nhs manchester clinical commissioning group business

NHS Manchester Clinical

Commissioning Group

Business Continuity Plan

(BCP)

Date Approved: 18 March 2019

Positive – Collaborative - Fair


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VERSION CONTROL

Title: NHS Manchester Clinical Commissioning Group (CCG)

Business Continuity Plan (BCP)

Version: 2.0

Author: Andrew Bidolak, Senior Resilience Manager, Greater

Manchester Shared Services

Supersedes:

Previous version (Version 1.0)

Approved by: Manchester Health & Care Commissioning

Governance Committee

Approved date:

18 March 2019

Review date:

Annually

Target audience:

All MHCC Staff [and GP Practices including GP Partners (or

where the practice is a company, each director) and

individuals in a practice directly involved with the business or

decision making of their CCG]

Equality Impact

Assessment Date: 20 November 2017

VERSION HISTORY

Version Date approved Comment

1.0 28 November 2017 Initial version

2.0 18 March 2019 Updated version


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Contents

1 1 Plan Summary .................................................................................................... 4

2 2 Purpose .............................................................................................................. 5

3 3 Introduction ........................................................................................................ 5

3.1 Scope ............................................................................................................ 5

3.2 Assumptions .................................................................................................. 6

3.3 Ownership and review ................................................................................... 6

3.4 Distribution .................................................................................................... 7

3.5 Awareness, training, testing and exercising................................................... 7

4 4 CCG Information ................................................................................................ 8

4.1 CCG summary ............................................................................................... 8

4.2 CCG stakeholders and interested parties ...................................................... 8

4.3 CCG priority activities .................................................................................... 9

4.4 Resources supporting CCG priority activities .............................................. 10

5 5 Incident Response ............................................................................................ 11

5.1 Detection and assessment .......................................................................... 11

5.2 Activation and notification ............................................................................ 11

5.3 Coordination ................................................................................................ 13

5.4 Communications .......................................................................................... 15

5.5 Resources and continuity options/strategies ............................................... 15

5.6 Documentation processes ........................................................................... 17

5.7 Action checklists .......................................................................................... 17

5.8 Incident stand down ..................................................................................... 18

6 6 Incident Recovery ............................................................................................. 19

6.1 Incident recovery group ............................................................................... 19

6.2 Incident recovery group membership .......................................................... 19

7 7 APPENDICES .................................................................................................. 21

7.1 Manchester CCG Contacts Directory .......................................................... 22

7.2 PREMISES: Maps, directions and instructions ............................................ 23

7.3 Incident Detection/Notification Sheet ........................................................... 24

7.4 Incident Impact Assessment Form .............................................................. 26

7.5 Action Checklists ......................................................................................... 27

7.6 Accessing the CCG Generic NHSmail Email Account ................................. 28


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7.7 Meeting Agenda for Incident Management Team ...................................... 311

7.8 Post Incident Review ................................................................................. 322

7.9 Overview of Directorates and Teams ........................................................ 323

8 8 Equality Analysis Establishing Relevance to Equality .................................... 334

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1 Plan Summary

As a member of staff you should… As an organisation we will…

• Become familiar with any role(s) that

are relevant to your involvement with

the arrangements set out in this plan.

• Participate in training and exercising

activities that are intended to support

you to fulfil your role(s) within the

arrangements described in the plan.

• Offer feedback on how arrangements

described within this plan could be

improved, particularly following your

involvement in relevant training,

exercising or actual incidents.

• Ensure that this plan and supporting

processes are clear and help staff

understand what they need to do.

• Identify a team or individual with

responsibility for:

o Keeping this plan under review to

ensure they are in line with the

guidance.

o Providing advice, training and

support for staff on how this plan

should be implemented and

monitored.

o Auditing this plan and its

associated processes and

procedures at least once every

year.

Business Continuity Plan (Version 2.0)

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2 Purpose

This Business Continuity Plan (BCP) aims to identify and document the priorities,

resources, responsibilities and procedures that will help Manchester CCG to formally

manage a disruptive incident while implementing business continuity and recovery

options.

The document is intended to support staff from Manchester CCG in the event of them

having to respond to an incident that disrupts the continued delivery of CCG priority

activities and whose impact could harm the CCG’s operational functioning, financial

position or reputation. As such, it is envisaged the document may be called upon in

high pressure situations when staff are under stress. Therefore, the document is

intentionally concise and only contains information, guidance and tools that are likely

to prove useful during a disruptive incident.

In this plan we refer to staff as NHS Manchester CCG staff who work collaboratively

as Manchester Health and Care Commissioning (MHCC).

3 Introduction

The plan consists of four sections and a number of appendices. This introductory

section outlines the plan’s scope, assumptions, ownership, distribution and the

requirements for BCP awareness raising, training, testing and exercising. A CCG

information section provides a summary of key information about the CCG,

including details of CCG staff and stakeholders as well as the priority activities and

essential resources in the event of disruption. The incident response section

documents important aspects of incident response, such as activation of the plan,

notification, incident response roles and responsibilities, communication procedures

and incident stand down. The incident recovery section outlines the CCG approach

to recovery from disruption.

Supplementary to the main body of the plan are a number of appendices that provide

information applicable to the CCG in the event of a disruptive incident, such as the

CCG Contacts Directory and Action Checklists that support the business continuity

priorities of the CCG.


