Risk, Health and Safety Resilience Planning Policy Manager Board Secretary Policy Group Executive Team Policy Established Last Updated June 2013 Policy Review Period/Expiry 2 years/march 2015 This policy does / does not apply to Medical/Dental Staff (delete as appropriate) UNCONTROLLED WHEN PRINT Page 1 of 12
VERSION CONTROL Version Purpose/Change Author Date Number 1.0 Version Control introduced July 2011. D Grewar 28/02/11 Previous versions of this policy, prior to this date, are available in the Electronic Document Store. 1.1 Section 3.2 - final paragraph added M Dunning 07/12/11 1.2 Page 5 NHS Tayside Major Incident Plan added and D Downie 12/12/11 Ninewells and PRI MEPs removed 1.3 Policy Group amended to Executive Team from D Downie 01/03/12 EPAG 1.4 Policy renamed Resilience Planning, Sections 6-15 D Grewar 11/04/13 added 2.0 Full document revision D Grewar 04/06/13 2.1 Sections 7 and 10 revised D Grewar 21/06/13 Page 2 of 12
CONTENTS VERSION CONTROL... 2 1. INTRODUCTION... 4 2. DUTIES OF NHS TASIDE... 4 3. RESPONSIBILITIES... 4 4. AIM OF RESILIENCE PLANNING... 5 5. DEFINITIONS... 5 6. REPORTING ARRANGEMENTS... 6 7. TASIDE STRATEGIC CO-ORDINATING GROUP (SCG)... 6 8. SCOTTISH GOVERNMENT RESILIENCE DIVISION AND NHS SCOTLAND RESILIENCE.. 6 9. PLANS... 7 10. MUTUAL AID FROM ANOTHER NHS BOARD... 8 11. DEBRIEFING... 8 12. FORMAL INVESTIGATIONS... 9 13. STAFF COUNSELLING... 9 14. TRAINING... 9 15. EXERCISES... 9 16. KE CONTACTS... 9 17. REFERENCES... 10 NHS TASIDE - POLIC/STRATEG APPROVAL CHECKLIST... 11 RAPID IMPACT CHECKLIST... 12 Page 3 of 12
RESILIENCE PLANNING 1. INTRODUCTION Preparing Scotland: Scottish Guidance on Resilience, Scottish Government guidance, defines resilience as "the capacity of an individual, community or system to adapt in order to sustain an acceptable level of function, structure and identity". For the purposes of this policy resilience is defined as the ability "at every relevant level to detect, prevent, and, if necessary, to handle and recover from disruptive challenges". The processes which underpin resilience form the fundamental elements of civil protection. In NHS Tayside the purpose of resilience planning is to prepare for the effective response and management of emergencies, business continuity and capacity issues. Preparation for emergency response lies at the heart of the Civil Contingencies Act 2004 provisions (The Act) and Civil Contingencies Act 2004 (Contingency Planning) (Scotland) Regulations 2005 (The Regulations). In brief, the Act places 7 duties on Category 1 responders: 1. Duty to assess risk 2. Duty to maintain emergency plans 3. Duty to maintain business continuity plans 4. Duty to promote business continuity (refers to Local Authority only) 5. Duty to communicate with the public 6. Duty to share information 7. Duty to co-operate The Act places a duty on the NHS as a Category 1 responder to plan for emergencies. The basis for planning and response will be Integrated Emergency Management (IEM). Under the principles of IEM preparation and response to an emergency must concentrate on the effects of the emergency rather than its cause and, wherever possible, must be planned and undertaken as an extension of normal day-to-day functions of local responders. An underlying aim of the process will be to develop flexible arrangements, which will enable agencies to deal with any crisis whether foreseen or unforeseen. 2. DUTIES OF NHS TASIDE NHS Tayside has the responsibility to meet the health care needs of the people in Tayside and this includes those needs which are not possible to forecast in detail or which arise or change unexpectedly. A resilience issue (emergency, business continuity or capacity) does not remove this statutory duty but its fulfilment may require sudden alterations as to how, where and when the diagnosis, treatment and comfort and care of patients is carried out. It is not possible to predict the exact form and nature of a future resilience issue or the amount of time available to prepare for it. Any part of NHS Tayside might need to contribute to the response to it and must be prepared accordingly. Planning and managing the NHS Tayside resilience response must be regarded as integral to the planning and management of every service NHS Tayside provides. 3. RESPONSIBILITIES The Chief Executive has overall responsibility to provide strategic leadership on behalf of Tayside NHS Board and is accountable to the Scottish Government Health Department and Page 4 of 12
