NHS HARINGEY CLINICAL COMMISSIONING GROUP EMERGENCY PREPAREDNESS, RESILIENCE AND RESPONSE (EPRR) POLICY 1
1 SUMMARY This policy sets out how the CCG will ensure that it has prepared and tested arrangements in place to respond to emergency and business continuity incidents, in accordance with its responsibilities under the Health and Social Care Act (2012) and the Civil Contingencies Act (2004) (CCA). 2. RESPONSIBLE PERSON: Steve Beeho, Head of Integrated Governance 3. ACCOUNTABLE DIRECTOR Sarah Price, Chief Officer 4. APPLIES TO: All CCG departments 5. EQUALITY IMPACT ANALYSIS COMPLETED: To be completed. 6. GROUPS/INDIVIDUALS WHO HAVE OVERSEEN THE DEVELOPMENT OF THIS SET OF PLANs: 7. GROUPS WHICH WERE CONSULTED AND HAVE GIVEN APPROVAL: 8. RATIFYING COMMITTEE (S) & DATE OF FINAL APPROVAL: Sarah Price, Chief Officer Senior Management Team Senior Management Team (14.9.16) Audit Committee (virtual date TBC) Haringey CCG Governing Body (29.9.16) 8. VERSION: 0.1 10. AVAILABLE ON: Intranet X Website X 11. RELATED DOCUMENTS: Haringey CCG Business Continuity Plan (2016) Civil Contingencies Act 2004 Health and Social Care Act 2012 ISO 22301 PAS 2015 Memorandum of Understanding between the NHS England and Haringey CCG NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR) The role of the Accountable Emergency Officers for EPRR NHS England Model Job Description and Competences for Emergency Preparedness Officers in NHS Provider Organisations Surge Management, Provider Operational Resilience and Surge Management Service Core Offer for CCGs 2015/16 2
12. DISSEMINATED TO: All Haringey CCG staff 13. DATE OF IMPLEMENTATION: October 2016 14. DATE OF NEXT FORMAL REVIEW: September 2017 NEL Commissioning Support Unit Assurance regarding the BCP and Surge Service Business Continuity Plans August 2015 North Central London CCGs EPRR On-call Manual Version 2.5 (dated July 2016) NHS England (London) Emergency Department Capacity Management, Redirect and Closure Policy (ED Policy Version 7.2 - February 2013 NHS England (London) Pressure Surge Management Arrangements Version 2 (November 2013) NHS England EPRR Operating Model and Command and Control Pan (December 2012 Version 1) NHS England Roles and Responsibilities of NHS Funded Organisations in a Major Incident Haringey CCG Incident Reporting & Serious Incident Policy NHS England CCG EPRR Responsibilities (January 2013) Haringey CCG Risk Management Strategy. Document Control Date Version Action Amendments 12.9.16 0.1 For review by SMT 3
CONTENTS Section Page 1.1 Introduction 4 1.2 Scope 4 1.3 Accountability 5 1.4 Implementation 5 2. Roles and Responsibilities 6 2.1 CCG EPRR Roles and Responsibilities 6 2.2 Governing Body 6 2.3 Accountable Emergency Officer 6 2.4 Emergency Planning Liaison Officer 6 2.5 Department Leads 7 3. Communications and Awareness 7 4. Maintenance 7 5. Testing and Training 7 6. Continuous Organisational Development 8 7. References and underpinning materials 8 Appendix 1 CCG EPRR Roles and Responsibilities 9 Appendix 2 Responsibilities of Accountable Emergency Officer 11 Appendix 3 Responsibilities of Emergency Planning Liaison 12 Officer 4
1.1 Introduction 1.1.1 NHS England requires the CCG to have prepared and tested arrangements to respond to emergency and business continuity incidents, in accordance with its responsibilities under the Health and Social Care Act (2012) and the Civil Contingencies Act (2004) (CCA). 1.1.2 This policy outlines the requirements to which the CCG must adhere and how these will be delivered. 1.1.3 This policy applies to all aspects of CCG operations and services. 1.1.4 The process of Emergency Preparedness, Resilience and Response (EPRR) is delivered by the whole organisation and is driven by the Governing Body through the CCG Accountable Emergency Officer. 1.1.5 The goal of the EPRR policy is to ensure that CCG can support the local health economy in the response to an emergency incident whilst maintaining high levels of service for the local population. 1.2 Scope 1.2.1 The scope of the arrangements for the response to emergency incidents covers the CCG response to all levels of incident as described by NHS England see figure 1. 5
Alert Dynamic Risk Assessment Declaration of incident level Alert Activity Action NHS England Incident Levels 1 A health-related incident that can be responded to and managed by local health provider organisations that requires co-ordination by the local CCG. 2 A health-related incident that requires the response of a number of health provider organisations across an NHS England area team boundary and will require an NHS England Area Team to co-ordinate the NHS local support. 3 A health-related incident that requires the response of a number of health provider organisations and NHS England Area Teams across an NHS England region and requires NHS England regional co-ordination to meet the demands of the incident. Figure 1: NHS Incident Response Levels 4 A health-related incident that requires NHS England national co-ordination to support the NHS and NHS England response. The CCG will be responsible for the coordination of Level 1 incidents within its area of operations. The CCG will provide support to NHS England in the response to Level 2, 3 and 4 incidents. 