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3.1 Scope

This plan is intended to offer support and direction in the face of a range of disruptive

challenges that may affect Manchester CCG. It is difficult to anticipate the extent,

duration or impact of disruptions and so the arrangements described within this plan

are not intended to address every eventually as incidents, by their nature, are

different and procedures may have to be modified to take in to account the particular

circumstances of an event.

This plan is primarily focused on providing information and guidelines on how to

maintain or recover priority activities within the operational scope of Manchester

CCG. The plan sets out procedures and considerations relating to a formal

business continuity response by the CCG to a disruptive incident. The plan

does not seek to address approaches to informal troubleshooting for lower level

disruptions.

3.2 Assumptions

This plan assumes the following:

• continued operation of the public telephone service

• continued availability of the internet and email communication despite

localised outages

• the scale of a disruptive incident being manageable within the capability and

capacity of the CCG and its staff

• a copy of this plan being accessible to relevant staff, either electronically or in

its printed form

In the event that any or all of the above assumptions are not met, staff should (a)

take all reasonable precautions to ensure their own safety and the safety of those

they work with/for and/or (b) escalate the situation to an appropriate level within the

CCG or, in the event of an emergency, to the relevant external agency e.g.

emergency responders.


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3.3 Ownership and review

The Chief Accountable Officer of Manchester CCG is the owner of this plan and is

responsible for its accuracy and maintenance. The Chief Accountable Officer is

responsible for ensuring that the continuity requirements of the CCG are sufficiently

resourced and remain adequately robust. The Chief Accountable Officer may

delegate the task of completing this BCP to an appropriate member of the CCG but

responsibility for its content remains with the Chief Accountable Officer.

Plan review: The Chief Accountable Officer of Manchester CCG will ensure that this

BCP is reviewed at least annually and that an appropriate review cycle is

implemented for the checking and update of essential contact details. Contact details

should be reviewed at least quarterly.

Post incident review: In the event of a disruption that negatively impacts upon the

CGG, it is important to identify any learning from the incident response. When

disruptions occur the Chief Accountable Officer will consider whether or not a formal

post incident review should take place. A post incident review will generally take the

form of a meeting chaired by the Chief Accountable Officer, or nominated deputy,

that includes interested parties who will consider:

(1) what went well during the incident;

(2) what, as a result of the incident, needs to be improved; and

(3) the actions required to address any identified gaps, issues or areas for

improvement.

A template for a post incident review is included within Appendix 7.8.

3.4 Distribution

Following approval by the Manchester Health and Care Commissioning Governance

Committee, this BCP should be made available to relevant interested parties. If

necessary, a restricted version that excludes confidential contact numbers and

supplier details can be made available.


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Copies of the Manchester CCG BCP will be held in the following locations:

• On the CCG shared network drive

• Within the ‘Manchester CCG’ folder of the CCG’s NHSmail generic mailbox

• Within ‘hard copy’ BCP folders stored in appropriate staff areas

• On an appropriate staff intranet page (E.R.N.I.E. – Employee Resource

Network and Information Exchange}

The Chief Accountable Officer of Manchester CCG must ensure that appropriate

version control is maintained for copies of this BCP.

3.5 Awareness, training, testing and exercising

The Chief Accountable Officer of Manchester CCG will ensure that relevant staff are

made aware of this plan and its content. The Chief Accountable Officer will also

ensure that appropriate training, testing and exercising is undertaken to validate the

information and arrangements detailed within this BCP. It is for the Chief Accountable

Officer to ensure that all relevant staff participate in training, testing and exercising.

In terms of the frequency of testing and exercising, the following minimum standards

should be adhered to:

Testing: A test of communications cascades using the CCG Contacts Directory

should be undertaken at least every 6 months

Exercising: A table top, scenario-based exercise should be held at least annually

4 CCG Information

4.1 CCG summary

Provided within Table 1 is a summary of key details relating to Manchester CCG. As

well as including key names, numbers and locations, the table also includes an

indication of suppliers or contractors that play an important role in supporting the

running of the CCG (‘CCG Dependencies’).


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Table 1: Summary of CCG details

CCG Name: NHS Manchester Clinical Commissioning Group

Chief Accountable

Officer (CAO): Ian Williamson

CAO Email: [email protected]

Accountable

Emergency Officer

(AEO):

Ian Williamson

AEO Email: [email protected]

Key functions of the

CCG:

Commission high quality and cost effective health

services for the local population

CCG Headcount: 270 (NOTE: excludes staff within Population Health and

Wellbeing)

CCG Teams or Sub-

elements:

CCG Board; CCG Senior Management Team;

DIRECTORATES: Clinical; Commissioning; Finance;

Nursing and Safeguarding; Performance and Quality;

Planning and Operations; Population Health and

Wellbeing – see Appendix 7.9 for Directorates detail

Main CCG Location:

(Full address)

Parkway Business Centre, Princess Road, Manchester,

M14 7HR

CCG Telephone: 0161-219-9497

CCG Email: [email protected]

Other CCG

Locations:

(Full address)

Citywide services located at Parkway Business Centre,

Princess Road, Manchester, M14 7HR

CCG Dependencies:

[nature of dependency]

Manchester Health & Care Commissioning

[partnership with CCG and Manchester City Council];

NHS Property Services [facilities management];

Greater Manchester Shared Services (GMSS)

[support services provider];

mailto:[email protected]




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4.2 CCG stakeholders and interested parties

Included within Table 2 are the main CCG stakeholders. Although the list is not

exhaustive it does describe the CCG’s main stakeholders and interested parties and

outlines the nature of the CCG’s relationship with them.