to Scottish Ministers. Just as securing the health of the population is the responsibility of NHS Tayside, so too is planning for the NHS Tayside response to meet the needs of any situation which may affect the resilience of the organisation. Directors and managers are responsible for ensuring that plans capable of maintaining a minimum acceptable standard of service delivery are in place for each key service by the development of incident specific plans and business continuity plans. Resilience Planning Officers have responsibility for the co-ordination of NHS Tayside s suite of plans as detailed on Page 8. Each department and service will ensure that it has plans in place to respond to a business continuity issue with the exception of the Directorates of Public Health and Operations who have responsibility for the production of a range of additional plans. All staff are responsible for ensuring that they are familiar with their department/service business continuity plan and, if applicable, their role during a major incident. 4. AIM OF RESILIENCE PLANNING To co-ordinate the preparation/maintenance and regular monitoring of NHS Tayside s major incident/emergency plans, business continuity plans and procedures developed by key managers and others identified above. To ensure the organisation is prepared to respond to an emergency, incident or business continuity issue and reduce the impact of such an occurrence on our routine business. 5. DEFINITIONS An emergency is something which arises unexpectedly, and which requires urgent action to resolve. The NHS faces many emergencies in the course of its routine activities. While each separate instance requiring urgent NHS action might in itself be unexpected, being faced with emergencies is a natural characteristic of meeting health care needs. To provide a basis for emergency planning there is a requirement to form an understanding between what are considered routine emergencies and those, which require special action. Major Incident the widely accepted term used by the Emergency Services to describe any emergency that requires the implementation of special arrangements by one or more of the Emergency Services, the National Health Service or a Local Authority. While a Major Incident might constitute a Major Emergency, as defined below, for one or more parts of the National Health Service, it may have only limited health care implications. Major Emergency - a situation, either arising or threatened, which requires special mobilisation and/or redeployment of staff or other resources with consequent interruption to routine activities. Business Continuity Management (BCM) - a flexible management framework designed to help organisations to continue operating in the face of a wide range of different types of disruptions. It can assist in dealing with a range of disruptions from "normal" internal business crises to major emergencies. Page 5 of 12
6. REPORTING ARRANGEMENTS To oversee the required actions NHS Tayside has established the Resilience Planning Advisory Group (RPAG) the purpose of which is to lead the planning and development of all aspects of NHS Tayside s resilience planning. Reporting arrangements: Strategic Risk Management Group Quarterly Report Key: Reports to Minutes to Operational Risk/Health and Safety Management Group Bimonthly Report/Minutes RPAG 7. TASIDE STRATEGIC CO-ORDINATING GROUP (SCG) In the event of an incident it is critical that NHS Tayside s response is co-ordinated with that of fellow Category 1 responders and other agencies including the voluntary sector at local level to maximise the effect of the response to the incident. The Strategic Co-ordinating Group (SCG) has been established to promote inter-agency cooperation at local level. The Group is representative of all Category 1 responders and is structured around a Strategic Group and a Tactical Group. Category 1 responders are the organisations that provide vital services in an emergency or incident. They include the emergency services, local authorities, health boards, Maritime and Coastguard Agency (MCA) and the Scottish Environment Protection Agency (SEPA). Category 2 responders are the organisations that provide key infrastructure services. They include amongst others the utilities, transport organisations and the Health and Safety Executive (HSE). Since formation of single police and fire services on 1 April 2013 development of SCG replacement structures, to be known as Regional Resilience partnerships (RRPs), has advanced in readiness for the transition date of 1 November 2013. Three RRPs North, East and West will be formed. The North RRP will comprise Highlands and Islands, Grampian and Tayside SCGs with each of these SCG areas forming a Local Resilience Partnership (LRP). 8. SCOTTISH GOVERNMENT RESILIENCE DIVISION AND NHS SCOTLAND RESILIENCE The Scottish Government's Resilience Division supports the frontline agencies that deliver emergency planning and response across Scotland. Page 6 of 12
