Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group Governing Body Meeting In- Common Date: Tuesday, 5 th December 2017 Time: 13.30 Location: Vassall Centre. Gill Avenue, Fishponds, Bristol, BS16 2QQ Agenda item: 11.3 Emergency Preparedness, Resilience and Response (EPRR) Core Standards Assurance Assessment 2017-18 Report Author: Tiina Mustonnen Report Sponsor: Jeanette George 1. Purpose The purpose of this the paper is to update the Governing Body on the outcome of the Emergency Preparedness, Resilience and Response (EPRR) annual assessment process for 2017/18 for both the BNSSG CCGs and the NHS providers for whom they are lead commissioner 2. Recommendations The Bristol, North Somerset and South Gloucestershire (BNSSG) Governing Bodies are asked to: Receive the report on compliance for the BNSSG CCGs against the EPRR Core Standards. Receive the report on compliance for NHS Providers for whom the CCG is lead commissioner. Approve the CCGs action plan. 3. Background The updated NHS England Core Standards for Emergency Preparedness, Resilience and Response (EPRR), issued 10th November 2015, 1 states that all NHS funded services must ensure they have robust and well tested arrangements in place to respond to and recover from an incident or an emergency. 1 https://www.england.nhs.uk/wp-content/uploads/2015/11/eprr-framework.pdf
BNSSG CCG Governing Body Meeting In-Common The Civil Contingencies Act (CCA) 2004 2 specifies that responders will be either Category 1 (primary responders) or Category 2 responders (supporting agencies). CCGs are Category 2 responders, and are expected to work closely with partners. They are required to cooperate with, and support other Category 1 and Category 2 responders. CCGs are also expected to provide support to NHS England in relation to the coordination of their local health economy. The responsibilities of CCGs can be summarised as: Ensuring contracts with all commissioned provider organisations (including independent and third sector) contain relevant EPRR elements, including business continuity Monitoring compliance by each commissioned provider organisation with their contractual obligations in respect of EPRR and with applicable Core Standards Ensuring robust escalation procedures are in place so that if a commissioned provider has an incident the provider can inform the CCG 24/7 Ensuring 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 Local Health Resilience Partnership (LHRP), either on their own behalf or through a nominated lead CCG representative Providing a route of escalation for the LHRP in respect of commissioned provider EPRR preparedness Supporting NHS England in discharging its EPRR functions and duties locally, including supporting health economy tactical coordination during incidents (Alert Level 2-4) Fulfilling the duties of a Category 2 responder under the CCA 2004 and the requirements in respect of emergencies within the NHS Act 2006 (as amended). 4. Outcome of the 2017/18 EPRR Assurance Process The EPRR core standards for 2017-18 were the same as in the last three years. This year s EPRR assurance deep dive topic was Governance. NHS England South South West have set the following criteria for assessing organisation s overall preparedness: Compliance Level Full Evaluation and Testing Conclusion Arrangements are in place that appropriately addresses all the core standards that the organisation is expected to achieve. The Board has agreed with this position statement. 2 http://www.legislation.gov.uk/ukpga/2004/36/contents Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 2
BNSSG CCG Governing Body Meeting In-Common Compliance Level Substantial Partial Non-compliant Evaluation and Testing Conclusion Arrangements are in place however they do not appropriately address one to five of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organisation is expected to achieve. A work plan is in place that the Board has agreed. Arrangements in place do not appropriately address 11 or more core standards that the organisation is expected to achieve. A work plan has been agreed by the Board and will be monitored on a quarterly basis in order to demonstrate future compliance. 4.1 BNSSG CCGs EPRR Assurance Outcome BNSSG CCGs EPRR Assurance Review meeting was held on 28 th September 2017. This was the first time the three CCGs have been assessed as one organisation. NHS England noted that the close working across the three CCGs has enabled BNSSG CCGs to maintain full compliance against the following areas: Duty to assess risk Duty to communicate with the public Information Sharing Co-operation However, reduced compliance is noted against eight individual core standards which were rated as amber (not compliant but with evidence of progress and in the EPRR work plan for the next 12 months) due to the impact of the alignment of the CCGs. Overall, the CCGs have therefore achieved a 79% compliance level and a Partial compliance rating. The core standards for which the CCGs were assessed as Amber are as follows: Core Standard 3 - Organisations have an overarching framework which sets out EPRR expectations Core Standard 9 - Corporate and service level Business Continuity Core standard 12 Arrangements in place to respond to Pandemic influenza Core standard 17 - Effective arrangements in place to respond to an Infectious Disease Outbreak Core standard 26 - Arrangements include how to continue your organisations prioritised activities Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 3
