Agenda item: 11 Paper no: 7 Title of Report: Status: Emergency Planning, Resilience and Response (EPRR) Annual Assurance TO APPROVE Committee: Governing Bodies in Common Date: 19/12/18 Venue: Mandolay Hotel, Guildford Presented by: Executive Lead sign off: Author(s): Elaine Newton, Executive Director of Communications and Corporate Affairs Elaine Newton, Executive Director of Date: 05/11/18 Communications and Corporate Affairs Mark Twomey, Head of EPRR Felicity Govas, Senior Resilience Manager Governance: Conflict of Interest: The Author considers: Previous Reporting: (relevant committees/ forums this paper has previously been presented to) Freedom of Information: The Author considers: None identified Audit Committees in Common; 16/11/18; Recommended to the Governing Bodies Open no exemption applies Executive Summary: Surrey Heartlands CCGs are required to oversee the annual NHS England Emergency Preparedness, Resilience and Response (EPRR) assurance process in Surrey, reviewing providers for which we are the lead commissioners. This paper provides an update to the Governing Bodies around the level of compliance of the CCGs, and of provider organisations against the NHS England Core Standards. The 2018 submission was made by the 26 September deadline, and an assurance meeting held with NHS England on the 11 October, as part of the Local Health Resilience Partnership assurance schedule. The Governing Bodies are required to have sight of the return, albeit retrospectively, the assessment of which is summarised in this paper and available in full on request. For 2018, a rating of substantial assurance has been confirmed by NHS England for the Surrey Heartlands CCGs, which this year was submitted as a single return. Working together as the Surrey Heartlands Clinical Commissioning Groups Guildford and Waverley CCG I North West Surrey CCG I Surrey Downs CCG Governing Bodies in Common/ 19/12/18/ EPRR Annual Assurance 1
Implications: What is the health impact/ outcome and is this in line with the CCG s strategic objectives? What is the financial/ resource required? What legislation, policy or other guidance is relevant? Is an Equality Analysis required? Any Patient and Public Engagement/ consultation required? Potential risk(s)? (including reputational) Objective 5: Safe, effective care providing the best possible health and care outcomes and patient experience No implication. Civil Contingencies Act 2004 and Health and Social Care Act 2012 (Sections 46 and 47) NHS Gateway ref: 08306 - EPRR Assurance Process Guidance 2018 EPRR Assurance Assessment Not applicable Not applicable None Recommendation(s): (1) APPROVE the Surrey Heartlands EPRR Core Standards Assurance Assessment Next Steps: N/A Governing Bodies in Common/ 19/12/18/ EPRR Annual Assurance 2
Emergency Preparedness, Resilience and Response Annual Assurance Introduction and context The purpose of the annual Emergency Preparedness, Resilience and Response (EPRR) Assurance Process is to provide evidence to NHS England that NHS organisations are maintaining comprehensive, robust arrangements enabling them to respond in the event of an incident or emergency. Through the Core Standards for EPRR, the CCGs have additional resilience responsibilities placed on them by NHS England. In addition to completing their own assurance return, the CCGs are required to undertake an assessment of the level of compliance of providers for which they are the lead, including reviewing the self-assessment of their position and examining documentary evidence to support this. The CCGs are required to report the results of the EPRR assurance process annually, and seek Governing Bodies acknowledgement of this assessment. There is also a requirement for the Accountable Emergency Officer, (the Executive Director of Communications and Corporate Affairs), to ensure that the Governing Bodies receives EPRR reports as appropriate, and no less frequently than annually, including reports on training and exercises undertaken by the organisation, and any significant incidents. The Governing Bodies should also be assured that adequate resources are made available to enable the organisation to meet the requirements of these core standards. This paper provides an update on the EPRR work stream and asks the Audit Committee to confirm the CCGs assurance return as submitted to NHS England, based on an assessment that Surrey Heartlands CCGs have achieved substantial compliance. The ongoing EPRR work plan is presented in support to demonstrate that plans are in place to address any gaps in arrangements. EPRR Activity 2018/19 Risk assessment, Co-operation and Information Sharing duties Surrey Heartlands CCGs have participated fully in (a) ensuring representation at both the Local Health Resilience Partnership (LHRP) Executive and Delivery groups; (b) responding to all information sharing requests with