambulance providers should report 3 compliance levels: - Calculate EPRR Core Standards against Core Standards 1-66 as per No 1 above. - Calculate their overall compliance against MTFA Core Standards and - Calculate their overall compliance HART Core Standards separately applying the criteria in the national letter (gateway 05356) letter for each tab. 4. The deep dive results should be reported separately and should not be included in any overall organisational compliance rating. The definitions of these ratings remain the same as the 2016/17 process and are detailed below: Compliance Level Full Substantial Partial Non-compliant* Evaluation and Testing Conclusion Arrangements are in place the organisation is fully compliant with all core standards that the organisation is expected to achieve. The Board has agreed with this position statement. Arrangements are in place however the organisation is not fully compliant with one to five of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Arrangements are in place however the organisation is not fully compliant with six to ten of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Arrangements in place do not fully address 11 or more core standards that the organisation is expected to achieve. A work plan has been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance. * Should an organisation be Non-Compliant, the Local Health Resilience Partnership will regularly monitor progress throughout the year until it is has attained an agreed level of compliance. 6. Summary: In summary, please can you: 1. Note that all organisations will undertake a self-assessment against the NHS EPRR Core Standards. 2. Note the approach to the 2017/18 EPRR assurance process that is expected to be followed by NHS England and Local Health Resilience Partnerships. 3. Note the timeframes for the delivery of the 2017/18 assurance process. 4. Liaise with local partners and stakeholders to achieve the outcomes required. 5. Note the additional implications of the NHS Strategic Asset assurance process for 2017/18 for the relevant organisations Page 6 of 7

7 Senior managers are asked to bring the contents of this letter to the attention of their emergency preparedness, resilience and response staff and disseminate to other organisations as applicable. For further information, please see the NHS England EPRR web-page 1 or if you have any further queries, please contact Stephen Groves (National Head of EPRR) at stephengroves@nhs.net. Yours sincerely, Simon Weldon Director of NHS Operations and Delivery 1 Page 7 of 7