NHS Scotland Resilience is the body responsible for resilience planning in NHS Scotland. They host the NHS Scotland Resilience Forum the purpose of which is to share best practice and raise awareness amongst the NHS Scotland emergency planning and business continuity community, complying with duties within the Civil Contingencies Act 2004 and other relevant legislation and guidance for designated Category 1 responders. In the event of a major incident, other incident or event the Scottish Government Resilience Room (SgoRR) can be activated to support the local NHS Boards and to provide a focus for the co-ordination and control of the NHS response at national level. Cabinet Office Briefing Rooms - COBR Cabinet Sub-Committee Scottish Government Resilience - CSC-SGoR National Security Council - NSC Scottish Government Resilience Room - SGoRR Scottish Police Information and Co-ordination Centre- S-PICC (under review) SGoRR (Officials) - SGoRR(O) 9. PLANS To plan separately and in detail for every possible incident/emergency is less effective than to develop generic plans with a general framework to respond to any incident/emergency. Emergency and business continuity plans in NHS Tayside are based on this methodology. NHS Tayside has adopted a hub and spoke model for creating resilience plans as outlined in Preparing Scotland: Scottish Guidance on Resilience, and this is now the adopted method being used by Resilience Planning for all NHS Tayside plans. The majority of NHS Tayside plans and procedures are stored in the Electronic Document Store (EDS) so that they are easily accessible for those leading and managing the response. The detailed model below (Figure 1) contains direct links to plans that are currently available electronically. Page 7 of 12
Figure 1 Mass Casualties Security: Bomb Threats and Suspicious Packages Lockdown and Hospital Lockdown Major Incident Plan Business Continuity Plans Corporate Business Continuity Plan Critical Incident Management Procedures Ninewells Hospital Perth Royal Infirmary Murray Royal Hospital Stracathro Hospital Chemical Biological Radiological Nuclear/ Hazardous Material (CBRN/HazMat) Resilience Planning Policy Hospital Evacuation Plans Fuel Disruption Plan Management Procedure for Accessing 4 x 4 Vehicles Health Protection Major Incident Plan VIP Plan Pandemic Influenza Preparedness and Response Plan Procedure for the Provision of Medical Services at Emergency Support Centres in Tayside Resilience Planning have developed 2 Staffnet micro sites, Emergency Planning and Keeping Services Running. Plans and useful documents are accessible via these sites to facilitate ease of access. 10. MUTUAL AID FROM ANOTHER NHS BOARD Where the response to an incident may subsequently prove beyond the resources of NHS Tayside due to its scale and complexity or because of the particular type of injury (for example serious burns) assistance will be sought from neighbouring NHS Boards. NHS Tayside has Mutual Aid Agreements with the North of Scotland Regional Planning Group (NoSPG) Health Boards for major incident assistance and with the South East and Tayside Regional Planning Group (SEAT) Health Boards for mutual public health support in the event of an incident which outstrips the capacity of a single NHS Board Public Health Department. 11. DEBRIEFING Debriefing will be essential to establish lessons learned, clarify outstanding issues, introduce any required amendments to emergency plans and to promote teamwork by encouraging Page 8 of 12
staff participation. As soon as is practicable, following an incident, NHS Tayside will ensure that arrangements are in place to review its response and to debrief relevant participants. 12. FORMAL INVESTIGATIONS To assist with any formal proceedings it is crucial that all incident logs, personal logs, records of events, communications, decisions taken and all other relevant materials are preserved. To this end it is essential staff keep a personal log. 13. STAFF COUNSELLING Despite the intensity of every day NHS tasks incidents can still be extremely stressful and demanding for all staff especially those at the frontline of the response. NHS Tayside recognises that there is a responsibility to provide support for staff by offering specialist counselling both during and after incidents, if required. Staff counselling will be made available through Occupational Health and Safety Advisory Services (OHSAS) (see NHS Tayside Critical Incident Employee Support Policy). 14. TRAINING NHS Tayside Resilience Planning Department will provide advice and assistance to staff on the preparation, planning and delivery of appropriate levels of training. Every opportunity should be taken by NHS Tayside personnel to participate in multi-agency training initiatives and conversely invitations should be given to non NHS partners. Staff should ensure they maintain a record of emergency training given and an entry should be placed on their individual personal record/eksf. 15. EXERCISES Every opportunity will be taken by NHS Tayside to exercise resilience plans and procedures to test their validity and ability of staff to fulfil their roles and responsibilities within the plans. Advice and assistance to managers in connection with the preparation of, planning of and delivery of any exercises, workshops will be provided by the Resilience Planning Department 16. KE CONTACTS Resilience Planning Team, Level 10, Ninewells Hospital Douglas Grewar 01382 740772 ext 40772 07795266824 Iain Dorricott 01382 740762 ext 40762 07807078345 Elisabeth Leslie 01382 740771 ext 40771 07887716063 (during office hours) Donna Downie 01382 740770 ext 40770 07786855063 (during office hours) Email: resilience.tayside@nhs.net Page 9 of 12