partner category one and two responders; (c) assisting NHS England in the production of an LHRP Risk Register specifically for health to cover the Surrey Local Resilience Forum area, and (d) supporting training and exercises, and debriefing incidents. Emergency planning In light of the new Surrey Heartlands landscape, additional staffing resource has been secured to support the EPRR work stream and fulfil a proposed subject matter expert (SME) rota for oncall. Strides are being made towards creating a suite of consolidated plans, to standardise operations across the three CCGs. A new EPRR Policy has been approved for use by the Governing Bodies in Common, and a reviewed Incident Management Plan (IMP) covering Surrey Heartlands has been approved by the Joint Executive Team (JET). The IMP was approved by the Audit Committees in November for review. These documents will be disseminated to CCG staff. The CCGs collaborative agreement with East Surrey CCG to share emergency planning resource and expertise continues. The agreement takes into account the increasing expectations made of CCGs by NHS England, in particular representing the health economy at the tactical level of response. The CCGs Resilience Team has also taken on responsibility for assuring EPRR for the South East Coast Ambulance Service NHS Foundation Trust (SECAmb) on behalf of the 22 commissioners across Kent, Surrey and Sussex. EPRR Assurance 1
Continuity Management The CCGs continue to develop their business continuity capability, with each directorate having completed a Impact Analysis (BIA) and a Continuity Plan (BCP). These are being revisited to align to the CCG collaborative model under joint management arrangements, and will in turn will feed into an overarching Continuity Plan for the three CCGs. Over the past 6 months, the CCGs have invested in technology to support a new working environment where colleagues are more peripatetic in their roles. This investment and the replacement of older equipment means that, should we face a denial of access to any site, such as was the case during the Weybridge Hospital fire, our workforce is better equipped to continue with critical business. The work programme for 2018/19 will focus on maximising the opportunities, both within our organisation and with other CCGs, as capabilities are built and through the closer working under the joint arrangements. Training and Exercising The CCG has engaged with our system partners through exercises such as Buzzard, which took place in July 2018, to test the major trauma capability across Surrey. A system exercise for the three Surrey Heartlands CCGs is planned for early 2019. A series of training sessions have been held for our on-call cohort around the Joint Emergency Services Interoperability Principles (JESIP) (the national standard best practice for all responders) building on emerging learning from the terrorist attacks in 2017 and the Grenfell Tower incident. System training was also provided in September 2018 to colleagues across the CCGs, to join up our approach to system management out of hours. Further sessions will be planned. New members of the on-call rota are being booked on to the Local Resilience Forum s Introduction to Civil Protection training, to ensure they have an awareness of partnership response arrangements beyond the local health economy. In the longer term, the Resilience Team are building a capability to provide this training in-house to CCG staff, and to share this with system partners. A series of bespoke courses are being developed to support staff in strategic and tactical roles, as well as additional courses to enhance and refresh training for loggists. Surrey Heartlands Assurance Return This is the first year that the Surrey Heartlands CCGs have submitted a consolidated EPRR core standards return. Of the 43 NHS EPRR core standards that are applicable to CCGs, 5 have been marked amber. These standards relate to the duty to maintain pandemic influenza plans, training for on-call staff, strategic and tactical responder training, monitoring and evaluation of the business continuity management system, and auditing of business continuity arrangements. Work is continuing around last year s area of improvement, training for staff undertaking an on-call function, to reflect the new Surrey Heartlands structure. The work to address these areas and capabilities has been mapped in the work plan in Appendix A. The deep dive this year focussed on Command and Control and an exploration of the arrangements that are in place. Following review by NHS England, two of these standards were deemed to be amber and six green. Of the two standards rated amber the first relates to the recovery planning phase of incident response. The second relates to the communication and IT equipment resources required to set up and run an Incident Coordination Centre (ICC). Pending National guidance relating to best practice for ICCs and resilient communications, NHS England advised that this second standard be rated as amber by all organisations in the South East. Further development of our on-call training capabilities, and the completion of our business continuity work place plans will be a focus for the next two quarters of the financial year, along with the move to a two-tiered on-call system across Surrey Heartlands. This will include a EPRR Assurance 2
