MAJOR INCIDENT PLAN 2017

MAJOR INCIDENT PLAN 2017 EAST AND NORTH HERTFORDSHIRE CLINICAL COMMISSIONING GROUP PLAN FOR RESPONDING TO MAJOR INCIDENTS IN HERTFORDSHIRE Page 1 of 46

DOCUMENT CONTROL SHEET Document Owner: Director of Operations Document Author(s): EPRR Lead Version: 2.6 FINAL Directorate: Operations Approved By: Governing Body Date of Approval: 15 January 2015 Date of Review: 10 th July 2017 Change History: Version Date Reviewer(s) Revision Description 1.0 Final October 2013 Steven Moore EEAST Annual update 1.1 Draft January 2015 Oskan Edwardson Annual update 2.0 Final January 2015 Jas Dosanjh Formatting 2.1 Final March 2015 Sharn Elton Minor Amendments formatting and references 2.2 Final September 2015 Sharn Elton Updated in line with NHSE EPRR Toolkit requirements 2.3 Final April 2016 Sharn Elton Annual update 2.4 Final July 2016 Sharn Elton Updates 2.5 Final August 2016 Sharn Elton Revised MI Definition 2.6 Final June 2017 Darren O Rourke Annual Update and JESIP principles. Equality and Privacy impact assessment review. National command and control structure update and CCG document retention policy inclusion. Implementation Plan: Development and Consultation Dissemination EPRR Consultant EPRR Manager Executive Team Staff can access this policy via the intranet and will be notified of new/revised versions via the staff briefing. This policy will be included in CCG Publication Scheme in compliance with the Freedom of Information Act 2000. External Distribution List: NHS England (Midlands and East (South Locality)) East of England Ambulance Service NHS Trust Hertfordshire Community NHS Trust Hertfordshire Partnership University NHS Foundation Trust Public Health England (Hertfordshire) East and North Hertfordshire NHS Trust Hertfordshire County Council Herts Urgent Care and 111 Page 2 of 46

Private Ambulance Service (Patient Transport Provider) GP Practice Managers Operational Delivery Network Training Monitoring and Review Equality and Diversity Associated Documents Training is provided for key staff that may be required to carry out essential tasks in response to a major incident. Staff are provided with training that ensures they understand the role they are to fulfill in the event of an incident and have the necessary competencies to fulfill that role. All staff members should familiarise themselves with the Major Incident Plan. This training will include skills allowing staff to operate at operational (Bronze), tactical (Silver) and strategic (Gold) levels and will also include training for Loggist and Business Continuity Awareness, depending on their role both within the Trust and during an incident. Staff members that are likely to follow an Action Card are sent an annual reminder that cards should be reviewed. Staff are also be given the opportunity to participate in NHS and multi-agency exercises. Assurance: ENH CCG will ensure that its business continuity plans are fit for purpose in line with the NHS England Business Continuity Framework 2013. It will be able to respond to any incident as part of a multiagency response. ENH CCG will be assured of plans and organisational resilience from all its providers. These are listed in the in accordance with the NHS England Core Standards 2015/16. NHS England (South Locality) will seek similar assurance from the CCGs using the NHS England EPRR Core Standards 2015/16. Providers of NHS funded care are responsible for providing assurance to the CCGs and NHS England (South Locality). In accordance with the NHS England EPRR Core Standards 2015/16. In gathering wide ranging assurances from individual NHS organisations, NHS England (South Locality) will provide assurance to the NHS England-Midlands and East that all providers of NHS funded care within their area, are fit for purpose. Directors of Public Health will seek NHS EPRR assurance through the LHRP. In the event of legal advice being required this can be obtained from Capsticks solicitors. Details are held by the Director Information Risk Owner (The Director of Finance) July 2017 - Equality Impact Assessment (Appendix 5) July 2017 - Privacy Impact Assessment (Appendix 6) This document should be read in conjunction with: ENCCG Surge, Escalation and Capacity Plan (Version 10) ENHCCG Business Continuity Plan ENHCCG Severe Weather Response Plan NHS England Business Continuity Management Framework Page 3 of 46

(Service Resilience) (2013) NHS England Emergency Preparedness Framework (2013) NHS England Core Standards for Emergency Preparation, Resilience and Response (2015) NHS England Command and Control Framework 2013 Hertfordshire Resilience Forum Multi Agency Response Plan Public Health England Centre (PHEC) major incident frameworks and incident response plans. Hertfordshire LRF Mass Casualties Framework 2016 Hertfordshire Infectious Disease Plan Hertfordshire Pandemic Influenza Plan Care of People Framework 2017 East and North Hertfordshire CCG Director on Call Pack Page 4 of 46

CONTENTS Section No Section Name Page No. 1.0 Introduction 6 2.0 Scope 6 3.0 Purpose 6 4.0 Definitions 10 5.0 Role and Responsibilities 15 6.0 Command and Control Structure 21 6.1 ENH CCG Response to a Major Incident 27 6.2 Communications 33 6.3 Business Continuity 34 6.4 Vulnerable Adults 34 6.5 Exercise and Test Plans 35 Appendix 1 Initial Risk Assessment 37 Appendix 2 METHANE REPORT 38 Appendix 3 NHS Major Incident Situation Report - SITREP 40 Appendix 4 National NHS England EPRR Structures 42 Appendix 5 Equality Impact Assessment 43 Appendix 6 Privacy Impact Assessment 45 Appendix 7 Memorandum of Understanding, Information Sharing 46 Appendix 8 Incident Coordination Centre Plan 46 Appendix 9 Hertfordshire LRF Response Plans 46 Page 5 of 46

1.0 Introduction The NHS carries out emergency planning to ensure it is able to respond appropriately and effectively to major incidents. The major incident plan for East and North Hertfordshire Clinical Commissioning Group (ENHCCG) is built on the principles of risk assessment, cooperation with partners, emergency planning, communicating with the public, and information sharing. This plan is sufficiently flexible to deal with a range of situations and comprises of two parts. The first part is the overarching Major Incident Plan which sets out the role of the Clinical Commissioning Group (CCG) in a major incident and explains how this role fits with those of other NHS organisations and the emergency services. This is the strategic part of the plan and is designed to be read by all staff, especially those on call. The second part is the Operational response action cards. This is designed to be used during a major incident. It summarises the practical steps that need to be taken in the event of a major emergency. This Plan will be published on ENHCCG website and on the intranet, all Directors who have on call responsibilities will have this plan included in their on call packs and will be required to sign for it. 2.0 Scope NHS Guidance The ENHCCG Major Incident Plan is based on the NHS England South Locality Incident Response Plan; it follows a set of general principles that guide all NHS organisations in developing their ability to respond to major incidents, significant incidents and other emergencies and to manage recovery locally within the context of the requirements of the Civil Contingencies Act 2004 (CCA 2004). 3.0 Purpose NHS Standard Contracts & NHS England Emergency Preparedness Framework The Civil Contingencies Act 2004 outlines a single framework for civil protection in the United Kingdom. Part 1 of the Act establishes a clear set of roles and responsibilities for those involved in emergency preparation and response at local level. The Act divides local responders into two categories, imposing a different set of duties on each. Category one responders are those organisations at the core of the response to most emergencies. This category includes all Acute Trusts and Ambulance NHS Trusts, NHS England and Public Health England. They are subject to the following civil protection duties:- assess the risk of emergencies occurring and use this to inform contingency planning; put in place emergency plans; put in place business continuity management arrangements; put in place arrangements to make information available to the public about Page 6 of 46

