paper: to be added by each ccg

Paper: # to be added by each CCG

Date Wednesday, 08 March 2017

Presenter Jonathan Webster, Director of Quality and Patient Safety

Author Mark Haggerty, NWL Business Continuity Manager / Simon Carney, CWHHE Head of Corporate Governance

Responsible Director

Jonathan Webster, Director of Quality and Patient Safety

Clinical Lead CCG Chair

Confidential Yes ☐ No Items are only confidential if it is in the public interest for them to be so

The Governing Body is asked to:

a) approve the CCG’s local combined Business Continuity Plan and Business Impact Assessment (Annex A);

b) note the latest version of the NW London CCGs Emergency Preparedness and Business Continuity policy, NWL Business Continuity Procedures (Annexes B and C);

c) agree to delegate to the CWHHE SMT approval of minor changes to the full suite of EPRR and Business Continuity Plans and procedures, noting that all such approvals will be flagged in the mandatory EPRR Annual Report to Governing Bodies; and

d) note that the specific EPPR plans are listed below under ‘Supporting Documents’ and are available on request.

Summary of purpose and scope of report

1. CCGs are required by both statute and regulation to plan for and respond to a) a wide range of incidents and emergencies that could affect health or patient care (Emergency Preparedness Resilience and Response (EPRR) and b) incidents that affect CCGs’ own capacity operate (Business Continuity). Both are related but separate requirements that do, necessarily, overlap at times.

2. EPRR relates to major issues / events - anything from extreme weather conditions to an outbreak of an infectious disease or a major transport accident – and establishes the CCGs’ priorities and role in relation to them. As ‘Category 2 responders’, the main duty is for CCGs to co-operate and share information with the ‘Category 1 responders’ (in short, emergency services and providers for these purposes).

3. There is, by agreement of NHS England, a NW London-wide EPRR Policy and Plan (Annex B) and an EPRR Report is presented to Governing Bodies, for approval, annually, is the subject of a comprehensive NHS England assurance review and elements of it are

Title of paper Business Continuity Plans


tested (again, annually) via desktop exercises.

4. The focus of Business Continuity Policy and Plans is on how the CCG responds to significant events / situations that affect its own business continuity specifically – for example the loss of IT systems or CCG premises. These plans focus on who should do what and when to ensure that the business is continued / restored in the correct order of business priority. Attached, at Annex A, is the local CCG BCP, as put together by the Governance Lead with the NWL Business Continuity Lead, for approval.

5. The Business Continuity plans and their supporting documentation are detailed and necessarily so. Whilst it is essential that the Governing Body is assured that robust and detailed plans are in place and under regular review, the detailed consideration of them does not necessarily represent the best use of its time. It is recommended, therefore, the Governing Body agrees that such plans, policies and procedures’ upkeep and maintenance is undertaken by management. In return, management will provide assurances / flag material changes / issues to the Governing Body as and when appropriate and, in any case, via the annual EPRR report to GBs.

Quality & Safety / Patient Engagement / Impact on patient services:

This paper and its attachments are intended to minimise the impact of significant unforeseen events on such.

Finance, resources and QIPP

No additional resources are required and, as above, the plans (etc) are intended to prioritise the deployment of the CCG’s resources when dealing with emergency and / or business continuity issues.

Equality / Human Rights / Privacy impact analysis

N/A

Risk Mitigating actions

The CCG cannot co-ordinate itself coherently and efficiently in response to emergencies or significant disruption, leading to impact on patient services and / or unnecessary and avoidable expense and confusion.

Having an up-to-date and well-understood set of policies and plans in place.

Supporting documents Annex A – CCG’s Local Business Impact Assessment and Continuity Plan;

Annex B – NWL CCGs’ Emergency Preparedness Resilience and Response and


Business Continuity Policy; and

Annex C NWL CCGs’ Business Continuity Procedures.

(Available on Request, NWL response plans to: ‘Flu Pandemic, Heatwave, Cold Weather, Bomb Threat, Fuel Shortage, Infectious Disease Outbreak and Recovery).