1.2.2 The scope of the arrangements for the response to Business Continuity incidents is limited to the activities of the CCG. Any staff directly employed by, or contracted to work for the CCG, are covered. It does not cover activities related to providers premises, processes, staff or systems where they are not related to a core contractual term with the CCG. 1.2.3 The CCG is also responsible for ensuring that contracts with provider organisations contain relevant emergency preparedness, resilience (including business continuity) and response elements. In this respect, the scope of this policy includes the arrangements directly commissioned by the CCG or where the CCG is the lead commissioner of a service provider. 1.3 Accountability 1.3.1 The person with senior level responsibility for the delivery of the CCG EPRR arrangements is the Accountable Emergency Officer. 1.3.2 The Accountable Emergency Officer will provide an annual report to the CCG Governing Body on EPRR arrangements and any significant activities (including the response to incidents) over the previous 12 months. 6
1.3.3 Haringey CCG sub-contracts its surge management, aligned with its EPRR responsibilities, to the NEL Commissioning Support Unit (NELCSU). 1.3.4 Designated leads in each directorate are responsible for delivering the information required for the directorate s EPRR arrangements. 1.4 Implementation 1.4.1 The CCG will maintain appropriate plans and procedures documenting their response to emergency and business continuity incidents. 1.4.2 This will include: i. This policy ii. iii. Director on-call pack Business Continuity Plan 1.4.3 The CCG Director on-call pack will enable the CCG to respond to and coordinate local provider responses to a Level 1 Incident. It will also enable the CCG to support NHS England to discharge its EPRR responsibilities for level 2, 3 and 4 incidents. Level 1 incidents will predominantly necessitate the management of pressures within provider organisations. 1.4.4 The CCG will maintain a corporate business continuity plan to enable it to respond to business disruptions. This plan will be scalable, enabling an individual directorate to manage low-level disruptions whilst also providing a framework for the Governing Body to manage disruptions that affect the whole organisation. 1.4.5 The Business Continuity Plan will be developed with regard to best practice both with the NHS and from industry standards. This will include ISO 22301 Business Continuity Management. 2 Roles and Responsibilities 2.1 CCG EPRR Roles and Responsibilities 2.1.1 Ensure contracts with provider organisations contain relevant emergency preparedness, resilience (including business continuity) and response elements; 2.1.2 Support NHS England in discharging its EPRR functions and duties locally; 2.1.3 Be represented on the Local Health Resilience Partnership (LHRP) and provide a route of escalation for the LHRP should a provider fail to maintain necessary EPRR capacity and capability; 2.1.4 Fulfil the responsibilities as a Category Two responder under the Civil Contingencies Act (2004), including maintaining business continuity plans for their own organisation; 2.1.5 Seek assurance provider organisations are delivering their contractual obligations. 2.1.6 Full CCG roles and responsibilities are detailed in appendix 1. 2.2 Governing Body 2.2.1 Acts to ensure/monitor the overall strategic direction of the EPRR programme across the CCG. 7
2.2.2 Ensures that the EPRR programme is enforced and resourced appropriately. 2.3 Accountable Emergency Officer 2.3.1 Undertakes leadership and sponsorship of the EPRR programme under the direction of the Governing Body. 2.3.2 Acts as a point of tactical leadership in support of the Emergency Planning Liaison Officer. 2.3.3 Manages, monitors and reports on the progress of the EPRR programme as required 2.3.4 Ensures that where appropriate, sections of EPRR Plans and Policy are published and accessible to the public. 2.3.5 Identifies individuals within the CCG to participate in the on-call rota. 2.3.6 More detailed responsibilities are set out in Appendix 2. 2.4 Emergency Planning Liaison Officer 2.4.1 Ensures that the CCG meets its statutory obligations under the CCA and complies with all relevant EPRR guidance for the NHS. 2.4.2 Develops and delivers the CCG s emergency preparedness and resilience function. 2.4.3 Leads the development and implementation of EPRR and Business Continuity Plans. 2.4.4 Ensures appropriate representation at local health resilience partnerships (LHRPs) and the local Haringey Borough Resilience Forum (BRF). 2.4.5 Co-ordinates EPRR training exercises for the organisation and with resilience partners. 2.4.6 More detailed responsibilities are set out in Appendix 3. 2.5 Department Leads 2.5.1 Ensure that where necessary relevant department level plans (including Business Impact Analyses) are completed and maintained. 2.5.2 Support the management team in the response to emergency and business continuity incidents. 2.5.3 Ensure that staff attend training relevant to their role. 3 Communications and Awareness 3.1.1 The EPRR Policy, Business Continuity Plan and other associated documents will be placed in an appropriate place on the CCG s intranet site and will actively be promoted to both new starters as part of the induction process and existing staff. 3.1.2 Where appropriate the CCG should share information with key partners and stakeholders ensuring they meet all requirements under Data Protection Act and Caldicott Principles. 4 Maintenance 4.1.1 The Accountable Emergency Officer will be responsible for ensuring that the EPRR Policy and associated plans and procedures are maintained in line 8