Table 2: Summary of CCG Stakeholders (add/delete rows as required)

Stakeholder: Member GP Practices • Provider of primary care

healthcare services

Stakeholder: Greater Manchester

Health and Social Care

Partnership

• Commissioner


Shared Services

• Provider of key commissioning

support functions such as IT,

communications

Stakeholder: NHS Property Services • Facilities management provider

Stakeholder: Manchester City Council • Co-commissioner of

healthcare services

Stakeholder: Northern Care Alliance

(North Manchester

General)

• Provider of secondary

healthcare services

Stakeholder: Manchester

University

Foundation Trust

• Provider of secondary

healthcare services


Mental Health

• Provider of mental health

services

Stakeholder: GTD Healthcare • Out of hours primary care

provider

Stakeholder: Manchester Local

Care Organisation

• Provider of community

healthcare services

Stakeholder: GP Federations • Links with Manchester GP

practices


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4.3 CCG priority activities

Taking in to account analysis of the impacts of disruption to the CCG, the Chief

Accountable Officer of Manchester CCG has determined priority activities in the

event of a business continuity disruption and these are listed in Table 3. It is

recognised that these priorities are subject to review depending upon the extent and

duration of an impact.

Table 3: CCG priority activities

Most

Urgent:

• Handle patient complaints

• Respond to Freedom of Information (FoI) and MP enquiries

• Maintain sound financial management

• Undertake performance management of commissioned

healthcare providers

• Undertake incident investigations

• Support requirements for safeguarding

• Monitor the safety of healthcare services

• Fulfil requirements as a Category 2 Responder

under the Civil Contingencies Act

Less

Urgent:

• Commission healthcare services

• Provide pharmacy support to member practices

• Lead on commissioning contract management, mainly mental

health

• Redesign healthcare pathways

• Collaborate with other CCGs and relevant statutory and

voluntary sector bodies to integrate healthcare services

• Promote the NHS Constitution

• Promote the involvement of patients in decision making

• Seek continuous improvement in the quality of services

• Maintain appropriate governance arrangements

Not Urgent: • Promote healthcare research


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4.4 Resources supporting CCG priority activities

Resource requirements of the CCG’s priority activities are documented in Table 4.

The list captures the resources that are used as part of routine operations for these

activities. Additional or replacement resources may be required in order to resume or

restore CCG priority activities following a disruption.

Table 4: Resources supporting CCG priority activities (add/delete rows as required)

Information, data, records,

documents:

• Commissioned healthcare provider contracts

• Safeguarding information

• Financial information, ledgers and records

• Freedom of Information requests

• Patient complaints

• On-call rota

IT software, databases, systems: • Access to NHSmail

• Microsoft Office applications

• Internet browser

• Access to DATIX database

Network drives & folders: • Access to folders on network drive

Telecommunications:

• Landline telephones

• Mobile telephones

• Wireless internet devices (iPads)

• Network enabled laptops

Specialist equipment: • n/a

Furniture, office equipment &

storage:

• Desks and chairs

• Monitors, keyboards, mice

• Printer

• Secure filing cabinets and drawers

Supplies & stationery: • Paper

• Replacement printer toner and drums

Qualified or expert practitioners,

specific technical

skills:

• Healthcare commissioning expertise

• Medicines management expertise

• Finance and accounting expertise

Other CCG specific resources: • n/a


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5 Incident Response

5.1 Detection and assessment

Upon detection or notification of a disruptive incident, a member of the CCG should

gather as much information as possible about the event or circumstances. An

Incident Detection/Notification Sheet is provided in Appendix 7.3 to help with

collation of initial reports or information about the situation giving cause for concern.

It should be recognised that some disruptions are limited in their nature and extent.

For instance, a short term loss of power, a time-limited cordon affecting CCG

premises or a problem affecting a small number of computers are examples of

events that may possibly be responded to and managed by individual staff members

working flexibly within business as usual capabilities or by accessing routine support

(e.g. calling the IT helpdesk). However, if a CCG staff member detects or is notified

of a situation that challenges, or may challenge, the functioning of the CCG’s priority

activities, they should escalate the matter to a relevant CCG colleague or manager.

As soon as is practicable after detection or notification of a disruptive incident, the

Chief Accountable Officer, or his/her nominated deputy, should be advised of the

situation and should assess the actual or the potential impacts upon the CCG and

the functioning of its priority activities.

When making an assessment of a disruptive incident, the Chief Accountable Officer,

or his/her nominated deputy, should seek to establish:

• the nature or cause of the incident (e.g. building fire, prolonged severe

weather, flu pandemic)

• the actual or potential disruption (e.g. denial of site access, loss of

information, significant staff shortages)

• the known or potential impacts (e.g. staff safety threatened, breach of duties

likely, priority activities at risk, stakeholder expectations not met)

• the extent and duration of the identified impacts, if known (e.g. CCG- wide

impacts, impacts on specific priority activities; disruption likely to last for days,

weeks, months)


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By gathering and evaluating this information, the relevant senior CCG staff member

should be better placed to decide if activation of a formal CCG business continuity

response is required.