BNSSG CCG Governing Body Meeting In-Common Core standard 31 Those on-call must meet identified competencies and key knowledge and skills for staff Core standard 49 - Arrangements include a current training plan with a training needs analysis Core standard 50 - Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work. BNSSG CCGs was fully complaint against four out of the six deep dive review questions concerning Governance. The CCGs were non-compliant against a requirement to have a non-executive Director with EPRR in their portfolio, however NHS England does not consider this as an issue for CCGs. A partial compliance rating was afforded to the requirement to have an internal EPRR oversight/ delivery group as whilst informal arrangements exist across the three CCGs, action is required to develop terms of reference for a group to reflect the aligned approach. CCG actions required to achieve compliance with amber rated standards can be summarised as follows: Review of Business Continuity Policy and Plan, This should include clear descriptions of roles and responsibilities in an emergency or incident as well as for such potential events as pandemic flu. Development of Directorate level Business Impact Assessments and continuity plans for business critical services. Incident Response Plan (IRP) review of the IRP and on-call support pack to ensure documentation is fit for purpose; Development of a training programme for all on-call staff ensuring core competencies are met. Development of an exercising programme for all on-call staff Ensuring training and exercising records are kept for all on-call staff. Appendix A shows a summary of the actions required by NHSE as a result of the CCGs EPRR assurance review. Work has already begun on these areas and the CCGs action plan and a status update is shown at Appendix B. The action plan will be reviewed quarterly at meetings with NHSE to review progress. 4.2 BNSSG Providers The annual EPRR Assurance Process for CCGs is twofold; as well as maintaining CCG compliance with the EPRR standards, as commissioners we are required to assess and assure ourselves of our providers EPRR arrangements. This year, BNSSG CCGs reviewed, jointly with NHSE, the following providers: University Hospitals Bristol NHS Foundation Trust North Bristol NHS Trust Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 4
BNSSG CCG Governing Body Meeting In-Common Weston Area Health NHS Trust Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) Bristol Community Health Sirona Care and Health North Somerset Community Partnership Care UK as the local NHS 111 provider All acute and community providers apart from AWP achieved a substantially compliant rating. AWP were assessed as partially compliant. NBT and Sirona have only one standard, for training, assessed as amber; and are expected to achieve a fully compliant status as soon as the Strategic Leadership in a Crisis course has been delivered. The BNSSG CCGs have not previously been responsible for assuring Care UK for 111 services, which has been managed by another NHSE area. The assurance process demonstrated that Care UK currently has a locally defined contract for the provision of NHS 111 services that does not capture the organisational EPRR requirements to the level of the NHS Standard Contract template. NHSE awarded Care UK an overall rating of non-compliant, which we considered as a risk and have included onto the EPRR risk register. Following the on-going procurement for these services, the new contract will be based on the NHS Standard Contract documentation. All providers have comprehensive EPRR work plans in place to maintain and deliver improvement in compliance against the core standards; and the CCGs will be having regular, quarterly review meetings jointly with NHSE to review progress for Care UK due to their non-compliant status. 5. Financial/resource implications The CCGs are required, as part of their assurance, to have a budget identified to support this work and to support mutual aid arrangements in the event of a major incident. Currently the three organisations have got individual cost centres identified for this. Work is underway to establish a BNSSG cost centre to be in place from 1 st April 2018. 6. Legal implications There are no legal issues raised in this paper. 7. Risks/mitigations The risk register for EPRR are held as part of the Commissioning Directorate risk register and reported to Governing Body as part of the overarching risk management framework where risks currently exceed a score of 15. No risks exceed this level currently. 8. Implications for health inequalities N/A Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 5
BNSSG CCG Governing Body Meeting In-Common 9. Implications for equalities (Black and Other Minority Ethnic/Disability/Age Issues) An Equality Impact Assessment is not considered necessary for the process of updating and reporting on CCG EPRR and business continuity planning. 10. Consultation and Communication including Public Involvement Patient and public involvement is not considered necessary for the process of updating and reporting on CCG EPRR and business continuity planning. 11. Appendices Appendix A - Summary of the actions required by NHSE as a result of the CCGs EPRR assurance review Appendix B BNSSG CCGs EPRR Action Plan Glossary of terms and abbreviations Emergency Emergency Preparedness Resilience Response Under Section 1 of the CCA 2004 an emergency means (a) an event or situation which threatens serious damage to human welfare in a place in the United Kingdom; (b) an event or situation which threatens serious damage to the environment of a place in the United Kingdom; (c) war, or terrorism, which threatens serious damage to the security of the United Kingdom. The extent to which emergency planning enables the effective and efficient prevention, reduction, control, mitigation of, and response to emergencies. Ability of the community, services, area or infrastructure to detect, prevent and, if necessary, to withstand, handle and recover from disruptive challenges. Decisions and actions taken in accordance with the strategic, tactical and operational objectives defined by emergency responders. Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 6