Governance and reporting (list committees, groups, other bodies in your CCG or other CCGs that have discussed the paper) Committee name Date discussed Outcome

Central London CCG Business Impact AssessmentSection One:CCG/Department Detail Ref: H&F CCG: CLCCG

Version COO / HoD Date Written

Department /Borough Continuity Lead Review Date

Main Operational Buildings

Address Postcode NWL CCGs Owned

Assessment of Impact

Level Descriptor Description

1

2 Moderate

3

4

5

Minimal business interruption - Minimal loss of reputation - Failure to meet (local) departmental standards - Minimal financial loss (£1k to £9k) - Injury requiring first-aid treatment or minor illness

(<3days Lost) - Minimal environmental damage

None

None

None

None

None

None

None

Minor

Serious

Moderate business interruption - Moderate loss of reputation - Failure to meet organisational standards - Moderate financial loss (£10k to £49k) - Break of minor bone or temporary minor illness (3- 7

days Lost) - Moderate environmental damage

Major business interruption - Major loss of reputation - Failure to meet national performance standards - Major financial loss (£50k to £249k) - Major bone fracture or temporary serious illness (8- 21

days Lost) - Major short term environmental damage

None

Unregistered

Back up 2

No

None

None

None

None

None

None

None

Backup 1

One (1)

Central London CCG

Jules Martin

Jules Martin

None

None

16/01/2017

16/01/2018

Notes/Other

Multi-occupancy Office Building Main

TypeFlood Alerts

NW1 5JD3rd Floor 15 Marylebone Road, London

Extreme and sustained business interruption - Major and sustained loss of reputation - Intermittent failure to meet national professional standards and/or statutory requirements - Extreme financial loss

(£250k to £499k) - Single Death/ Permanent serious illness/ disability - Major medium-term environmental implications

Catastrophic business interruption - Catastrophic and permanent loss of reputation - Sustained failure to meet national professional standards and/or statutory requirements - Catastrophic financial

loss (£500k +) - Multiple Deaths of any persons/ Multiple permanent serious illness/ disability - Catastrophic and long-term environmental implications

Major

Catastrophic

1

Central London CCG Business Impact AssessmentFunctions Provided by Teams within Department or Borough

Function/Team Name Manager Day Night 4hrs 8hrs 24hrs 48hrs

2 2 2 3 3

6 2 2 3 3

6 1 2 3 3

Finance Elke Taylor 11 1 2 2 2

Primary Care Holly Mankletow 10 1 1 1 1

Mental Health Robert Holman 2 1 1 1 1

Contracts Team Leroy Cordle 4 1 2 2 3

Turnaround Will Reynolds 3 1 1 1 2

Corporate Jules Martin 6 1 1 1 1

6 1 1 1 2

2 1 1 1 2

5 1 1 1 2

3 1 1 1 2

3 1 1 1 2

2 1 1 1 2

48 hours+Jonathan Webster

Judy Durrant MEDIUM

Postcode (if applicable)

MEDIUM 48 hours+

LOW 48 hours+

48 hours+ CATEGORY B48 hours+ NW1 5JD

Engagement and Corporate Affairs

Priority

Recovery

RTO MTPD

CATEGORY B NW1 5JD

Integrated Care

Homelessness

BI

Emma Playford

Steve Buckerfield MEDIUM 48 hours+ CATEGORY B

NW1 5JDLOW 48 hours+ 48 hours+

48 hours+ 48 hours+

LOW

NW1 5JD

NW1 5JD

NW1 5JD

CATEGORY C

Staffing min. Impact of Disruption

Unscheduled Care

Planned Care 48 hours+ 48 hours+

CWHHE Quality team

Children's Joint Commissioning

CWHHE Safeguarding Adults and Childrens

LOW

NW1 5JD

NW1 5JD

LOW 48 hours+ 48 hours+

NW1 5JD

CATEGORY C NW1 5JD

Siobhan Herron

48 hours+ NW1 5JD

CATEGORY C

NW1 5JD

CATEGORY C

CATEGORY C NW1 5JD

48 hours+ 48 hours+ CATEGORY C

LOW 48 hours+ 48 hours+ CATEGORY C

LOW 48 hours+ 48 hours+ CATEGORY C

Sophia Malik LOW

48 hours+

Holly Mankletow LOW 48 hours+ 48 hours+ CATEGORY C NW1 5JD

CATEGORY C NW1 5JD

Rufus Fearnley LOW 48 hours+ 48 hours+

Susan Harrison LOW 48 hours+ 48 hours+ CATEGORY C

CATEGORY C

LOW 48 hours+ 48 hours+

Continuity Rating

2

Central London CCG Business Impact AssessmentSection Two: CCG/Department Continuity Ref: CLCCG CCGCLCCG

Continuity Lead Nominated Backup 1

Contact Mobile Contact Mobile Contact Mobile

Additional Number Additional Number Additional Number

Resources Required for Minimum Service Resumption for Priority Services or those which require specialist

Function Required Within Building Requirement Day Night No.