An Incident Impact Assessment Form is provided within Appendix 7.4 to assist

the CCG with documenting the nature of the disruption and its associated

consequences.

5.2 Activation and notification

Activation of a formal BC response is likely to be the result of a judgment call on the

part of the senior CCG staff member(s) who discovers or receives information about

a disruptive incident. It is important, therefore, that as much information as possible is

gathered about the nature of the event. It is usually better to stand up an incident

response rather than let a situation develop beyond the capacity of the CCG to

manage the situation. A process for activation is set out in Figure 1. The Chief

Accountable Officer or, in his/her absence, their appointed deputy has the authority

to activate a formal CCG business continuity response. In the first instance, a formal

response is likely to involve convening an Incident Management Team to consider

immediate steps required to address the circumstances of the disruptive incident.

Circumstances that may prompt the CCG to consider activating a formal business

continuity response could arise from situations such as:

a) significant impact upon CCG priority activities (see section 4.3)

b) loss of critical CCG resources (see section 4.4)

c) complete denial of access to CCG premises


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Figure 1: Activation of a formal CCG business continuity response

In the event of a disruptive incident requiring activation of a formal business

continuity response, Table 5 provides a suggested list of people who may need to be

notified by the CCG. The nature, extent and duration of any impacts should be

considered before communicating with interested parties. Contact details are

provided in Appendix 7.1.

As a minimum, notification of a business continuity incident should include known

information covering the following:

• Date/time of the incident

• Incident summary

• Staff/teams affected

• Location(s) affected

• Initial indication of what to do/ not to do

Impact of disruption upon CCG assessed

CCG staff discover or receive

notification of disruptive incident

Activate formal CCG

BC response

Monitor situation

Significant impact on CCG priority

activities

Limited or no impact on CCG priority activities


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Table 5: Notification (see Appendix 01 for contact details)

Stakeholder/Organisation Potential messages

CCG staff

• Incident taking place

• Impact on CCG

• Action required/being taken

• What to do/where to go

CCG Member Practices


• Impact on CCG

Greater Manchester Health

and Social Care Partnership

(GMHSCP)


• Impact on CCG

• Request for escalation or support

Greater Manchester

Shared Services (GMSS)


• Request for support

Landlord, estates and facilities • Incident taking place

• Request for support

5.3 Coordination

In order to better coordinate the response to a disruptive incident that extends

beyond the scope of an individual, or individuals, to manage the resulting impacts,

the CCG Chief Accountable Officer or, in his/her absence, their appointed deputy will

establish a business continuity Incident Management Team comprising appropriate

members of the CCG and, if necessary, relevant participants from partner or

stakeholder organisations.

By default, the Chief Accountable Officer of Manchester CCG or, in his/her absence,

their appointed deputy will lead the CCG Incident Management Team.

Table 6 provides an indication of the possible roles and responsibilities in the event

of a CCG Incident Management Team being established.


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Table 6: Incident Management Team (IMT) – Roles and responsibilities

Role

(role fulfilled by) Responsibilities

IMT Lead(s)

(CCG CAO or deputy)

• Activate an appropriate CCG Incident

Management Team

• Brief CCG Incident Management Team

members and participants

• Decide appropriate response actions and

direct the CCG Incident Management Team

• Ensure key information about incident response is

recorded

• Decide whether to stand down formal incident

response


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Table 6: Incident Management Team (IMT) – Roles and responsibilities

Role

(role fulfilled by) Responsibilities

IMT Admin Support

(CCG admin staff)

• Assist with mobilising a CCG Incident

Management Team

• Support Incident Management Team meetings

• Assist with maintaining incident logs or documents

• Support the CCG Incident Management

Team Lead as directed

IMT Member

(relevant CCG

manager/staff)

• Support the CCG Incident Management Team

Lead as directed

• Liaise with partners and stakeholders as required

• Update the CCG Incident Management Team as

requested

IMT Participant

(partner/stakeholder rep.)

• Provide, as appropriate, assistance to the

CCG Incident Management Team

• Update the CCG Incident Management Team as

requested

As described in Table 6, it is the responsibility of the Incident Management Team

Lead (or leads if the incident extends over a prolonged period) to ensure the team is

appropriately activated, briefed and staffed. The Incident Management Team Lead

must also decide the requirements (e.g. frequency, format, focus, location) for any

team meetings or reporting procedures and whether to escalate or de-escalate the

formal incident response.

It should be noted that the membership of an Incident Management Team will usually

be determined by the nature of the disruptive incident affecting the CCG. Therefore,

in order to support effective coordination the Incident Management Team Lead

should be mindful of the specific impacts and interested parties associated with the

circumstances causing disruption.

The primary location from which Manchester CCG will coordinate its formal business


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continuity response is:

Primary location for coordinating a CCG business continuity incident

Room M2.2

Parkway 3

Parkway Business Centre

Manchester

M14 7HR

Tel: 0161-765-4017

In the event of the primary location being unavailable, the Incident Management

Team Lead will identify an appropriate alternative space for incident coordination. If a

physical location is not required, the Incident Management Team Lead may consider

a remote coordination arrangement, such as by teleconference (see Table 7), so that

key decisions may be made promptly.