civil protection matters and maintain arrangements to warn, inform and advise the public in the event of an emergency; share information with other local responders to enhance co-ordination; co-operate with other local responders to enhance co-ordination and efficiency. Primary care, community providers, mental health and other NHS organisations (NHS Blood and Transplant, NHS Logistics and NHS Protect) are not listed in the Civil Contingencies Act 2004. However, Department of Health (DH) and NHS England guidance expects them to plan for and respond to incidents in the same way as category one responders. Category two responders are required to cooperate and share relevant information with other Category one and two responders. Category two responders, such as Clinical Commissioning Groups (CCGs), are seen as co-operating bodies. They are less likely to be involved in the heart of the planning, but they will be heavily involved in incidents that affect their sector. It is vital that they share relevant information with other responders (both category one and two) if Emergency Preparedness, Resilience and Response (EPRR) arrangements are to succeed. To support this requirement the LHRP has a MOU in place (see appendix 7) Category one and two responders come together to form local resilience forum based on police areas. These forums help to co-ordinate activities and foster cooperation between local responders. For ENHCCG the strategic forum for joint planning for emergencies is the Hertfordshire Local Health Resilience Partnership (LHRP). They provide the health sector s contribution to multi-agency planning through Hertfordshire Local Resilience Forum (LRFs). Hertfordshire LHRP will coordinate health input and support the NHS England (South Locality), Local Authorities and Public Health England (PHE) in ensuring that member organisations develop and maintain effective planning arrangements for major incidents, significant incidents and emergencies. There are two Hertfordshire Accountable Emergency Officers representing East and North Hertfordshire and Herts Valleys CCGs on the LHRP. The Director of Operations is the Accountable Emergency Officer for ENHCCG and attends the LHRP. Category 1 responders for health are: Department of Health (DH) on behalf of Secretary of State for Health (SofS) NHS England Acute service providers Ambulance service providers Public Health England (PHE) Local authorities (Inc. Directors of Public Health (DsPH)) 3.1 Risk Assessment The Civil Contingencies Act 2004 places a risk assessment duty on all category one responders to ensure that planning is proportionate to each risk. A Community Risk Register is compiled by the Hertfordshire Local Resilience Forum and consists of a table of hazards summarising hazard information, outcome descriptions, risk rating and mitigation plans). http://wwwhertsdirect.org/emergency The top five risks currently identified on the Hertfordshire Resilience Community Risk register are: Page 7 of 46

Pandemic flu Terrorist and malicious attacks Utility Failure (Power Networks) Extreme temperatures Flooding The national and community risk registers have informed local health and multiagency planning and the Hertfordshire Local Health Resilience Partnership Three Year Strategy and work Programme, 2016 reflects this. The CCG has its own Risk Register which is maintained and will hold information specific to EPRR risks which are identified within the CCG. The EPRR risks will be reviewed amended and update at the CCG EPRR Meetings. These meetings will feed into the Governance and Audit Committee. 3.2 Requirements applicable within the Health and Social Care Act 2012 The Health and Social Care (2012) Act embeds the requirement of NHS services to respond effectively to incidents and emergencies. The key elements are:- NHS England and each CCG must take appropriate steps for ensuring that it is properly prepared for dealing with a relevant emergency. NHS England must take steps as it considers appropriate for securing that each relevant service provider is properly prepared for dealing with a relevant emergency. 3.3 Core standards The minimum core standards, which NHS organisations and providers of NHS funded care must meet, are set out in the NHS England Core Standards for EPRR. These standards are in accordance with the Civil Contingencies Act 2004, the Health and Social Care Act 2012, the NHS England planning framework ( Everyone Counts: Planning for Patients ) and the NHS standard contract. NHS organisations and providers of NHS funded care must: nominate an accountable emergency officer who will be responsible for EPRR; contribute to area planning for EPRR through local health resilience partnerships; contribute to an annual NHS England (South Locality) report on the health sector s EPRR capability and capacity in responding to national, regional and LRF incidents. Reports must include control and assurance processes, information-sharing, training and exercise programmes and national capabilities surveys. They must be made through the organisation's formal reporting structures; have suitable, up to date incident response plans which set out how they plan for, respond to and recover from significant incidents and emergencies. The plans should fulfill the testing schedule as detailed in the CCA 2004; have suitably trained, competent staff and the right facilities (incident coordination centres) available round the clock to effectively manage a major incident or emergency; share their resources as required to respond to a major incident or emergency. Page 8 of 46

3.4 Business Continuity (service resilience) planning The CCA 2004 places a statutory duty on organisations to develop a comprehensive approach to business continuity. This framework follows the principles of ISO 22301 and PAS 2015. Some elements of ISO 22301 must be done in partnership with other health organisations and this will be led by the Hertfordshire Local Health Resilience Partnership and Hertfordshire Local Resilience Forum. The NHS England Business Continuity Framework 2013 can be found at: http://www.england.nhs.uk/ourwork/gov/eprr 3.5 Local cooperation At the local level, it is important that planning for major and significant incidents and emergencies is co-ordinated within individual NHS organisations, between NHS funded organisations and at a multi-agency level with emergency services, local authorities, voluntary agencies, the independent health and social care sector and other partner organisations. Training, exercising and testing of all EPRR plans within ENHCCG, between NHS funded organisations and with multi-agency partners will be an important part of emergency preparedness and will be documented as part of the annual work programme. NHS England (South Locality) is responsible for maintaining a mechanism that will enable NHS organisations to plan and cooperate appropriately and to performance manage these organisations for this aspect of their responsibilities. This will be supported by the Hertfordshire LHRP, the memorandum of understanding and annual assurance process. Provider responsibilities are contained within the NHS Standard Contract (http://www.commissioningboard.nhs.uk/nhs-standardcontract/ - The independent healthcare sector may be used in a disruptive incident to assist with service delivery by providing capacity, resources including staff, equipment and consumables. The CCG has contract in place with some independent sector providers. The contract outlines the responsibility to respond in a major incident in line with NHS providers. 3.6 Mutual Aid Mutual Aid can be defined as an arrangement between Category one and two responders, other organisations not covered by the CCA 2004, within the same sector or across sectors and across boundaries, to provide assistance with additional resource during any incident that may overwhelm the resources of a single organisation. The NHS England (South Locality) will be responsible for the co-ordination and implementation of mutual aid requests if a disruptive incident occurs. ENHCCG will respond to any requests received to provide mutual aid during a major or significant incident or emergency. Provider responsibilities are contained within the NHS Standard Contract (http://www.commissioningboard.nhs.uk/nhs-standard-contract/) Page 9 of 46

3.7 Networks (critical care, trauma, burns, PPCI, stroke) Major Trauma and Burns The Operational Delivery Network co-ordinates specialist areas of care, including critical care trauma and burns and ensures that patients can access the optimum care for their condition. The Operational Delivery Network that covers East of England including Hertfordshire is hosted by Cambridge University Hospitals Foundation Trust which effectively ensures mutual aid arrangements when needed. PPCI and Stroke Stroke and PPCI now form part of a national network, so should transfer of services be required mutual aid arrangements nationally should be implemented; NHS England should take the lead in arranging this process in association with the Acute Trust. East of England Ambulance Service NHS Trust should be involved in arrangements due to the potential impact on Service delivery and ambulance cover locally. 3.8 Information Sharing Under the CCA 2004 local responders have a duty to share information and this is seen as a crucial element of civil protection work, underpinning all forms of cooperation. HM Government Data Protection and Sharing Guidance for Emergency Planners and Responders Stipulates: Data protection legislation is not a barrier to appropriate information sharing. The sharing of information will include, if required for the response, details of vulnerable people. The general definition of a vulnerable person is a person: present or resident within an area known to local responders who, because of dependency or disability, need particular attention during incidents See appendix 7 for the Hertfordshire MOU regarding information sharing. 4.0 Definitions 4.1 Major or Significant Incident or Emergency This section describes various definitions of major incidents, significant incidents and emergencies as they may apply to NHS organisations and providers of NHS funded care and the varying scale of these incidents. There may be times of severe pressure such as during winter periods, or where there is an increase in demand for service (surges) or an infectious disease outbreak. These should be managed through normal process and business continuity plans. Page 10 of 46