with the standard CCG process for document control and version management. 4.1.2 The EPRR Policy and associated plans will be reviewed at least annually or in the event of any changes to: Business objectives and processes Organisational function Organisational structures and staff Key suppliers or contractual arrangements If an updated risk assessment highlights a new or changed vulnerability 4.1.3 The Policy, plans and procedures may also be reviewed following the response to a real incident or exercise. 4.1.4 Where changes are made these will be communicated with all relevant staff and partner organisation and where necessary, updated documents will be circulated. 5 Testing and Training 5.1.1 The Accountable Emergency Officer (AEO) is responsible for identifying appropriate levels of training and awareness sessions for relevant CCG staff who will be involved with a response to an emergency or business continuity incident. 5.1.2 CCG on-call Directors must undertake training that meets the relevant National Occupational Standards and NHS England competencies. 5.1.3 NELCSU are contracted to provide on-call training for staff on behalf of the AEO. 5.1.4 The CCG will maintain a training plan, which is based on a training needs analysis to focus the training delivered within the organisation. 5.1.5 The AEO will ensure that staff attend required training and that training records are maintained by the CCG. On-call directors will maintain individual training portfolios that demonstrate their competencies. 5.1.6 Plans and procedures will be tested on a regular basis, no less than annually or following significant changes to the organisation. 5.1.7 Plans and procedures will be exercised in line with the requirements of the NHS England Emergency Preparedness Framework (2013) and will involve a communications exercise every six months; a desktop exercise once a year; and a major live exercise every three years; 5.1.8 The CCG will maintain an exercise plan based upon these requirements. 6 Continuous Organisational Development 6.1.1 As part of its commitment to continual development, the CCG will undertake reviews of its response and procedures following major exercises or real incident response. 6.1.2 Where appropriate this may take place as part of a multi-agency process. 9
6.1.3 The CCG will maintain appropriate procedures for debriefing staff and identifying and acting on lessons. 6.1.4 Lessons identified will be addressed through changes to policy, plan and procedures and or staff training. 6.1.5 The AEO will be responsible for ensuring that this process takes place and that appropriate actions are included in the EPRR work programme. 7 References and underpinning materials The Civil Contingencies Act 2004 The Health and Social Care Act 2012 NHS Commissioning Board planning framework ( Everyone Counts: Planning for Patients) NHS standard contract NHS Commissioning Board EPRR documents and supporting materials NHS Commissioning Board Business Continuity Management Framework (service resilience) (2013) NHS Commissioning Board Command and Control Framework for the NHS during significant incidents and emergencies (2013) NHS Commissioning Board Core Standards for Emergency Preparedness, Resilience and Response (EPRR) National Occupational Standards (NOS) for Civil Contingencies Skills for Justice22; BSI PAS 2015 Framework for Health Services Resilience ISO 22301 Societal Security - Business Continuity Management Systems Requirements The role of accountable emergency officers Cabinet Office National Recovery Guidance 10
Appendix 1 CCG EPRR Roles and Responsibilities As detailed in the NHS England Emergency Preparedness Framework 2013: Planning and Prevention [CCGs] g. co-operate and share relevant information with category one responders but they will be engaged in (LHRP) discussions where they will add value. They must maintain robust business continuity plans for their own organisations. h. corporately, CCGs will support the NHS CB in discharging its EPRR functions and duties locally, ensuring representation on the LHRP and engaging in health economy planning groups. i. include relevant EPRR elements (including business continuity planning) in contracts with provider organisations in order to: ensure that resilience is commissioned-in as part of standard provider contracts and to reflect local risks identified through wider, multi-agency planning; reflect the need for providers to respond to routine operational pressures, e.g. winter, failure of providers to continue to deliver high quality patient care, provider trust internal major incidents; enable NHS-funded providers to participate fully in EPRR exercise and testing programmes as part of NHS CB EPRR assurance