strategic tier to support the tactical level. A staff consultation on the new rota system has now been concluded. With the above taken into consideration, Surrey Heartlands has put forward a position of SUBSTANTIAL assurance, this being defined by NHS England as The organisation is 89-99% compliant with the core standards they are expected to achieve. For each non-compliant core standard, the organisation s Board has agreed an action plan to meet compliance within the next 12 months. This position has now been confirmed following NHS England regional and national assurance review meetings. The CCGs have a work plan in place which the Governing Bodies are asked to approve (please see Appendix A). CCG review of provider assurance Surrey Heartlands CCGs are required by NHS England to undertake the assurance of providers for which we are the lead commissioner, (6 in total). In addition, Surrey Heartlands assure providers that East Surrey CCG lead on as part of our collaborative agreement. The Surrey Heartlands providers are set out in the table below. Each provider is required to adhere to a number of core standards, dependent on the type of organisation, and must submit evidence to support their assessment of compliance. Other providers including Epsom and St. Helier and South Central Ambulance Service (PTS provider) are coordinated by other CCGs with input from Surrey Heartlands. A breakdown of provider information is contained in the table below and will inform future contract meetings: Name of provider Surrey and Borders Partnership Royal Surrey County Hospital Care UK South East Coast Ambulance Service Ashford and St Peter s Hospitals Central Surrey Health Type of organisation 2017 level of compliance Mental Health Non- Compliant Acute and Community Out of hours GP service Ambulance Trust 2018 level of compliance Non- Compliant Number of applicable standards 54 22 Partial Partial 64 87 N/A Partial 47 20 Substantial Partial ERRR Standards 49 Partial Interoperable Standards 163 Acute Substantial Substantial 64 65 Community Substantial Substantial 54 87 Number of documents submitted for review 66 Furthermore, all providers were required to rate their compliance against the 8 deep dive standards focussing on Command and Control. These standards are not counted towards the overall compliance rating. In addition to reviewing documentary evidence of each organisation s level of compliance, confirm and challenge meetings were held with each provider, during which additional questions were asked and information sought. The results of the Surrey Heartlands review of provider assurance were presented to NHS England on the 4 th October 2018 and are now confirmed following NHS England South East, or at the NHS England regional or national assurance review meetings. These will be reported to Providers own Trust Boards. EPRR Assurance 3
Appendix A - Surrey Heartlands CCG s EPRR Work Plan 2018-19 Surrey Heartlands Emergency Planning, Resilience and Response Work Plan 2018/19 Planning Lead Training Lead Exercising Lead July August On-Call Consultation for new setup with Joint Staff Partnership Forum Training material project commences Incident Management Plan review EPRR Assurance September EPRR Assurance ICC and On-call systems review New Directorate Impact Analysis Review activation system October November setup Review of Resilience / EPRR Policy New Directorate Continuity Plan Review NHSE EPRR LHRP Assurance Pandemic Flu Plan Work Area Recovery Plan review New Directorate Continuity Plan Review MT On-call Training for new Managers Skype for MT DD On-Call Training DD/ for new Manager MT/ TCG Training DD for new On-call MT/ JESIP Training MT/ for On-call MT/ Loggist training for EPRR lead - MT JP System Training for new On-call managers Training for new on-call managers Introduction to Civil Protection /DD Exercise Buzzard BH Exercise Radialem System Exercise for all 3 CCGs Directorate Continuity Exercises JP/ EPRR Assurance 4
December January ICC Plan Emergency Response Directory Review BREXIT Scenario planning Review Annual Report material Work Area Recovery Plan review MT JP Training starts Loggists Training Directorate Continuity Exercises system go-live (STC) February MTPAS Review Work Area Recovery Plan exercise March Contracts Review Continuity Audit (TBC) MT/IT New ICC Test Exercise Exercise COMET JP/ / EPRR Assurance 5