The revised Major Incident definition is: An event or situation, with a range of serious consequences, which requires special arrangements to be implemented by one or more emergency responder agencies. Emergency responder agencies describes all Category one and two responders as defined in the Civil Contingencies Act (2004) and associated guidance; The term emergency is used as defined in the Civil Contingencies Act 2004: To describe an event or situation that threatens serious damage to human welfare in a place in the UK or to the environment of a place in the UK, or war or terrorism this threatens serious damage to the security of the UK. The term major incident is commonly used to describe such emergencies. These may include multiple casualty incidents, terrorism or national emergencies such as pandemic influenza. For the NHS, a significant incident is defined as: Any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or other acute or community provider organisations. Individual NHS organisations can self-declare a significant incident when their own facilities and/or resources, or those of its neighbours, are overwhelmed. What is a significant incident or emergency to the NHS may not necessarily be a significant incident or emergency for other local agencies and the reverse is also true. A major incident, significant incident or emergency may arise in a variety of ways: big bang: a serious transport accident, explosion, or series of smaller incidents rising tide: a developing infectious disease epidemic, or a capacity/staffing crisis cloud on the horizon: a serious threat such as a major chemical or nuclear release developing elsewhere and needing preparatory action, dangerous epidemics, armed conflict headline news: wave of public or media alarm over health issue or perceived threat internal incidents: fire, breakdown of utilities, equipment failure, hospital acquired infections, violent crime deliberate release of chemical, biological, nuclear or explosive materials mass casualties pre-planned major events that require planning such as demonstrations, sports fixtures, air shows. There are a number of incidents which may need to be dealt with under the Major Incident Plan, some of which will not necessarily be either affecting other organisations or which will have a different impact on other organisations. These will include industrial action (IA) which will be dealt with by the CCG Business Continuity Plan. Other incidents such as those involving the need for locking down part, or all, of the CCG HQ building during an incident such as one which involved CBRN material can be found in Action Card 5. Page 11 of 46

Incidents such as wide spread flooding or other weather related incidents (ie snow, heat wave, prolonged periods of cold weather) will be dealt with in line with the CCG s Severe Weather Plan and in conjunction with the Major Incident Plan and Business Continuity Plan. 4.2 Emergency Preparedness The extent to which emergency planning enables the effective and efficient prevention, reduction, control, mitigation of, and response to emergencies. 4.3 Resilience Ability of the community, services, area or infrastructure to detect, prevent and, if necessary, to withstand, handle and recover from disruptive challenges. 4.4 Response Decisions and actions taken in accordance with the strategic, tactical and operational objectives defined by emergency responders. 4.5 Incident For the NHS, incidents are classed as either: Business Continuity Incident Critical Incident Major Incident Each will impact upon service delivery within the NHS, may undermine public confidence and require contingency plans to be implemented. NHS organisations should be confident of the severity of any incident that may warrant a major incident declaration, particularly where this may be due to internal capacity pressures, if a critical incident has not been raised previously through the appropriate local escalation procedure. 4.6.1 Major Incident Any occurrence that presents a serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care organisations. Any event whose impact cannot be handled within routine service arrangements. Critical Incident A critical incident is any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions. Business Continuity Incident A business continuity incident is an event or occurrence that disrupts, or might disrupt, an organisation s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed) Page 12 of 46

4.6.2 Major Incident Declaration Guidance a) a major incident is beyond the scope of business-as-usual operations, and is likely to involve serious harm, damage, disruption or risk to human life or welfare, essential services, the environment or national security; b) a major incident may involve a single-agency response, although it is more likely to require a multi-agency response, which may be in the form of multiagency support to a lead responder; c) the severity of consequences associated with a major incident are likely to constrain or complicate the ability of responders to resource and manage the incident, although a major incident is unlikely to affect all responders equally; the decision to declare a major incident will always be a judgement made in a specific local and operational context, and there are no precise and universal thresholds or triggers. Where LRFs and responders have explored these criteria in the local context and ahead of time, decision makers will be better informed and more confident in making that judgment. Hertfordshire LRF publishes the Counties response plans on Resilience Direct. 4.6.3 The section below identifies the who leads the health response during a specific incident Lead Organisation Business Continuity Incident Critical Incident Major Incident A business continuity incident is an event or occurrence that disrupts, or might disrupt, an organisation s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed) A critical incident is any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions. A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented. All organisations are responsible for coordinating their response to a business continuity disruption. The CCG will coordinate the health community response where the disruption is disrupting the wider health economy or where one or more health organisations require support. All organisations are responsible for coordinating their response to a critical incident. The CCG will coordinate the health community response where the incident is disrupting the wider health economy or where one or more health organisations require support. NHS England will lead the mobilisation and coordination of the overall NHS response to the major incident. In coordination with NHS England, the CCGs will lead the local health community response to the major incident. Page 13 of 46

Incident level NHS England Incident Levels Level 1 An incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. Level 3 An incident that requires the response of a number of health organisations across geographical areas within a NHS England region. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Level 4 An incident that requires NHS England National Command and Control to support the NHS response. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Underpinning Principles for NHS EPRR a) Preparedness and Anticipation the NHS needs to anticipate and manage consequences of incidents and emergencies through identifying the risks and understanding the direct and indirect consequences, where possible. All individuals and organisations that might have to respond to incidents should be properly prepared, including having clarity of roles and responsibilities, specific and generic plans, and rehearsing arrangements periodically. All organisations should be able to demonstrate clear training and exercising schedules that deliver against this principle. b) Continuity the response to incidents should be grounded within organisations existing functions and their familiar ways of working although inevitably, actions will need to be carried out at greater pace, on a larger scale and in more testing circumstances during response to an incident. c) Subsidiarity decisions should be taken at the lowest appropriate level, with coordination at the highest necessary level. Local responders should be the building block of response for an incident of any scale. d) Communication good two way communications are critical to an effective response. Reliable information must be passed correctly and without delay between those who need to know, including the public e) Cooperation and Integration positive engagement based on mutual trust and understanding will facilitate information sharing. Effective coordination should be Page 14 of 46

exercised between and within organisations and local, regional and national tiers of a response. Active mutual aid across organisational, within the UK and international boundaries as appropriate (see section 8.7) f) Direction clarity of purpose should be delivered through an awareness of the strategic aim and supporting objectives for the response. These should be agreed and understood by all involved in managing the response to an incident in order to effectively prioritise and focus the response. A strong capacity in NHS England to oversee the health service working. Abbreviations CCA CCG COBR DCLG DH EPRR HETCG ICC ISO LHRP LRF ENHCCG PALS PAS PHE PHEC SAGE SCG STAC Civil Contingencies Act Clinical Commissioning Group Cabinet Office Briefing Room Department for communities and Local government Department of Health Emergency Preparedness, Resilience and Response Health Economy Tactical Coordination Group Incident Coordination Centre International Standards Organisation Local Health Resilience Partnership Local Resilience Forum Patient Advice and Liaison Service Publicly Available Specification Public Health England Public Health England Centre Scientific Advisory Group for Emergencies Strategic Coordinating Group Science and Technical Advice Cell 5.0 Roles and Responsibilities 5.1 Clinical Commissioning Groups (CCGs) CCGs are expected to provide support to NHS England in relation to the coordination of their local health economy. Primary care, including out of hours providers, community providers, mental health service providers, specialist providers, NHS Property Services and other NHS organisations (for example NHS Blood &Transplant, NHS Supply Chain and NHS 111) are not listed in the CCA 2004. However, DH and NHS England guidance expects them to plan for and respond to emergencies and incidents in a manner which is relevant, necessary and proportionate to the scale and services provided. NHS England will represent the NHS at the Local Resilience Forum (LRF); NHS ambulance service providers will also be present as an emergency service. NHS funded organisations can find specific Cabinet Office content on the CCA at https://www.gov.uk/guidance/preparation-and-planning-for-emergenciesresponsibilities-of-responder-agencies-and-others. Page 15 of 46