Coordination will typically be supported by holding structured Incident Management

Team meetings or discussions. A template Incident Management Team Meeting

Agenda is provided in Appendix 7.7.

5.4 Communications

In the event of a disruptive incident, the communications channels described in Table

8 are available to Manchester CCG.


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Table 8: CCG communications channels

Channel Details Limitations

Teleconference:

Dial-in number: 0800-032-8069

Dial-in Passcodes:

• Chairperson: 97617746 then #

• Participant: 28549517 then #

Require communication of

dial- in details

Individual email:

Emails to personal email accounts

Requires access internet

access and relevant

contact details

Generic Mailbox: cmccg.manchester-ccgs-

[email protected]

Requires access to NHSmail

and familiarity with login;

Staff text

message

cascade:

Cascade by personal mobiles or

cascade via ‘text by email’ option in

NHSmail

Requires sharing of

confidential personal mobile

numbers;

requires setup of

distribution lists

CCG message cascade Via CCG email distribution list,

website or other corporate

communications

mechanism

Requires availability of

corporate communications

mechanisms

5.5 Resources and continuity options/strategies

In the event of a disruptive incident, the following continuity options/strategies are

available to Manchester CCG.

PEOPLE

Remote working

In some circumstances an appropriate continuity strategy may be for members of

Manchester CCG to work remotely, either from home or from other premises.




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Staffing options

In the event that Manchester CCG faces a significant negative impact upon its

staffing levels, the Incident Management Team Lead may consider one or more of

the following staffing options for continuity of priority activities:

1. suspension of specific CCG activities in order to maintain priority activities

2. redeployment of CCG staff, as appropriate, to more urgent activities

3. seek staffing assistance from partner organisations, e.g. neighbouring CCG(s)

4. use of agency staff

Staff Welfare

Manchester CCG takes the welfare and wellbeing of its staff seriously. The

organisation has a duty of care to its employees and will seek to support staff

affected by a disruptive incident in a proportionate and appropriate manner. Staff

should be aware of the following options for support:

Capita Employee Assistance Programme (EAP): Capita’s experienced and

qualified telephone counsellors provide around the clock support to help with a range

of personal and work related problems in areas such as stress, relationship

difficulties, bereavement, anxiety, family worries, alcohol/drug abuse, employment, or

financial concerns.

You can access the EAP at any time, day or night, either by:

• Calling 0800-716-017

• Visiting the EAP website (http://www.firstassistonline.com/login.aspx)

and then typing in the following: 72990 in the Access Code field and

72990 in the Password field

PREMISES

Premises options

In the event that Manchester CCG faces a significant negative impact upon its main

premises, the Incident Management Team Lead may consider one or more of the

http://www.firstassistonline.com/login.aspx


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following options for continuity of priority activities:

1. remote working by CCG staff

2. seek premises assistance from partner organisations, e.g. neighbouring

CCG(s)

3. rental of temporary accommodation

Alternative premises

In the event of Manchester CCG needing to temporarily relocate staff to alternative

accommodation or premises, the location(s) listed below have been identified as

having potential to accommodate some or all CCG requirements.

Alternative Location A

Address: Manchester Town Hall Extension

Contact

Name:

To be confirmed

Contact

Number:

See Appendix 7.1

Notes: Arrangements under review at time plan issued


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RESOURCES

Resource options

In the event that Manchester CCG faces a significant negative impact upon its key

resources, the Incident Management Team Lead may consider one or more of the

following resource options for continuity of priority activities:

1. utilise any backup or standby resources

2. reallocation of CCG resources, as appropriate, to more urgent activities

3. seek resource assistance from partner organisations, e.g. neighbouring

CCG(s)

4. rental or purchase of replacement resources

5.6 Documentation processes

In the event that Manchester CCG activates a formal business continuity response to

a disruptive incident, the Incident Management Team Lead will ensure that key

information is recorded about the incident, the actions taken and the decisions made.

Although the CCG needs to respond flexibly to the requirements for documenting

details during the incident response, the following processes should help the CCG to

ensure that key information is recorded:

• Keeping minutes or notes of Incident Management Team meetings

• Maintaining an Actions Tracker for Incident Management Team meetings

• Maintaining a Key Decisions Log for the incident response

• Maintaining an incident documents file

• Maintaining Personal Logs as appropriate

Templates for the above processes can be found

• On the CCG shared network drive

• Within the ‘Manchester CCG’ folder of the NHSmail generic mailbox

• Within BCP folders stored in staff areas at Parkway

• On the appropriate staff intranet page


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5.7 Action checklists

Based upon the CCG priorities indicated in section 2.4 (CCG priority activities), the

procedures listed in Table 9 have been identified as those that will support continuity

of CCG priority activities. Action Checklists that give specific instructions for these

procedures are contained within Appendix 7.5.