2 2

2

6 10+

10+

6 6

6

11 10+

10+

Jules Martin Philippa Mardon

TBC

Internet

Telephone

Staff Type

CWHHE Quality 48+ Office Space

Type

48+

Computer

Information

systems

InternetAdmin and Clerical

Supplies/ Services Other (*List here)

Computer

Computer

Internet

Email

Admin and Clerical

additional screens x11

Email

Telephone Internet

TBC

02033504886

Office Space

TechnologyStaff Number

Emma Playford

0203350469202033504783

TBC

CWHHE Safe Guarding Adult & Children

Telephone

48+

Computer Email

Admin and Clerical

Finance 48+ Office Space Admin and Clerical

Children's Joint Commissioning Office Space Telephone

Email

Nominated Backup 2

3

Central London CCG Business Impact Assessment

10 10+

10+

5 5

5

4 4

4

2 2

2

Mental Health 48+ Office Space Admin and Clerical 2 2 Internet

2 Email

Internet

BI 48+

Computer

Office Space Admin and Clerical

Telephone

Telephone Internet

Office Space Admin and Clerical Telephone

Computer Email

Email

Internet

Computer

48+ Office Space Admin and Clerical

Computer

Telephone

Contracts Team Admin and Clerical

Email

additional screens x2

Email

Telephone Internet

Computer

additional screen x1

Primary Care & Unscheduled Care

48+ Office Space

Planned Care 48+

4

Central London CCG Business Impact Assessment6 6

6

6 6

6

3 33

3 33

3 33

Integrated Care 48+ Office Space Admin and Clerical TelephoneComputer

Homelessnes 48+ Office Space Admin and Clerical TelephoneComputer

Corporate 48+ Office Space Admin and Clerical

Turnaround 48+ Office Space Admin and Clerical

Telephone

Computer

additional screen x1

TelephoneComputer

Admin and ClericalEngagement and Corporate Affairs48+ Office Space Telephone

Computer

5


Key Functions/Services Provided to Internal or External Partners

Service/Function Provided Provided by Supplied? Main Contact Number Other Contact DetailsOrganisation Name Contact Name

6

Central London CCG Business Impact AssessmentSection Three: Key Contact Details Ref: CLCCG

Function/ Team Key Contact Details-

Staff Name Function/Team Name Other Contact Number Other Skills Email refer to staff contact list

External and Internal (outside of this service) Key Contact Details

Contact Name Company Main Contact Number Other Contact Number Email

02033504783

Role

Chair

Contact Number

Managing Director

Interim Deputy Managing Director02033504692 07973747488

02033504783

Vice Chair

Business Manager to Chair & MD02033504783

07554333716

Interim Deputy Managing Director02033504679

Senior Engagment and Corporate Affairs Manager

Corporate Affairs Manager02033504061

2033504886

Neville Pursell

Mona Vaidya

Jules Martin

Philippa Mardon

Chris Neil

Role Internal or External

Chathura Malalasena

Emma Playford

Natalie Osanquaye

07554535684

7


Internal 0203 350 4050 [email protected]

[email protected]

Local Police MET External 101

Internal 0203 350 4224

Internal 0208 966 1066Mark Haggerty [email protected]

Marylebone IT Service Desk NWL CCGs

NWL CCGs On-Call Director

Jonathan Webster NWL CCGs Director of Quality and Safety

Telephony NWL CCGs 0203 350 4764IT Service Desk Internal

NWL CCGs

08448222888 Paging Service

External

07824 609 629

Accountable Emergency OfficerCWHHEClare Parker (AEO) Internal 020 3350 4504

Emergency Planning/Business Continuity

0208 962 4000 0203 688 2244

07950286635

Call Sign NWLCP01NWL CCGs On-Call Director Internal

Internal 02033504798 07940269270

NHS Property Services

Comms

8

Central London CCG Business Impact AssessmentSection Four: Risk and Threat Assessment Ref: CLCCG

Assessment of Likelihood

Level

12345

Assessment of Impact

Level Descriptor Description

1

2 Moderate

3

4

5

Resilience Risk and Threat Assessment

Ref. Hazard/ Issue Current Mitigations/ Measures in place Further Action(s) Required

1

2

Adverse Weather NWL CGGs Severe Weather/Heatwave / Cold Weather Plan and

Procedures. Dependent on the number of staff available H&F CCG will

utilise its own resources to deliver critical business outputs, Senior Staff

have the ability to work anywhere using Smart phone/ Laptop/Wifi: not

premises dependent.