It is essential that commissioners and providers ensure they have effective, coordinated structures in place to adequately plan, prepare and rehearse the tactical and operational response arrangements with their local partners. ENHCCG has a Director on call available at all times through a mobile phone system should a provider of NHS funded care have a problem that needs escalating either in or out of normal hours. The Director will be available to providers or NHS England (South Locality). ENHCCG will use the NHS England Framework (as detailed in appendix 2) to determine how and when issues should be escalated. As category two responders under the CCA 2004, CCGs must respond to reasonable requests to assist and cooperate during an emergency. NHS England Midlands and East (South Locality) may decide to include CCG members in the formal command and control structure and to assist in any response to a major incident. CCG s may assist and support NHS England (South Locality) by undertaking the following tasks: Mobilising resources from locally commissioned services Providing local NHS leadership if required liaise with relevant partner organisations Cascading information to relevant service level providers Inform and maintain dialogue with neighboring CCGs where appropriate Support CCG commissioned organisations with any local demand, capacity and systems resilience issues Organisation Role Key Actions and Outputs Clinical Commissioning Groups (CCGs) CCGs are responsible for the commissioning of most nonspecialist hospital care, most community care and mental health services in the area they serve. They are designated Category 2 responders and as such have a duty to support NHS England. They routinely have roles and responsibilities in respect of surge capacity management. They will therefore have a significant role in mass casualty incident. Ensure, as part of the contracting process, that providers have a clear and agreed understanding of what would be expected of them during a major incident, especially one involving mass casualties. Ensure that providers of healthcare for their populations (eg Community Services, Independent Sector providers) are planning to manage the impact of an incident that results in a large number of casualties affecting their service and staff. Ensure contingencies are in place to maintain patients in the community and limit or avoid referrals to acute hospitals as far as possible. Contingencies should also include active measures to supplement maximum bed capacity available in acute hospitals. Ensure that the use of non-acute NHS facilities, any independent sector capacity and/or the preidentification of suitable Page 16 of 46

accommodation that could be utilized if required has been considered and discussed in conjunction with Local Authorities. Ensure plans are in place to deploy community staff to supplement acute services if that is required. These plans need to consider issues around clinical indemnity and support for colleagues who may be working in a different environment to their normal place of work. Ensure plans are in place with the Local Authority to assist in expediting appropriate early discharge routinely in both acute and community care areas. Ensure that staff have received clear information about what would be expected of them in an emergency and appropriate training Ensure that unused physical capacity which could be brought into use in an emergency has been identified in conjunction with NHS Acute providers Ensure that plans are in place to use existing capacity more intensively to create extra capacity for a higher level of dependency. For example, some community or intermediate beds could be used to deliver acute care, or general acute beds used to create additional capacity for critical care or burns cases (with specialist staff). These plans should be consistent with plans to create additional hospital capacity for major outbreaks of infectious diseases. This planning should be carried out in conjunction with Acute Trusts. Ensure that plans and procedures consider the needs of disabled and vulnerable casualties. 5.2 Providers of NHS funded Care Providers of NHS funded services are to: Support CCGs and NHS England, within their health economies, in discharging their EPRR functions and duties, locally and regionally, under the CCA 2004 Page 17 of 46

Have robust and effective structures in place to adequately plan, prepare and exercise the tactical and operational response arrangements both internally and with their local healthcare partners Ensure business continuity plans mitigate the impact of any emergency, so far as is reasonably practicable Ensure robust 24/7 communication cascade and escalation policies and procedures are in place, to inform CCGs and healthcare partners, as appropriate, of any incident impacting on service delivery Ensure that recovery planning is an integral part of its EPRR function Provide assurance that organisations are delivering their contractual obligations with respect to EPRR Ensure organisational planning and preparedness is based on current risk registers Provide appropriate director level representation at LHRP(s) and appropriate tactical and/or operational representation at local health economy planning groups in support of EPRR requirements 5.3 NHS England (South Locality) NHS England (South Locality) will provide leadership across Hertfordshire. If an incident requires a wider NHS or multi-agency response, this co-ordination and leadership is provided by a NHS England (South Locality) Director. The NHS England (South Locality) Director has overall responsibility for ensuring that NHS England (South Locality) and the local health economy are able to respond to a major or significant incident or emergency. The NHS England (South Locality) on-call director; may take command and control of the situation if several NHS and partner organisations need to be involved and the need for a coordinating role arises. If a Strategic Coordination Group is convened, health will be represented by the NHS England (South Locality) on-call director (NHS Gold). If necessary, Public Health England, local authority directors and the East of England Ambulance Service will also attend. (see section 6.0, Escalation for further details) NHS England (South Locality) may be required to respond actively by: escalating the use of GP surgeries as necessary, to see patients that, but for the major or significant incident or emergency, would normally be at or would go to the local acute hospital e.g. patients with less serious problems that, because of the incident, cannot be readily seen in the emergency department. mobilising support from GPs to help at a local acute hospital receiving the casualties and/or by referring other patients to other hospitals. Mobilise assistance from GPs to support at a rest centre. A rest centre is managed by the Local Authority and is for people evacuated from a scene of a major incident. Coordinating and managing NHS response to the public and media. Page 18 of 46

5.4 NHS England- Midlands and East (Regional team) If an incident affects two or more areas, the NHS response will normally be led by the Regional Team first affected and responding to it. If the NHS England Midlands and East have to take command of all NHS resources across the region, the Regional team s on-call director will if necessary provide leadership and direction across the region. Actions for local organisations will be actioned through the Regional Team. 5.5 NHS England (National team) At a national level NHS England will: Support the AEO to discharge EPRR duties Participate in national multi-agency planning processes including risk assessment, exercising and assurance Provide leadership and coordination to the NHS and national information on behalf of the NHS during periods of national incidents Provide assurance to DH of the ability of the NHS to respond to incidents including assurance of capacity and capability to meet National Risk Assessment (NRA) requirements as they affect the health service Provide support to DH in their role to UK central government response to emergencies Action any requests from NHS organisations for military assistance 5.6 Public Health England At a local level PHE will: Ensure that PHE has plans for emergencies in place across the local area Support the LHRPs, coordinating with local government partners Provide assurance of the ability of PHE to respond in emergencies Provide a representative to the LHRP, as required, and to represent PHE on the LRF 5.7 PHE Regional Offices At a regional level PHE will: Ensure the delivery of the national EPRR strategy across their region Provide strategic EPRR advice and support to PHE centres Ensure integration of PHE emergency plans to deliver a unified public health response across more than one LHRP Maintain PHE s capacity and capability to coordinate regional public health responses to emergencies 24/7 Page 19 of 46

5.8 PHE National Level At a national level PHE will: Ensure there is a comprehensive EPRR system that operates for public health at all levels and provides assurance that the system is fit for purpose Work together with the NHS at all levels and where appropriate develop joint response plans Provide specialist expert public health services and input to national and local planning for emergencies Undertake at all levels, its responsibilities on behalf of SoS as a Category 1 responder. 5.9 Local Authorities Through the Director of Public Health (DPH), the local authorities within Hertfordshire will take steps to ensure that plans are in place to protect the health of their populations and escalate any concerns or issues to the relevant organisation or to the LHRP as appropriate. The DPH will co-chair the LHRP alongside the Director of Commissioning Operations for the NHS England (South Locality). ENHCGG has a Memorandum of Understanding in place with Hertfordshire Public Health Team, which outlines roles, responsibilities and expectations (see appendix 9) Each DPH will provide initial leadership with PHE for the response to public health incidents and emergencies within their local authority area. The DPH will maintain oversight of population health and ensure effective communication with local communities. PHE will deliver and manage the specialist health protection services. In addition they fulfill the responsibilities of a Category one responder under the CCA 2004 5.10 Department of Health The EPRR role of DH is to: Identify EPRR policy requirements for the health sector and communicate these, as appropriate, to NHS England, PHE and other relevant organisations Provide assurance to ministers, the Cabinet Office and other government departments of the health system preparedness for and contribution to the UK Government s response to domestic and international emergencies, in line with the NRA As the lead government department for health, ensure that plans are in place for identified risks to health in the NRA Ensure the coordination of the whole system response to high-end risks impacting on public health, the NHS and the wider healthcare system Support the UK central government response to emergencies including ministerial support and briefing, informed by data and reports provided by NHS England and PHE Page 20 of 46