Table 9: List of procedures with an Action Checklist

Checklist CCG Procedure (add/delete rows as required)

A Reporting IT/computer network issues

B Accessing the CCG generic NHSmail email account

C Holding a teleconference


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5.8 Incident stand down

The Chief Accountable Officer or, in his/her absence, an appointed deputy will be

responsible for standing down the CCG’s formal incident response. As a minimum,

stand down should include communicating to interested parties, via an appropriate

channel, the following messages:

• the end or resolution of the disruption

• an outline of the impacts experienced

• an outline of any follow up actions or ongoing issues

• an expression of gratitude for any support, understanding and/or patience

demonstrated during the period of disruption

Following a significant disruption, consideration should be given at incident stand

down to the need for a post incident review. Whether or not a formal post incident

review (a ‘cold debrief’) is undertaken, the Incident Management Team Lead(s)

should seek to assess soon after incident stand down (‘hot debrief’) any learning

points from the disruption. The Incident Management Team lead(s) should collate

observations and comments relating to the incident and, if necessary, take

appropriate follow up action.

A template for a post incident review is included within Appendix 7.8.

When undertaking a debrief the following considerations should be kept in mind:

• the debrief(s) should be conducted in an open and honest manner;

• the purpose of the debrief(s) will be to assess aspects of the incident response

with a view to capturing examples of good practice and requirements for

improvement;

• expectations relating to follow up actions should be clearly defined and

documented with an appropriate date set for review of progress.


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6 Incident Recovery

6.1 Incident recovery group

The core responsibilities of a CCG incident recovery group are not dissimilar to those

of the CCG Incident Management Team. However, whereas the CCG Incident

Management Team is focused on handling the immediate incident impacts and ‘quick

time’ actions needed to address an unfolding situation affecting all or most of the

CCG, the CCG incident recovery group takes as its focus the longer term

consequences and the ‘slow time’ requirements for resumption and restoration of

acceptable levels of CCG activity following a major impact.

The Manchester CCG incident recovery group will take responsibility for the

following:

• Staff welfare

• Mobilising CCG staff

• Activating CCG plans

• Devising strategic objectives for the recovery from the incident impacts

• Monitoring the overall recovery

• Resolving conflicts in the recovery process

• Invoking resources

• Communicating to interested parties

• Approving external CCG statements to interested parties and the media and

monitoring and adjusting as necessary any communications strategy

• Staff welfare

• Communicating decisions within the CCG

• Approving significant expenditure and delegation limits

• Ensuring the financial health of the CCG

• Changing priorities as the situation evolves

6.2 Incident recovery group membership

The extent and duration of the impacts of a disruption will influence the membership

of the CCG’s incident recovery group. Nonetheless, the group’s core membership


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should take into account the identified roles and functions/interests described in

Table 10.

Table 10: Incident recovery group roles and representation

Role

(role fulfilled by)

Function/Interest/Areas Represented

IRG Lead

(CCG CAO or deputy)

• CCG Executive Management Team

IRG Admin Support

(CCG admin staff)

• Administrative support

Table 10: Incident recovery group roles and representation

Role

(role fulfilled by)

Function/Interest/Areas Represented

IRG Member

(relevant CCG managers)

• Finance

• Corporate Services

IRG Participant

(partner or

stakeholder rep.)

• People and welfare

• Communications

• Technical support

• Estates and facilities

• Staff side representation

• Legal representation

The above list is not prescriptive and it is for the group lead or senior CCG manager

to determine an appropriate membership of a CCG incident recovery group.

As the CCG incident recovery group is concerned with the high level, strategic

recovery priorities, it is important that nominated members of the group have

sufficient authority to commit resources and to make decisions on behalf of the

functions they represent.


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7 APPENDICES


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7.1 Manchester CCG Contacts Directory

Refer to the current contacts directory (appendix A) of the Manchester Health

Economy Incident Response Plan which can be found on under the policies

section of the MHCC website.

7.2 PREMISES: Maps, directions and instructions

This appendix includes maps and/or instructions relevant to the CCG’s business

continuity and directions to any alternative locations.

Maps showing: Parkway Business Centre, Princess Road, Manchester, M14 7HR

https://www.mhcc.nhs.uk/


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7.3 Incident Detection/Notification Sheet

This sheet is intended to act as an aide memoire should staff from the CCG discover

or receive notification of a disruptive incident.

Incident detection/notification sheet

Date completed

(dd-mmm-yyyy)

Time completed

(hh:mm)

Sheet completed

by (Name, Title)

Detection by /

notification from

(Name, org, title,

contact details)

Nature of incident

in a few words

(e.g. CCG office

fire)

Further information about the incident (e.g. staff or activities affected, resources lost,

warnings received):

Action taken, if any, prior to discovery or notification (by whom, when):


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Incident detection/notification sheet

Action required following discovery or notification (by whom, when):

Comments/additional information:


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7.4 Incident Impact Assessment Form

This form can be used to assess the impacts of a disruptive incident. It may form a

stand-alone assessment, or may be used during incidents that cause wider disruptive

impacts upon Manchester CCG. The criteria should not be seen as restrictive or

exhaustive.