processes. j. maintain performance levels, CCGs need to provide their commissioned providers with a route of escalation on a 24/7 basis. Conversely, the NHS CB will need a conduit in which to mobilise relevant support provider arrangements during significant and widespread incidents (see Response below). k. develop, test and update their own business continuity plans to ensure they are able to maintain business resilience during any disruptive event or incident. Escalation l. ensure robust escalation procedures are in place such that if an NHS funded provider has a problem (rather than an immediate emergency or significant incident), the locally agreed route for escalation (whether out of hours or during normal business hours) is available via the CCGs. This will require CCGs to establish their own 24/7 on-call arrangements, this may include working in collaboration with other local CCGs to provide cost effective robust arrangements. Response m. as Category two Responders under the CCA, CCGs must respond to reasonable requests to assist and co-operate. n. support the NHS CB Area Team should any emergency require wider NHS resources to be mobilised. CCGs must have a mechanism in place to support NHS Area Teams to effectively mobilise and coordinate all applicable providers that support primary care services should the need arise. 11
o. maintain service delivery across their local health economy to prevent business as usual pressures and minor incidents within individual providers from becoming significant or major incidents. This could include the management of commissioned providers to effectively coordinate increases in activity across their health economy, which may include support with surge in emergency pressures. CCGs need a process that enables them to escalate incidents to the NHS CB area team as applicable. p. some, but not all, CCGs may become more involved in the provision of emergency response, for example: where there are specific risks identified in local risk registers, such as hazardous materials nuclear, chemical or biological; and where there is a significant issue of geographic remoteness or complexity, which may compromise a NHS CB area team to act alone as a Category one responder. In such circumstances, the area team may request support from CCG members to become part of the initial health response. This will be through agreement between the area team and the relevant CCG staff who will act on behalf of the NHS CB locally during the initial stages of an incident. Under any such agreement, the NHS CB is still responsible for ensuring an effective response is delivered and retains command and control. 12
Appendix 2 The Accountable Emergency Officer responsibilities as defined by NHS England 1. Ensuring contracts with providers incorporate requirements to have emergency preparedness, response and business continuity arrangements in place. 2. Attending meetings of the local Borough Resilience Forum to share plans and ensure health response is integrated into multi-agency plans in its role as a commissioner. 3. Ensuring business continuity plans are in place to manage the impact of any incident on its own services. 4. Ensuring that the providers it commissions have a robust point of escalation (24/7/365) in the event of any failure or potential failure of a service. 5. Have in place a system to manage surge capacity issues as they arise and which will integrate with London wide surge capacity systems. 6. Ensuring that the system above is well communicated to providers, NHS England (London) and other significant agencies. 7. Ensuring the CCG participates in training and exercises to ensure plans are robust and integrated. 13
Appendix 3 The Emergency Planning (Liaison) Officer Responsibilities defined by NHS England 1. Ensure that the organisation meets its statutory obligations under the CCA and complies with all relevant EPRR guidance for the NHS, including non-statutory guidance that accompanies the CCA and also for business continuity and resilience preparedness; 2. Develop and deliver the organisation s emergency preparedness and resilience function, improve standards of such preparedness across the organisation and provide leadership on specialist emergency preparedness and resilience issues; 3. Ensure that EPRR corporate responsibilities are met and provide assurance to the organisation s Board that it complies with relevant legislation and guidance (as summarised by the NHS England core standards for EPRR); 4. Developing and contributing to professional relationships within the organisation, with other commissioners and NHS funded organisations and multi-agency partners that facilitate the continual development of EPRR arrangements; 5. Lead the development and implementation of EPRR delivery plans; 6. Ensure appropriate representation at local health resilience partnerships (LHRPs), the local Haringey Borough Resilience Forum (BRF) and any associated sub-groups and work streams; 7. Coordinate emergency preparedness and training exercises for the organisation and with resilience partners; 8. Work with communications staff to ensure an appropriate communications and media response by the NHS to significant events and emergencies. 14