Take other action as required on behalf of the SofS to ensure a national emergency is appropriately managed Work with devolved administrations and internationally for planning and responding to relevant emergencies The structures of Emergency Preparedness, Response and Recovery are shown in Appendix 3 6.0 Concepts of Command and Control The management of emergency response and recovery is undertaken at one or more of three ascending levels: Operational, Tactical and Strategic. This is based around the concepts of command, control and coordination which are defined as follows: Command is the exercise of vested authority that is associated with a role or rank within an organisation (the NHS), to give direction in order to achieve defined objectives. Control is the application of authority, combined with the capability to manage resources, in order to achieve defined objectives. Coordination is the integration of multi-agency efforts and available capabilities, which may be interdependent, in order to achieve defined objectives. The coordination function will be exercised through control arrangements, and requires that command of individual organisations personnel and assets is appropriately exercised in pursuit of the defined objectives. The levels are defined by their differing functions rather than specific rank, grade or status. Operational (Bronze) Operational is the level at which the management of immediate hands on work is undertaken. Operational commanders will concentrate their effort and resources on the specific tasks within their geographical or functional area of responsibility. Individual organisations retain command authority over their own resources and personnel but each organisation must liaise and coordinate with all other organisations involved, ensuring a coherent and integrated effort. This may require the temporary transfer of personnel or assets under the control of another organisation. These arrangements will usually be able to deal with most events or situations but if greater planning, coordination or resources are required an additional tier of management may be necessary. The operational commander will consider whether a tactical level is required and advise accordingly. Tactical (Silver) The purpose of the tactical level is to ensure that the actions taken by the operational level are coordinated, coherent and integrated in order to achieve maximum effectiveness, efficiency and desired outcomes. Page 21 of 46

Where formal coordination is required at tactical level then a TCG may be convened with multi-agency partners within the area of operations. The tactical commanders will: Determine priorities for allocating available resources Plan and coordinate how and when tasks will be undertaken Obtain additional resources if required Assess significant risks and use this to inform tasking of operational commanders Ensure the health and safety of the public and personnel The tactical commanders must ensure that the operational commanders have the means, direction and coordination to deliver successful outcomes. The NHS tactical commander at the TCG will be identified and agreed by NHS England in consultation with the CCG. They will ensure that all NHS service providers are coordinated through health economy tactical coordination groups. Where it becomes clear that resources, expertise or coordination are required beyond the capacity of the tactical level it may be necessary to invoke the strategic level of management to take overall command and set the strategic direction. Strategic (Gold) The purpose of the strategic level is to consider the incident in its wider context; determine longer-term and wider impacts and risks with strategic implications; define and communicate the overarching strategy and objectives for the response; establish the framework, policy and parameters for lower level tiers; and monitor the context, risks, impacts and progress towards defined objectives. Where an event or situation has a particularly significant impact; substantial resource implications, or lasts for an extended duration it may be necessary to convene a multi-agency coordinating group at the strategic level bringing together the strategic commanders from relevant organisations. This group is known as the SCG. The SCG does not have the collective authority to issue commands to individual responder agencies; each will retain its own command authority, defined responsibilities and will exercise control of its own operations in the normal way. The NHS strategic commander at the SCG will be identified and agreed by NHS England in consultation with the CCG(s) and empowered to make executive decisions on behalf of the NHS. In addition the NHS ambulance service(s) will be present in their role as an emergency service. The purpose of the SCG is to take overall responsibility for the multi-agency management of the incident and to establish the policy and strategic framework within which lower tier command and coordinating groups will work. The SCG will: Determine and promulgate a clear strategic aim and objectives and review them regularly Establish a policy framework for the overall management of the event or situation Prioritise the requirements of the tactical tier and allocate personnel and resources accordingly Formulate and implement media-handling and public communication plans Page 22 of 46

Direct planning and operations beyond the immediate response in order to facilitate the recovery process For incidents across multiple SCG areas then NHS England regional and national teams, as appropriate, will undertake command, control and coordination of the NHS and will be responsible for appropriate representation to regional and central coordination structures and groups. 6.2 NHS command and control Response arrangements need to be flexible to match individual situations, many of which can be dealt with by individual organisations at the operational or tactical level. The NHS in England Responses at Alert Level 1 or 2 may be managed by an individual organisation or local health economy through the CCGs in liaison with the regional team. For a response at Alert Level 1 managed by an individual organisation the local/lead commissioner must be informed through their on call arrangements. All actions that are, or would be undertaken at lower alert levels will need to be maintained in addition to any actions arising from a higher alert level. For example, an incident identified as Level 3 will require all actions identified at Level 1, 2 and 3 to be maintained. NHS England regions NHS England regions provide leadership across a geographical area. If a response requires a wider NHS or multi-agency response then the respective regional team will provide command, control and coordination for the NHS. Responses at Alert Level 3 will require the regional office to take command, control and coordination of the NHS across their region. Tactical command will remain with local responding organisations, as appropriate. Responses at Alert Level 4 will require national NHS England command, control and coordination of the NHS across England. Tactical command will remain with local responding organisations, as appropriate. NHS England national For responses at Alert Level 4 and in certain situations such as pandemic influenza, national fuel shortage or extensive extreme weather events, NHS England (national) may take command of all NHS resources across England. In this situation direction from the national team will be actioned through the regional teams Page 23 of 46

Table 1 NHS England incident alert and response levels Incident level Level 1 An incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. Level 2 An incident that requires the response of a number of health providers within a defined health economy and will require NHS coordination by the local commissioner(s) in liaison with the NHS England local office. Level 3 An incident that requires the response of a number of health organisations across geographical areas within a NHS England region. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Level 4 An incident that requires NHS England National Command and Control to support the NHS response. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. The establishment of a Strategic Coordinating Group (SCG) has been excluded from Table 1, as this is at the discretion of the Chief Constable of Hertfordshire Police and the NHS follows these arrangements. NHS England (South Locality) will provide NHS input to the SCG if required. In some circumstances the ENHCCG may provide the NHS input to a SCG, but this will be the exception rather than the rule. ENHCCG Responsibilities and On Call The EPRR role and responsibilities of CCGs are to: Ensure contracts with all commissioned provider organisations (including independent and third sector) contain relevant EPRR elements, including business continuity Monitor compliance by each commissioned provider organisation with their contractual obligations in respect of EPRR and with applicable Core Standards Ensure robust escalation procedures are in place so that if a commissioned provider has an incident the provider can inform the CCG 24/7 Ensure effective processes are in place for the CCG to properly prepare for and rehearse incident response arrangements with local partners and providers Be represented at the LHRP, either on their own behalf or through a nominated lead CCG representative Page 24 of 46