17. REFERENCES Civil Contingencies Act 2004 Civil Contingencies Act 2004 (Contingency Planning) (Scotland) Regulations 2005 Preparing Scotland Scottish Guidance on Preparing for Emergencies Page 10 of 12
NHS TASIDE - POLIC/STRATEG APPROVAL CHECKLIST This checklist must be completed and forwarded with policy to the appropriate forum/committee for approval. POLIC/STRATEG AREA: Risk Management POLIC TITLE: Resilience Planning Policy LEAD OFFICER: Board Secretary Why has this policy/strategy been developed? Has the policy/strategy been developed in accordance with or related to legislation? Please give details of applicable legislation. Has a risk control plan been developed? Who is the owner of the risk? Who has been involved/consulted in the development of the policy/strategy? Has the policy/strategy been assessed for Equality and Diversity in relation to:- Race/Ethnicity Gender Age Religion/Faith Disability Sexual Orientation Please indicate es/no for the following: Does the policy contain evidence of the Equality & Diversity Impact Assessment Process? Is there an implementation plan? Which officers are responsible for implementation? When will the policy/strategy take effect? Who must comply with the policy/strategy? How will they be informed of their responsibilities? Is any training required? If yes, has any been arranged? Are there any cost implications? If yes, please detail costs and note source of funding Who is responsible for auditing the implementation of the policy/strategy? What is the audit interval? Who will receive the audit reports? When will the policy be reviewed and by whom? (please give designation) To outline the approach taken by NHS Tayside to demonstrate its compliance with the Civil Contingencies Act Civil Contingencies Act 2004 Corporate Risk contained within DATIX system owned by Chief Executive and managed by Board Secretary Resilience Planning Advisory Group in the first instance. Has the policy/strategy been assessed For Equality and Diversity not to disadvantage the following groups:- Minority Ethnic Communities (includes Gypsy/Travellers, Refugees & Asylum Seekers) Women and Men Religious & Faith Groups Disabled People Children and oung People Lesbian, Gay, Bisexual & Transgender Community N/A Please indicate es/no for the following: N/A Resilience Planning Department On completion of consultation process. All staff included within scope of the policy By Resilience Planning es es No N/A Resilience Planning Advisory Group Biennial Resilience Planning Advisory Group Biennially by Resilience Planning Officers on behalf of RPAG Page 11 of 12
RAPID IMPACT CHECKLIST 1. Rapid Impact Checklist (RIC) Each policy must include a completed and signed template of assessment Which groups of the population do you think will be affected by this proposal? minority ethnic people (incl. gypsy/travellers, refugees & asylum seekers) women and men people in religious/faith groups disabled people older people, children and young people lesbian, gay, bisexual and transgender people N.B. The word proposal is used below as shorthand for any policy, procedure, strategy or proposal that might be assessed. What impact will the proposal have on lifestyles? For example, will the changes affect: Diet and nutrition? Exercise and physical activity? Substance use: tobacco, alcohol or drugs? Risk taking behaviour? Education and learning, or skills? Will the proposal have any impact on the social environment? Things that might be affected include Social status Employment (paid or unpaid) Social/family support Stress Income Will the proposal have any impact on Discrimination? Equality of opportunity? Relations between groups? Will the proposal have an impact on the physical environment? For example, will there be impacts on: Living conditions? Working conditions? Accidental injuries or public safety? Transmission of infectious disease? Will the proposal affect access to and experience of services? For example, Health care Transport Social services Housing services Education people with mental health problems homeless people people involved in criminal justice system staff None What positive and negative impacts do you think there may be? None Which groups will be affected by these impacts? None No No No No No Page 12 of 12