BNSSG CCG Governing Body Meeting In-Common LHRP IRP ICC This refers to the Avon and Somerset Local Health Resilience Partnership that covers the geographical area of the Avon and Somerset Local Resilience Forum. The LHRP is a strategic forum for local organisations to facilitate health sector (including voluntary and independent sector) preparedness and planning for emergencies at LRF level. Members of the LHRP are Accountable Emergency Officers (Executive Representatives) who are able to authorise plans and commit resources on behalf of their organisations, and are able to provide strategic direction for health EPRR in their area. Incident Response Plan contains our framework for response to an incident. The plan has been developed to ensure key participants carry out their respective functions when responding to major incidents or during emergency situations. It includes a command and control framework to manage the response and sufficient operational procedures to enable responders to manage an incident. The Incident Control Centre is the hub of the CCG s strategic response to a major incident. It will be set up at the discretion of the Accountable Emergency Officer or the On-Call Director. Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups 7
Appendix A - Bristol, North Somerset, South Gloucestershire CCGs EPRR Assurance Review 2017/18 actions required to achieve compliance with amber rated standards Core Standard 3: Organisations have an overarching framework which sets out EPRR expectations CS3-1 BNSSG CCGs to review their Incident Response Plan (IRP) and on-call pack to ensure documents have a clear purpose and are user-friendly for on-call staff. CS3-2 BNSSG CCGs to write an EPRR policy document setting out CCGs roles and responsibilities in emergencies/ incidents and Business Continuity (BC) incidents CS3-3 Actions above to be reflected in the EPRR work programme. Core Standard 9: Corporate and service level Business Continuity CS9-1 Work required around BC plans needs to be reflected in the EPRR work programme CS9-2 Review of Business Continuity Policy for BNSSG CCGs CS9-3 Consolidation of departmental / service level Business Impact Analyses (BIAs) across BNSSG CS9-4 Review Business Impact Analyses post CCG alignment Core Standard 12: Pandemic influenza CS12-1 CCG roles and responsibilities around Pandemic flu planning to be reflected in appropriate plan (i.e. within the Business Continuity Plan), CS12-2 Action related to pandemic flu planning to be reflected on the EPRR work programme. Core Standard Infectious Disease Outbreak 17: N/A: Awaiting sign-off of Avon and Somerset Communicable Disease Outbreak Framework and supporting operational plans Core Standard 26: CS26-1 Arrangements include how to continue your organisation s prioritised activities Ensure a summary of critical functions is included in the Business Continuity Plan once BIAs are completed.
Core Standard 31: CS31-1 Those on-call must meet identified competencies and key knowledge and skills for staff. Training programme for on-call staff to be developed to ensure core competencies are met. Core Standard Arrangements include a current training plan with a training 49: needs analysis SC49-1 A training programme for on-call staff needs to be developed and the workstream added to the EPRR work plan. SC49-2 BNSSG CCGs to combine training and exercising record for all on-call staff from BNSSG CCGs. Core Standard 50: CS50-1 Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work An exercising programme for on-call staff needs to be developed and the workstream added to the EPRR work plan.
Appendix B - BNSSG CCGs - Emergency Preparedness Resilience and Response (EPRR) Action Plan 2017-18 v.7.1 Accountable Emergency Officer - Jeanette George, Director for Corporate Services (Interim) (JG) Operational Lead - Tiina Mustonen, Operations Manager (TM ) Resilience Lead - Louise Hudson (LH) Date for Lead Work area Activity Work package completion Status Update Confirm AEO arrangements JG COMPLETED Jeanette George, BNSSG Director of Corporate Services confirmed as AEO for BNSSG CCGs with effect from 1st September 2017. Update all relevant plans and Business Impact Assessments for key services to BNSSG. Establish a tactical on-call rota to support major incident management (currently tactical on-call supports system management only). EPRR policy document setting out CCGs roles and responsibilities in emergencies/ incidents and BC incidents. Updated BNSSG Business Continuity Policy Updated BNSSG corporate and Directorate level Business Continuity Plans Updated BNSSG BIAs in the light of organisational change Updated BNSSG IRP and on-call pack TM TM for corporate level plan Directors (once in post) LH 30.11.2017 On-going, BNSSG Business Continuity Policy and corporate level plan documents in draft. EPRR elements to be incorporated into the policy document. BIAs to be drafted, but can be finalised only once Directorate structures have been