Provide a route of escalation for the LHRP in respect of commissioned provider EPRR preparedness Support NHS England in discharging its EPRR functions and duties locally, including supporting health economy tactical coordination during incidents (Alert Level 2-4) The CCG Director on Call is available at all times on 0330 124 1725. The On call rota is manned by the Chief Executive, Directors and Associate Directors. The on call shift runs 24 hours a day Tuesday to Tuesday. The on call rota is manned on a daily basis over Christmas, New Year and Easter. The phone is switched over by a member of the HBL ICT administrative team and a text confirming the switch is sent to the outgoing and incoming manager. Each Director on Call has an on call folder which includes the contact details of CCG staff. The rota is produced and communicated on a six monthly basis by the Governance Team. ENHCCG may establish an Incident coordinating centre (ICC) from which the incident can be managed. The incident coordinating centre for ENHCCG is based in meeting room 1.2, First Floor, Charter House, Parkway, Welwyn Garden City, AL8 6JL. In the event that Charter House is not accessible see page 6 of the ICC Plan for alternative provision and remote ICC management. The role of the Incident coordinating centre is to: manage the operational response to the incident Co-ordinate response across the local health economy report to the NHS England (South Locality) handle media issues/enquiries coordinate with district councils manage the return to normality ensure liaison with other key partners as required The Incident Co-ordination Centre has its own ICC Plan (see appendix 9) which details how it should be established, run and resourced. Incident Level 1 East and North Hertfordshire CCG - GREEN The response will initially be led by the ENHCCG Director on call. If required the Director on call responding to the major incident may convene an Incident Management team with relevant expertise from within the CCG and externally (as necessary). The Incident Management team will manage the incident. Where the incident is managed from the ENHCCG Incident Coordination Centre (ICC) (see separate plan which can be found in appendix 9), there will be sufficient supplies / stores present to ensure logging and other administration tasks can be completed. It is likely that the ENHCCG Escalation Framework will be triggered, but at level 1 the incident would normally be managed by the CCG with escalation to NHS England (South Locality). See East and North Hertfordshire Clinical Commissioning Group Escalation Framework. Page 25 of 46

Incident Level 2 NHS England (South Locality) - YELLOW The NHS England (South Locality) on-call director may convene an incident management team with relevant expertise from within and external to the NHS England (South Locality) to direct and coordinate the management of the major incident. The team will take executive decisions in the light of best available information and obtain input from all relevant sources of expertise and agencies and convene quickly. An NHS England (South Locality) Incident Co-ordination Centre (ICC) may be set up to co-ordinate the incident. The location of which will be determined by the nature of the incident. The ICC will have direct contact with all responding NHS providers. Its role is to remain informed of their current status and provide relevant information to the SCG Health Gold representative. Incident level 3 - NHS England - AMBER An NHS England Regional ICC will normally be based at the offices in Cambridge. The role of the ICC will be: strategic management of the incident and return to normality; reporting to the NHS England National team; downwards links with NHS England (South Locality) ICC; communications and media management. Incident level 4 - NHS England National Command - RED An NHS England National ICC could be established, where appropriate, feeding into either local or regional ICCs to ensure a consistent management approach across the incident area Multi-agency Command and Control There are three commonly accepted levels within emergency management command and control (Table 2) and adherence to these by all organisations ensures a coordinated response to a major incident. Table 2: Levels within command and control structures Level Role Colour Strategic Establish strategic objectives and overall Gold management framework. Ensure long-term resourcing/expertise. Tactical Determine priorities in obtaining and allocating Silver resources. Plan and co-ordinate overall response. Operational Manage front line operations. Bronze The multi-agency response to a major or significant incident or emergency is described below: The DH will be the source of information regarding the NHS for the Cabinet Office Briefing Room at national level; Page 26 of 46

NHS England (South Locality) will represent the NHS at regional level; NHS England (South Locality) will attend the Strategic Coordinating Group led by Hertfordshire Police. Public Health England Centre will provide the Public Health Consultant to attend and chair the Scientific and Technical Advice Cell (STAC); NHS England (South Locality) may attend multi-agency silver and interact at a bronze level; Local CCGs may attend county wide silver and interact at a local bronze level. Science and Technical Advice Cell (STAC) The Scientific and Technical Advice Cell (STAC) provides technical advice to the Strategic Coordinating Group. The STAC would be expected to advice on issues such as the impact on the health of the population, public safety, environmental protection, and sampling and monitoring of any contaminants. In the event of a major incident the STAC is activated by the Police Gold Commander through the cell lead or relevant duty officer. However, a Director public health professional (i.e. Director of Public Health or the PHE Director) may recommend to the Gold Commander that a STAC needs to be established due to the potential impact on the health of the local population from an actual or evolving incident. 6.1 ENH CCG response to a major incident 6.1.1 Alerting arrangements The ambulance service is likely to be the first NHS service to be notified of, and respond to, a no notice major incident. The ambulance service will: immediately notify or confirm with the police and the fire and rescue service the location and nature of the incident, including identification of specific hazards, for example, chemical, radiation or other known hazards alert the most appropriate receiving hospital(s) alert the wider health community via the appropriate NHS England (South Locality) alert appropriate voluntary sector services The standard alerting messages are: 1. Major Incident standby This alerts staff members that a major incident may need to be declared. Preparatory arrangements are then made appropriate to the incident 2. Major Incident declared activate plan This alerts staff members that the plan should be activated and additional resources mobilised. 3. Major Incident stand down Following the conclusion of an incident or the involvement of health in an incident, a Major Incident Stand Down message should be cascaded to all stakeholders who were initially informed of the incident or who Page 27 of 46

have become involved during the incident. The CCG will review their own requirements, in conjunction with NHS England (South Locality); following a Major Incident Stand Down message to determine the most appropriate response from the CCG. Where the incident is a slow burn incident, for example pandemic flu, the CCG will link closely with specialist advice obtained from PHE and NHS England to ensure a structured and coordinated response. The Director on Call for could be alerted to a major incident by one of a number of NHS organisations. Each CCG can declare its own major incident when its own services and/or assets are affected (or potentially) by, for example, fire, flood, major equipment breakdown, or civil disturbance (firearms). In the event of being advised of a major incident standby or declared, the Director on call will implement actions outlined in the Major Incident Response action cards (which are referenced including contacting key ENH CCG staff including a Loggist). In cases where the CCG is alerted to a local incident within a local provider the CCG Director on call will determine whether there is a need to inform the Director on call for NHS England (South Locality) or any other local NHS providers or neighboring CCGs. In line with NHS England incident alert and response levels and utilising the template in Appendix 2. 6.1.2 Incident Management Team (IMT) In exceptional circumstances and if required, the ENHCCG Director on Call responding to the major incident will convene an incident management team (see Operational Response Action Card 5) with relevant expertise from within and external to the CCG to direct and co-ordinate the management of the major incident and provide SITREP reports as required. Specialist advice will be sought from the NHS England (South Locality) or Public Health England Centre, according to the particular nature of the incident being faced. The team will take executive decisions in the light of best available information and obtain input from all relevant sources of expertise and agencies and convene quickly. The Team will include a Loggist, who will record all actions and decisions by the Director On Call and decisions made by the Incident Management Team (see Operational Response Action Card 10). A list of system wide loggists is held in ICC. The template in Appendix 2 will be used for any reports generated by the IMT to NHS England. In the event of a mass casualty situation ENH CCG will work together with Herts Valleys CCG in line with the Hertfordshire LRF Mass Casualties Plan. Page 28 of 46

6.1.3 Joint Working JESIP Principles The ability to coordinate and develop collaborative working is essential to ensure the successful management of any incident. The Joint Emergency Services Interoperability Principles (JESIP) is best practice guidance aimed at all organisations engaged in incident response. Utilisation of joint decision making, risk assessment and joint situation awareness is vital to understanding the entire incident response from all organisations involved. Hertfordshire LRF has mandated that all organisations across Hertfordshire adopt the JESIP principles which have been agreed by ENHCCG. Joint Decision Making Model (JDM) Decision making, especially during an incident, is often complex and decisions are open to challenge. Decision makers will be supported in all instances where they can demonstrate that their decisions were assessed and managed reasonably in the circumstances existing at a particular point in time. Use of decision support models and processes assist in providing this evidence, particularly in conjunction with decision logs. The common sense approach to information sharing, communications, jointdecision making, shared situational awareness, co-locating and risk assessment are essential to ensure the safety of a response is maintained and risks mitigated from a multi-agency approach. The diagram overleaf explains the key JESIP principles, which can be used in order ensure common sense approach to incident management. For the CCG co-locating is not an essential requirement however, arranging regular Health Economy Tactical Coordination telephone conferences is vital, in order develop and share joint situational awareness. Clear concise communication and logging is vital, the use of acronyms should be avoided and only the national recognised emergency responder interoperability Lexicon guide should be used. https://www.gov.uk/government/publications/emergency-responder-interoperabilitylexicon Page 29 of 46