BEST incident outcome

Impact

expectations:

WORST incident outcome

Low Med. High

STAFF/PERSONNEL

Illness or injuries minor or non-

existent

Serious illness or injuries and/or

fatalities

No impact on staff morale Severe impact on staff morale

FINANCIAL LOSS

Key assets unaffected One or more key assets out-of-action

or destroyed

No contract penalties Substantial contract penalties

No additional operating costs Substantial uninsured additional

operating costs

No loss of income Substantial loss of Income

FAILURE OF PRIORITY ACTIVITIES

Single event Multiple events

No prioritised activities affected One or more prioritised activities

affected

Site/building access not affected Access to site/building denied for a

week or more

Impact will be for a short time

only

Impact will be for weeks

Staff and management continuing

normal duties

Staff and management attention

diverted for an extended period

All site business functions are

working/continuing

Full off-site re-location necessary

No impact on low priority Severe impact on low priority


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business operations business operations

REPUTATIONAL DAMAGE

No impact on reputation Severe impact on reputation

No impact on local community Severe impact on local community

No media interest in the

event/impact

Media interest certain

No single interest group

involvement

Single interest group involvement

certain

No pollution/environmental

impact

Severe impact on environment

REGULATORY/LEGAL NON-COMPLIANCE

No Health &Safety impact Significant Health & Safety impact

No legal or regulatory

implications

Inevitable legal and regulatory

implications

No external agencies involved External agencies must be notified

CURRENT IMPACT

Incident impact: 1:

Low

2: Moderate

3: Significant 4: Major

Current

assessment

undertaken:

Date: Next

review

:

Date:

Time: Time:

Assessor (name,

title):

Service/team:

This form is OFFICIAL - SENSITIVE COMMERCIAL when in use


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7.5 Action Checklists

This appendix includes instructions, procedures and guidelines to support the

business continuity priorities identified in the Manchester CCG Business Continuity

Plan.

Based upon analysis of the CCG’s activities, essential requirements and business

continuity priorities, Actions Checklists have been developed for the following

procedures:

List of CCG Procedures with an Action Checklist

Checklist CCG Procedure (add/delete rows as required)

A Reporting IT/computer network issues

B Accessing the CCG generic NHSmail email account


D <space for additional procedure>

A Reporting IT /computer network issues

To call IT Service Desk (open 8am-6pm Monday to Friday) dial 0161-765-6688

Before calling the Service Desk gather the following information: location of the

equipment; availability of the equipment; urgency of the fault; impact on other users

To report a fault or make a request to the IT Self-Service Portal (24/7 from any

internet enabled device, including smartphones) login to https://nwcsu.service-

now.com/csu/main

When using the IT Self-Service Portal, you will need your Username (usually your

NHS.net

email address) and your Password

B Accessing the CCG Generic NHSmail email account

Using your own NHSmail Username and Password, login to the web version of NHSmail

via

www.nhs.net (Internet Explorer officers optimal ease of access)

http://www.nhs.net/


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Step by step instructions for accessing the mailbox are provided in Appendix 7.6


Agree the date and time of the teleconference

Notify participants of the relevant date and time as well as the dial in details

Dial in details: 1. Dial 0800-032-8069 2. Enter Passcodes as appropriate:

o Chairperson: 97617746 then # or Participant: 28549517 then #

D <space for additional procedure>

<insert actions or steps>




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7.6 Accessing the CCG Generic NHSmail Email Account

An NHSmail generic mailbox has been set up for shared use during an incident. Staff

with an NHSmail account and who have been given the appropriate permissions can

access this mailbox. As NHSmail is web-based, it offers the benefit of being

accessible over any internet connection to those who have an NHSmail account and

it can be viewed by multiple users.

The CCG’s generic mailbox address is:[email protected]

How to access the CCG NHSmail Generic Mailbox through Outlook Web

1 Log in to your NHSmail account via the Outlook Web App at www.nhs.net

2 In the top right corner beside your name, click on the symbol to bring up

a box similar to the example below that offers an option to Open another

mailbox…

3 Click on Open another mailbox… to bring up a box similar to the one below

4 Enter cmccg.manchester-ccgs-eprr in the text field and click Search

contacts and directory to bring up a box similar to the one below


http://www.nhs.net/


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5 Click Open and the mailbox should open in a separate window

How to add the Generic Mailbox to Outlook

1 Go into File > Account Settings. Choose Account Settings…

2 The Account Settings window should appear. Select the Change… button


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3 Click on More Settings…

4 Click the Advanced tab then choose Add…

5 Enter the name of the mailbox i.e. [email protected] and

click OK



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6

Once the mailbox is listed in the additional mailboxes section on the

Advanced tab, click on OK. Click on Next. Click on Finish. The mailbox will

now be listed on the left- hand side in Outlook


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7.7 Meeting Agenda for Incident Management Team Incident

Management Team Meeting Details

Agenda

1. Introductions

2. Current situation report

3. Impact of the incident upon the CCG

4. Communications

a. Internal CCG communications

b. External communications (providers, suppliers, contractors)

c. Public information and media implications

5. Resource implications and expenditure (e.g. staffing, equipment, supplies)

6. Horizon scanning (i.e. ongoing issues, risks posed, potential further impacts)

7. Agreed decisions and actions

8. Next discussion /meeting

CCG: Manchester CCG Chair: add name

Date: dd-mmm-yyyy Start: hh:mm Format: Teleconference / Meeting / Combined

Access:

meeting venue, including postcode Teleconference Dial-in number: 0800-032-8069

• Participant Passcode: 28549517 then #

Incident: add brief description of incident


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7.8 Post Incident Review

Embedded below is a report template for a post incident review. Responding to

incidents provides an invaluable opportunity to identify learning and areas for

improvement in relation to the CCG’s business continuity arrangements.