Descriptor Description

Rare May only occur in exceptional circumstances (< 5% chance)

Unlikely Could occur at some time (6 - 25% chance)

Catastrophic business interruption - Catastrophic and permanent loss of reputation - Sustained failure to meet national professional standards and/or statutory requirements - Catastrophic financial

loss (£500k +) - Multiple Deaths of any persons/ Multiple permanent serious illness/ disability - Catastrophic and long-term environmental implications

MinorMinimal business interruption - Minimal loss of reputation - Failure to meet (local) departmental standards - Minimal financial loss (£1k to £9k) - Injury requiring first-aid treatment or minor illness

(<3days Lost) - Minimal environmental damage

Moderate business interruption - Moderate loss of reputation - Failure to meet organisational standards - Moderate financial loss (£10k to £49k) - Break of minor bone or temporary minor illness (3- 7

days Lost) - Moderate environmental damage

SeriousMajor business interruption - Major loss of reputation - Failure to meet national performance standards - Major financial loss (£50k to £249k) - Major bone fracture or temporary serious illness (8- 21

days Lost) - Major short term environmental damage

Extreme and sustained business interruption - Major and sustained loss of reputation - Intermittent failure to meet national professional standards and/or statutory requirements - Extreme financial loss

(£250k to £499k) - Single Death/ Permanent serious illness/ disability - Major medium-term environmental implications

Unavailability of IT systems/ Telephones Contact and Essential Information are available in hard copies. All key

staff have access to a mobile phone and laptop, additionally some

members of staff are able to work from home. Majority of staff use NHS.net

which is independent of NWL CCGs IT Systems. IT DR Procedures in

Place Main Server MBR/Secondary Server St.Charles

3 2 MEDIUM

The event will occur in most circumstances (51 - 75% chance)

Certain The event is expected to occur in the next 5 years

NWL CCGs will continue to monitor

the MET weather warnings and will

respond if any adverse conditions are

forecast in London.

Major

Moderately Likely The event should occur at some time (26 - 50% chance)

Likely

Likelihood Impact Risk Rating

3 3 MEDIUM

Catastrophic

9

Central London CCG Business Impact Assessment3

4

5

6

7

Mass absence due to:

Illness/Incident

Flu Pandamic / Infectious Disease Outbreak/ Incident Response Plan.

Liaise with other departments or CCGS to see if personnal can be

provided to support or review current capacity and determine whether

critical business outputs can be maintained with available staff. If not look

at agency options, fomer staff and mutual aid from other organisations. MEDIUM

3 LOW

Majority of staff are able to work remotely at home- key staff have laptops

and mobile phones, Staff are aware of other sites to be utilsed.

Building damage due to fire or water Any issues directly impacting on the ability to deliver an effective service at

their premises will result in the relocation of the team to another BHH

site.

2 LOW

1

3

Industrial Action In the event of industrial action team managers will utilise own resources to

deliver essential business outputs. Where possible managers will engage

with staff before the event to determine the likely impact of staffing levels.

4 MEDIUM

MEDIUM

2 4

2

2

Inability to get to work base/ Denial and access

to the normal base of business delivery

2

Fire Fire procedures and evacuation plans are in place for each site. All staff

have undertaken relevant fire training. NWL CCGs Bomb Threat Plan

10

Central London CCG Business Impact Assessment8

Section 7. Business Continuity Plan- Any other Information in the event of a disruption or the loss of key systems

LOW

Public Transport Suspension Staff are able to work from home, not premises dependent

Teleconferencing with clients/colleagues

Consider Driving if essential

22

Additional useful contact numbers for 15 MBR:

Ben Westmancott , Director of Governance 020 3350 4313 07507 857 254

Simon Carney- Governance Officer 020 3350 4868 0787 087 6273

Helen Christodoulou – Facilities Manager 020 3350 4270 07830 337 881

Angela Roberts – Deputy Manager 020 3350 4637 07958 913 964

Howard Grandos- Facilities Officer 020 3350 4035 07910 312 549

Rafal Barowski- Cleaning Supervisor 07783 025 872 Sergio (cover) 07943 648 452

Spiros Kakoullis-Building Manager 020 3350 4003 07931 856 829

Universal Security - Lazari 020 7837 3535/ 07825 123 416/07711 448 523

Section 14. Staff Contact List

11


Version Changes/Reason Author(s) Documents Replaced

Please refer to current Staff Contact List

VERSION CONTROLDate

16/01/2017 One(1) New Document

Mark Haggerty/Natalie

Osanquaye

12

Central London CCG

Business Continuity Plan

1. About This Plan

2. CCG/Department Details

Dept/ Borough

Version

Continuity Lead

Backup 1

Backup 2

Main Location 1

Main Location 2

Main Location 3

3. Teams/ Functions Covered By This Plan

4. Incident Response

5. Escalating The Incident

6. Emergency Actions

Central London CCG

Jules Martin 02033504783

Homelessness

CWHHE Quality team

Mental Health

BI team

Unscheduled Care

Contracts Team

3rd Floor 15 Marylebone Road, London NW1 5JD

Philippa Mardon 02033504692 07973 747488

Emma Playford 02033504886

CWHHE Safeguarding Adults and Children

Engagement Corporate Affairs


Finance

Primary Care

In the event of a incident or disruption that effects any of the above teams, the team leader (or most

senior member of staff) should be informed in the first instance for resolution within the team, if this is

not possible then they should follow the emergency actions (page 2) before informing the continuity

lead, or their nominated back up, of the disruption. If it is deemed necessary, the continuity lead will

invoke this Continuity Plan and make operational decisions for the CCG or Department to ensure the

continuity of essential business outputs. Should further tactical decisions need to be made outside of

their CCG or department then the below escalation procedures will be followed.

Should the Continuity Lead, or their nominated deputy, require further resources from outside of their

CCG or department in order to keep their key business outputs running, then notify the:

On-Call Director via PageOne Pager 08448222888 include a contact name and telephone number

and request your message is sent to call sign NWLCP01 and you will need to complete the situation

report (Sitrep) form (Appendix C- BC Procedures)

This plan is part of NWL CCGs overall business continuity strategy, and may be used to support NWL

CCGs response to a major incident. The plan should be used by the Continuity Lead, or their

nominated back up, in the response to any reported disruption to their CCG or department. In

business continuity managment business disruptions are managed at the lowest practical level and

escalated though the CCGs usual management hierarchy if additional resources or expertise is

needed.

In the event of an emergency or disruption the effected teams/functions listed below should

follow the actions on Page 2.

Turnaround Team

Integrated Care

Planned Care

One (1)

Version 1 1 of 8

Central London CCG


Clinical Area Actions Complete

Non-Clinical Area Actions Complete

7. Additional Actions in the event of a disruption or the loss of systems

Electricity

Loss of power could also

result in disruptions to

water and gas supplies

as these may depend on

electrically operated

pumps or relays

Continuity Lead should

consider the following actions:

(Record all your actions and

decisions in a log)

Wait for further instruction from the Continuity lead or their nominated back up

Establish provision of food and drinks availableCheck supplies of drugs, clean equipment, continence products etc.Ensure infection control arrangements are in place

Identify any patients at immediate risk and take corrective actions to protect them, evacuating if

necessary

Request assistance from nearby clinical areas if necessary and if patients will not be placed at

risk by doing so

Ensure the safety of yourself and others, evacuating if necessary and if required contact the

relevant emergency services

Conduct an assessment, and take relevant emergency measures to maintain key business

ouputs in your CCG or department as far as possible

1) Continuity Lead

2) And/or Nominated Back Up

Inform them of the level of disruption and of any emergency measures you have put into placeWait for further instruction from the Continuity Lead or their nominated backup

•Manual Fallback Processes for IT systems

•If emergency generator is running, turn off non-

essential electrical equipment to save power

• During a mains electrical failure, switch off the

computers to prevent damage from a power

surge when the power is restored. (This

protection may already be built in to some areas)

• Comply with Health and Safety Regulations

•Inform NHS Property Services or

Estates/ liaise with Site Maintenance

to get estimation when power will be

restored.