JESIP Principles The incident management team will take responsibility for local communication with the Accountable Officer / CEO and other external provider organisations. It will also ensure (through the NHS England (South Locality) and with communication managers) that the public is informed and the media is briefed. It is likely that any communications would be through the NHS England (South Locality) or Public Health England. 6.1.4 Logging In any incident it is essential that concise, clear, chronological and objective logs are completed. The log is the responsibility of the person completing it and they take ownership of the log until handed over to another person or the incident is completed. The information contained in the log is kept and stored for up to 25 years should it be required for inquest or legal purposes. The JESIP principles should be used when completing logs, in particular METHANE reporting. Clear logging guidelines are available in the ENHCCG log book which can be accessed via the link below or a copy is available in the Director on Call folders and ICC. \\Char-fp01\enhccg\Corporate\Governance\On Call\Master Herts CCG On Call Pack\ENHCCG ON CALL PACK version 12 160617\CCG Log Book Version 1.0.pub The use of electronic logs is permitted but the same processes applies and the logs should contain as much information and data surrounding incidents or issues as possible. However, should a significant, serious or major incident be reported a formal ENHCCG log MUST BE USED! Page 30 of 46

Meetings, investigations and actions will be properly documented If these are related to an incident reference should be made in the incident log book and details submitted with the log book as appendices. 6.1.3 Finances The CCG recognises its obligations with regards to emergency planning, resilience, responding to major incidents and business continuity. Funds, as identified as being necessary, will be made available in the event of a major incident to ensure the CCG meets its obligations with respect to these. A dedicated cost code will be made available to track costs associated with the major incident. The cost code can be requested through the Finance Department by contacting Duty Director or Director of Finance. 6.1.4 Health and Safety Issues During and after a major incident the welfare of staff is of paramount concern to the CCG. Staff should, as under normal circumstances, pay due regard to the health, safety and welfare of themselves and other employees at all times. The need to regularly risk assess during major incidents is extremely important and employees should not expose themselves to unnecessary risks. Where a higher risk situation is identified this should be assessed with the support of a line manager. It is also particularly important during emergency situations, where staff may experiencing higher levels of stress than normal, that regular meal breaks and periods of off duty are observed. 6.1.5 Shift arrangements In the event of a significant / major incident or emergency having a substantial impact on the population and health services, it may be necessary to continue operation of the IMT for a number of days or weeks. In particular, in the early phase of an incident, the IMT may be required to operate continuously 24/7. Responsibility for deciding on the scale of response, including maintaining teams overnight, rests with the lead director. A robust and flexible shift system will need to be in place to manage an incident through each phase. These arrangements will depend on the nature of the incident and must take into consideration any requirements to support external (for example SCG) meetings and activities. The Incident Manager is accountable for ensuring appropriate staffing of all shifts. During the first two shift changes 1-2 hours of hand over time is required. All changes in responsible Director will be preceded by a formal recorded handover. The CCG may need to consider staff accommodation dependent on the nature of the incident. A list of local hotels is available and accessible via the internet search hotels in Welwyn Garden City. Page 31 of 46

6.1.6 Stand down arrangements at the end of a major incident As the incident diminishes and emergency services declare major incident - stand down a decision should then be made by the Director on Call from the CCG when it is appropriate to disband the IMT. This is because the CCG is likely to have a continuing role after emergency services have stood down. Remember the CCG has a role in supporting the recovery phase of any incident. The recovery phase can be protracted and long lasting robust resourcing is required to support the wider health and social care systems. Before the IMT team is disbanded an incident report should be prepared and supported via a hot debrief and arrangements made to formally review the incident and the outcome. The conclusions of the report and any debriefings will help to inform future training and improve procedures. 6.1.7 Records Management An essential element of any response to an incident is to ensure that all records and data are captured and stored in a readily retrievable manner. These records will form the definitive record of the response and may be required at a future date as part of an inquiry process (judicial, technical, inquest or others). Such records are also invaluable in identifying lessons that would improve future response. The Incident Director is formally responsible for signing off the decision log and all briefing papers and documents relating to the incident. All records will be maintained by the CCG in line with the Data Protection Act and CCG s policies relating to data protection. Staff must be mindful when completing documentation that any record pertaining to an incident may be requested under the Freedom of Information Act. All documentation relating to any incident is kept in line with the CCG Records Management Policy subsection Retention and Disposal Schedule. 6.1.8 Debriefing In order to identify lessons learned from an incident that will affect future plans, a series of debriefs post incident are seen as good practice. Hot debrief: Immediately after incident with incident responders (at each location); Organisational debrief: 48-72 hours post incident; Multi-agency debrief: within one month of incident; Post incident reports: within six weeks of incident. These will be supported by action plans and recommendations in order to update ENH CCG plans and provide any training and further exercising required. ENH CCG may also contribute to multiagency debriefing and actions from incident reports. The Incident Control Centre Plan includes the process for the maintenance of incident logs and minutes of meetings during and after the meeting. 6.1.9 Recovery Recovery and the return to normal working is an important part of the management of all major incidents and should commence at the earliest opportunity. In many incidents, the aftermath of the major incident becomes another phase, taking stock of Page 32 of 46

the overall impact and facilitating the restoration of normal health services in line with ENHCCG Business Continuity Plan The Business Continuity Plan references the Business Impact Assessments which include recovery time objectives, restoration principles and how they will be managed. The recovery from an incident in many situations will be run in parallel to the management of the incident and may require the appointment of a separate Incident Manager to lead this function. s role in recovery might include: renegotiating priorities with commissioned services; assessing and arranging for the continuing need of primary and community health services such as psychological support and counselling; provision of care and support to staff that may have been personally affected; consideration of legal and financial risks that might ensue. The national Emergency Response and Recovery Guidance provides detailed advice for organisations; https://www.gov.uk/emergency-responseand-recovery. It may also offer opportunities for service redesign and changes to operational practice. 6.2 Communications Effective communication is paramount to any major incident response. East and North Hertfordshire Clinical Commissioning Group have an effective communications cascade system and full details are set out in the Operational Response Action Cards 15. This cascade is tested through regular exercises. The communications cascade which is activated on declaration of a major incident includes alerting the communications desk (in hours) or on call Communication Manager (out of hours) in the first tranche of contacts. The communications manager is responsible for media handling and represents the CCG in multiagency press briefing arrangements. Additional responsibilities of the communications manager might include: to agree with other NHS agencies locally the procedure for coordinating information in an incident; to plan facilities which can be made available at short notice, e.g. rooms for the media; to prepare simple, easily understood information about NHS organisations; to ensure communications leads and designated spokespersons have appropriate training. NHS England Regional Team is also available to offer communications support to Trusts during an incident. Page 33 of 46