The focus of the post incident review should be:

1. what went well during the incident;

2. what, as a result of the incident, needs to be improved; and

3. the actions required to address any identified gaps, issues or areas for

improvement.

Please read the Manchester CCG Incident Debrief Summary.

7.9 Overview of Directorates and Teams

DIRECTORATE TEAMS

Clinical

• Clinical Leads

• Medicines Optimisation

• Primary Care

Strategic

Commissioning

• Adult Social Care

• Community Health

• Continuing Healthcare

• Integrated Commissioning, Single Hospital Service

• Market Development & Management

NHS%20Manchester%20CCG%20Incident%20Debrief%20Summary


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Finance

• Adult Social Care, Quality Performance & Compliance

Team

• Business Intelligence

• Finance & Contracting

• Finance Projects

• Improvements

• Operational Finance

• Strategic Planning & Integration

Nursing &

Safeguarding

• Children & Young People Commissioning

• Mental Health Commissioning

• Specialised Commissioning

Performance, Quality &

Improvement

Planning & Operations

• Business Support Team

• Corporate Affairs

• LCO Procurement

• Information Management & Technology

• Planning & Policy

• Workforce & Organisational Development


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8 Equality Analysis Establishing Relevance to Equality

1. Name of the

proposal being

analysed

NHS

Manchester

CCG BCP

2. Officer/s

responsible

for the

analysis

Andrew

Bidolak

3. Senior

responsible

officer/s

Nick

Gomm

4. Date

analysis

started

20-11-2017

5. Date

analysis

completed

22-12-2017

6. Date of

approval

28-11-

2017

Please state if the proposal being analysed is:

(please tick which one is applicable)

1. Strategy 2. Policy 3. New service

4 Service

redesign

5 Service

review

6. Decommissioned

services

Please state organisation this proposal relates to:

(please tick which ones are applicable)

MHCC MCCG

MCC Other please state:

The purpose of the Analysis

The purpose of this relevance assessment is to analyse the information gathered on

(proposed or existing function name here) to test it for potential relevance to equality.

A relevance ranking of high medium or low will be applied.

1. About the Service

Please use this section to provide a concise overview of your service, its key delivery

objectives and its desired outcomes.

This business continuity plan relates the operations and key activities of Manchester CCG as

commissioning body.

2. General Questions

Please complete the questions below in support of the relevance test assessment

Que

stio

Answer


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n

Does the service affect service users,

employees or the wider community &

potentially have a significant effect in

terms of

equality?

No

Is it a major Service change

that will significantly affect how

functions are

delivered in terms of equality?

No

Will it have a significant effect on how

other

organisations operate in terms of

equality?

No

Does the Service relate to functions

that previous engagement has

identified as being

important to particular protected groups?

No

Does or could the policy affect different No

protected groups differently?

Does it relate to an area with known

inequalities e.g. access to public

transport for disabled people.

No

Does it relate to an area where

equality objectives have been set

by your

organisation?

No

Please provide any evidence of

engagement that you have considered

to assess the service for its relevance

to equality include any data, research,

engagement etc.:


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3. Relevance Assessment Findings

If your assessment has identified a relevance to equality you will be required to

undertake an Equality Analysis, please complete the following table:

The analysis has demonstrated relevance to equality with regard to:

Protected Groups – Please tick

relevant groups

Aims of the Equality Duty – Please tick

relevant aim

• Age

• Disability

• Race

• Gender

• Gender reassignment

• Marriage and Civil Partnership

• Pregnancy and Maternity

• Sexual Orientation

• Relief or Belief

Eliminate unlawful discrimination, harassment

and victimisation (i.e. the function removes or

minimises disadvantages suffered by people due

to their protected group)

Advance equality of opportunity between those

who share a protected group and those who do

not (the service takes steps to meet the needs

of people from protected groups where these

are different from the need of other people)

Foster good relations between people who share

a protected groups and those who do not (i.e. the

service encourages people from protected

groups to participate in public life or in other

activities where their participation is

disproportionately low)

If the assessment has identified NO relevance to equality please detail below your

rationale and how the information you have used supports this conclusion.

4. Conclusions

Relevance Ranking – Please identify in this section the degree to which the function

has been assessed as relevant to equality. (Please mark the applicable box):

No Ranking description X

1

High – The function shows a high degree of relevance to one or more

protected groups and/or one or more aim of the general equality duty


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2

Moderate – The function shows a moderate degree of relevance to one

or more protected groups and/or one or

main aim of the general equality duty

x

3 None – The function is not relevant to any protected group and/or any of

the aims of the general equality duty

5. Outcome – Please identify here whether your analysis demonstrates the need for

the completion of an Equality Analysis (please mark the applicable box):

No Outcome Description

1 The relevance assessment has identified a high or medium

relevance ranking and a Equality Analysis is required

2

The relevance assessment has identified a low relevance ranking and in

consideration of the evidence above a Equality Analysis process is not

required

x

Sign off and Approval Process Line

Management sign off

Name: Line

Manager

Signature:

Date: Service:

Director Level sign off

Name: Director

Signature:

Date: Directorate:

Once completed please send to [email protected]

Thank you.


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