confirmed, this goes for directorate level BCPs as well, but these should be completed in draft by target date. Governance Update on-call role descriptions and person specifications to BNSSG and to support Tactical Co-ordination Groups as a response to a major incident. Create a role description/jd for BNSSG EPRR Lead Manager. Complete EPRR self-assessment for the organisation. Strategic On-Call Role Description Tactical On-call Role Description BNSSG JD for BNSSG EPRR Lead Manager TM TM TM COMPLETED Strategic and Tactical on-call role descriptions and person specs, and BNSSG EPRR Lead Manager JD were agreed by the Exec Team on 25.10.17 TM and JG COMPLETED Assurance meeting held on 28.09.2017. Arrange Assurance meetings for BNSSG CCGs, with providers and NHS England South - South West Schedule meetings, invite provider and NHS E reps, request required documents two weeks prior to meeting. JM COMPLETED All provider assurance meetings held jointly with NHSE. Sign off of Assessment and Work Plan. Ensure the Assessment result and work plan are reviewed and approved by the Executive Team prior to submission to Governing Bodies JG COMPLETED Paper to Exec Team on outcome of CCG assurance to approve action plan 25/10/17. EPRR Assurance and Action Plan on December Governing Bodies agenda for consideration and sign off. TM COMPLETED EPRR Risk Register to be included in the Commissioning Directorate Risk Register going forward Duty to assess risk Merge all existing CCG location specific EPRR risk registers into one BNSSG risk register and ensure alignment with LHRP process and risk register. Agree owner and frequency for updating. On-going risk management. Proposed monthly review of EPRR risk register. All risks 12 onto the Corporate Risk Register 1 of 3
Work area Activity Work package CCG roles and responsibilities around Pandemic flu planning to be strengthened in BCP. Further detail and identification of specific CCG roles and responsibilities to be included in corporate BCP. Date for Lead completion TM 30.11.2017 Status Update Duty to maintain plans CCG does not have an internal infectious disease outbreak plan as their responsibilities are described in the Communicable Disease Framework and the 3 BNSSG Local Authority Operational plans, which are out of date, and currently being reviewed; the operational plans are not yet finalised. Updated Communicable Disease Framework and the 3 BNSSG Local Authority operational plans. NHSE Comments by Avon and Somerset LHRP Communicable 28.11.2017 Disease Incident & Outbreak Response Final draft to Framework V1.3 issued for consultation with LHRP TPG on LHRP partners on 14th Nov for comments by 30.11.2017 28th Nov NHSE South - South West Executive Group 13.12.2017 Final 14.11.2017 Keep BNSSG plans up to date as required from any changes in the system or as identified by the LRF, LHRP or NHSE. Updates to the BNSSG Business Continuity and EPRR plans as required. BNSSG EPRR Lead Manager once appointed Ongoing. Command and Control Co-operation Those on-call must meet identified competencies and key knowledge and skills for staff. Confirm arrangements and equipment for joint Incident Control with NHSE in South Plaza. Confirm arrangements for tactical coordination of major incident response Training programme for on-call staff to be developed to ensure core competencies are met. Document and agree arrangements for a joint ICC. Establish a joint programme of training on the set-up of the joint ICC for all on-call directors/managers. Deliver training for CCG tactical coordination role to strategic and tactical on-call directors/managers. TM, LH and NHSE TM (till 30.11.17), LH and JaG for NHSE 31.12.2017 for booking training First on-call and tactical-on call role training delivered. Bespoke tactical on-call training course to reviewed and signed off for delivery 1.11.17. First part of Strategic Leadership in Crisis scheduled for 7th Dec. Awaiting confirmation from NHSE of Tactical Coordination Centre and Loggist training course details and dates 31.12.2017 Joint programme for training ICC set-up in place and included in on-call diary. First on-call and tactical-on call role training delivered. Bespoke tactical on-call training course reviewed and signed off for delivery 1.11.17 2 of 3
Work area Activity Work package Training and BNSSG EPRR (and on-call) Training Deliver BNSSG on-call refresher training Exercising Programme 12.09.2017 and monthly until all strategic and tactical directors/managers have completed training. Ensure all Strategic On-call Directors attend Strategic Leadership in a Crisis training once available. Lead LH, and JaG for NHSE Date for completion Ongoing Status Update On-call refresher training designed and delivered in September. Strategic Leadership in a Crisis training planned in December/January. Tactical Control Group training designed and being delivered in the new year. Repeat on-call directors Out of Hours access walk through. Participate in all NHSE Exercises. Arrange date and participation for walk through. LH TBC Out of Hours access detail confirmed and rota updated. All on-call directors have swipe cards to access South Plaza out of hours. Further OOH Walk through and on-call staff Incident Control Centre set up to be arranged due to recent staff changes. Undertake an exercise to stress test the BNSSG Business Continuity Plan To be delivered on BNSSG corporate and directorate level plans have been signed off. JG, LH Mar-18 Key JG - Jeanette George TM - Tiina Mustonen LH - Louise Hudson AN - Amanda Norman JM - Jenny Macken JaG - Jane Grey 3 of 3