6.2.1 Media The presence of media can be used effectively to support the coordination of a major incident response. Press and social media statements will be coordinated through Hertfordshire Police when there is a Strategic Coordinating Group established. In the event that a Scientific and Technical Advice Cell is set up to advise the Strategic Coordinating Group, the Director of Public Health and Public Health England Centre will be responsible for agreeing clear public health messages to be given to the public. At levels below this the Director on call responsible for coordinating the incident will ensure advice/active involvement is sought from the communications desk (in hours) or Communication Manager (out of hours). 6.2.2 Public Information will be required to ensure public / patients and their next of kin are appropriately informed. Depending on the nature of the incident, provision of suitable facilities for the public will also need to be made. The provision of help lines for ENHCCG will be via Herts Urgent Care (HUC) (111 and GP OOH) who will assist by diverting enquires away from NHS switchboards (e.g. hospitals, GP Practices) which may already be experiencing a high volume of calls. 6.2.3 Languages Where necessary, support in interpretation will be requested from HUC who uses the services of Language Line, for who HUC have a contract with. 6.3 Business Continuity The Civil Contingencies Act (CCA) 2004 places a statutory duty on organisations to develop a comprehensive approach to business continuity. As a category two responder ENHCCG is required to maintain plans to ensure that services are provided in the event of an incident so far as is reasonably practical. Business continuity plans have been developed in line with these requirements and link to arrangements for the recovery phase after a major incident. (See ENH CCG Business Continuity Plan for more details, which can be found via the intranet www.enhertsccg.nhs.uk ENHCCG will also ensure that providers have in place adequate business continuity plans and major emergency plans for their own organisation, as laid out in the NHS Standard Contract. http://www.commissioningboard.nhs.uk/nhs-standard-contract/ 6.4 Vulnerable Persons The major incident plan is for the CCG only. Our plan feeds into the Local Resilience Forums (LRF) plans and procedures that lay outside of the CCG and are owned by the Resilience Team at Hertfordshire County Council (HCC). The major incident plan recognises that there may be vulnerable persons, including those covered by the Equality Act, impacted by a major incident and covers, at a high level, the types of impact that may happen. As this plan feeds into the LRF plans owned by HCC this high level consideration of impact is sufficient and a full equality Page 34 of 46

impact assessment it not required. Within the Civil Contingencies Act (2004) the particular needs of vulnerable persons are recognised. These individuals are defined as people present or resident within an area known to local responders who, because of dependency or disability, need particular attention during incidents. Vulnerable persons could therefore include children and older people; BME communities, particularly those for whom English is a second language, and people with disabilities, including physical disabilities and impairments, learning disabilities, mental illness and those with complex needs. 6.4.1 Black and Minority Ethnic Communities Care will be taken when producing and distributing information to ensure that it is accessible to all. This may necessitate the production of translated materials, the use of health advocates, and the use of interpreting services. 6.4.2 Children Many major incidents involve children and in some cases children are the main casualties. Children have special needs that are different from adults in terms of their size, physiology and psychological needs all of which have an impact on their care. The Director on call and the IMT will need to consider and take account of the children s needs in planning and response to a major incident. Special consideration must be given to schools, nurseries, childcare centers and medical facilities for children. 6.4.3 People with inhibited physical ability This may be by reason of age, illness, disability, pregnancy or other reason. Attention should be paid to hospitals, residential homes, care homes and day centers likely to be housing any people with inhibited physical ability. Access to records of residents in the community who have inhibited physical ability is also important and may be achieved in partnership with Social and Community Services. 6.4.4 People with learning disabilities and mentally ill people ENHCCG will respond as appropriate in order to assist people with learning disabilities or mental illness by using existing facilities and arrangements wherever possible. If there is a need for additional or specialist assistance then help will be sought from Hertfordshire Partnership Foundation Trust as appropriate. 6.5 Exercises and Testing Plans In accordance with emergency planning guidance, plans are tested through regular exercises, in partnership with other partners and dependent stakeholders including: Providers including primary care neighboring CCGs, social care, county and borough councils. Page 35 of 46

Exercises can be led by the NHS England (South Locality) or be multiagency and ENHCCG will participate in all those that are relevant. A communication exercise is held on at least a six monthly basis, a CCG table top exercise is carried out annually. Details of all exercises are reported to the ENHCCG Governing Body annually and amendments as a result of training are incorporated into annual reviews of all EPRR plans, as appropriate. The Accountable Emergency Officer is responsible for ensuring that plans are regularly reviewed to ensure that they reflect legislative and/or organisational change and the ongoing risk assessment process. The ENHCCG works closely with partners through the LHRP sub-group to develop three year training and exercise plan for Health. The exercise plan holds details of all planned exercises across the County of Hertfordshire relating to Health. In addition an annual training program of courses is a developed and offered out to all providers for senior incident management and other incident response staff to ensure all staff that could be involved in incidents are appropriately trained. These external courses complement internal training to all CCG staff relating to EPRR principles and expectations. Staff Abilities to Respond to Requests for Assistance Consideration should be given to the physical abilities of all staff expected to respond to an incident should it be required. The Incident Manager should understand these constraints and where necessary make arrangements to support these needs of where possible for that individual. Page 36 of 46

Appendix 1 ACTION: Initial risk assessment The following need to be considered by the Director on Call An assessment of the situation will determine what action needs to be taken. Using the information at hand and taking account of a worst case scenario where knowledge is limited, consider the following and record all relevant information. Questions to consider Information Collected?* What is the size and nature of the incident? Area and population likely to be affected - restricted or widespread Level and immediacy of potential danger - to public and response personnel Timing - has the incident already occurred or is it likely to happen? What is the status of the incident? Under control Contained but possibility of escalation Out of control and threatening Unknown and undetermined What is the likely impact? On people involved, the surrounding area On property, the environment, transport, communications On external interests - media, relatives, adjacent areas and partner organisations What specific assistance is being requested from the NHS? Increased capacity - hospital, primary care, community Treatment - serious casualties, minor casualties, worried well Public information Support for rest centers, evacuees Expert advice, environmental sampling, laboratory testing, disease control Social/psychological care How urgently is assistance required? Immediate Within a few hours Standby situation *Key = Yes X = no? = Information awaited N/A = Not applicable Page 37 of 46

Appendix 2 METHANE REPORT MAJOR INCIDENT METHANE REPORT TIME OF CALL:.. DATE:... Actions NAME OF CALLER: ORGANISATION:... Tick Major incident Exact location of incident? Type of incident? Hazards Access Number (of those involved) Emergency services Declared or standby by who? (E.g. Grid Reference, building, street, village, town, landmark, etc.) Flooding/Fire/Utility Failure/Disease outbreak/cbrn/heat wave Present and potential? (E.g. fuel spillage, weather conditions, etc.) (Best routes avoiding hazards for staff, evacuation routes, road blocks, etc.) Number and type of casualties. Priority P1, P2, P3, deceased. specialist needs i.e. burns, paeds etc Partner orgs etc. required/on scene (Contact details) Specialist National Assets etc (Burns beds) CCG incident log started Yes / No Log number Major Incident Plan Jan 2015 to Jan 2016 (FINAL v.2.0) Page 38 of 46

Trust Intentions Support Additional Intentions/Actions required/requested to take Support/Mutual Aid required (whom from?) specialty, activate P3 pathways if needed, inform primary care Free Text: Additional Information/thoughts and requirements Has NHS England been informed? If a major or significant incident has been declared please ensure a copy of the ENHCCG incident log book is completed in order to log all decision making processes. Major Incident Plan Jan 2015 to Jan 2016 (FINAL v.2.0) Page 39 of 46

Appendix 3 NHS MAJOR INCIDENT SITUATION REPORT SITREP Note: Please complete all fields. If there is nothing to report, or the information request is not applicable, please insert NIL or N/A. Organisation: Name (completed by): Date: Time: Telephone number: Email address: Authorised for release by (name & title): Type of Incident (Name) Organisations reporting serious operational difficulties Impact/potential impact of incident on services / critical functions and patients Impact on other service providers Mitigating actions for the above impacts Major Incident Plan Jan 2015 to Jan 2016 (FINAL v.2.0) Page 40 of 46

Impact of business continuity arrangements Media interest expected/received Mutual Aid Request Made (Y/N) and agreed with? Additional comments Other issues NHS CB Regional Incident Coordination Centre contact details: Name: Telephone number: Email: Major Incident Plan Jan 2015 to Jan 2016 (FINAL v.2.0) Page 41 of 46

Appendix 3 Planning Structure Response structure EPRR Response Structure for NHS England Nationally NHS EPRR Framework 2015 Major Incident Plan Jan 2015 to Jan 2016 (FINAL v.2.0) Page 42 of 46