•Source laptops / Mobile Phones for

critical business outputs

•Consider cancelling all non-

essential meetings/appointments

•Consider relocating staff to

alternative premises or remote

working depending on the severity of

the power outage

•Consider the temporary suspension

of all non high priority functions

1) Continuity Lead2) And/Or Nominated Back Up

Inform them of the level of disruption and of any emergency measures you have put into place

Prioritise staffing tasks based on patient needReview staffing levels for patient safetyIdentify any patients who may need transfer to another clinical areaIdentify patients who could be safely discharged home or to alternative services

Alert:

Check medical care is adequate and address any urgent patient needs

Check discharge arrangements in progress for patients to be discharged

Remember to ensure the Safety and Welfare of Staff at all times

Alert:

Disruption/System Action For All Staff

Version 1 2 of 8

Central London CCG

Business Continuity PlanGas

Water

•Assess safety of building and work area

(evacuate if necessary)


Estates / liaise with Site Maintenance

to get estimation when building will

be safe

•Ask staff to work from home or

alternative premises

•Source laptops for critical business

outputs

•Consider cancelling all non-

essential meetings/appointments

• Advise staff to put on additional

layers of clothing

• Ensure regular hot drinks are

available

• Provide mobile heaters

•Consider the temporary suspension

of all non high priority

functions/services•Assess water need for the building (drinking

and for sanitation)


Estates/ liaise with Site Maintenance

to get estimation when water will be

returned to the building

•Consider relocating or remote

working until water is restored

Telephones •Use email/mobile phones if working

•Conduct business face to face if necessary

•Consider using runners for critical messages

•Contact your Telephone Provider to

get estimate for when telecoms will

be restored

• Instigate divert schemes if relevant

• Consider using email

• Source mobile phones for critical

activities/ staff

Loss of Staff Source replacement staff from:

• Agency staff

• Temporary Contracted staff

• Freelance staff

• Former Staff

• Professional Associations

• Mutual Aid Agreements

• Contact Human Resources for help

in identifying skills available in

current workforce

• Consider cancelling non-essential

meetings/ appointments

• Consider stopping non-essential

activities

Version 1 3 of 8

Central London CCG


8. Department/Borough Continuity Arrangements

Day Night Priority RTO MTPD

9 Resources Required for Minimum Service Resumption

Function

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

CATEGORY CCATEGORY CCATEGORY CCATEGORY CCATEGORY CCATEGORY C

CATEGORY CCATEGORY CCATEGORY CCATEGORY C

CATEGORY BCATEGORY BCATEGORY CCATEGORY C

48 hours+

48 hours+

48 hours+

48 hours+

LOW

LOW

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

48 hours+

LOW

LOWLeroy Cordle

LOW

LOW

LOW

LOW

LOW

LOW

6

2

5

3

3

2

Planned Care

Integrated Care

Homelessness

BI

Susan Harrison

Rufus Fearnley

Mental Health

Contracts Team

Turnaround

Corporate

Engagement and Corporate Affairs

Unscheduled Care

48 hours+CATEGORY BCWHHE Quality team


6

6

11

10

2

4

3Will Reynolds

Holly Mankletow

Robert Holman

Finance

Primary Care

CWHHE Safeguarding Adults and ChildrensJudy Durrant 2 MEDIUM 48 hours+

MEDIUM

MEDIUM

LOW

LOW

Jonathan Webster

Steve Buckerfield

Elke Taylor

Additional Information in the event of a disruption or the loss of a key systems

Staff Min.Team/Function

48+Required WithinCWHHE Children and Adult safeguarding & Quality

Manager

Recovery

IT Systems •Work manually

•Use telecoms to communicate

•Revert to paper files

•Contact your IT provider to get

estimate for when systems will be

restored

• Request IT Disaster Recovery plan

is invoked, if appropriate

• Revert to paper systems

48 hours+6Jules Martin

48 hours+Holly Mankletow

48 hours+Emma Playford

Siobhan Herron

Additional useful contact numbers for 15 MBR:

Ben Westmancott , Director of Governance 020 3350 4313 07507 857 254

Simon Carney- Governance Officer 020 3350 4868 0787 087 6273

Helen Christodoulou – Facilities Manager 020 3350 4270 07830 337 881

Angela Roberts – Deputy Manager 020 3350 4637 07958 913 964

Howard Grandos- Facilities Officer 020 3350 4035 07910 312 549

Rafal Barowski- Cleaning Supervisor 07783 025 872 Sergio (cover) 07943 648 452

Spiros Kakoullis-Building Manager 020 3350 4003 07931 856 829

Universal Security - Lazari 020 7837 3535/ 07825 123 416/07711 448 523

Sophia Malik

Version 1 4 of 8

Central London CCG


Function

Function

Function

Function

Function

Email10+

Building Information

Staff Number

NightDay No.Type

Information

systems

Building

Requirement Staff Type

Computer 3 Email

Internet3

Technology

Office Space Admin and Clerical 3 Telephone

Other Resources

Supplies/

Services

Computer 6 Email

48+

Building


Staff Number Technology Information

systems

Mental Health and Integrated Care Required Within

Office Space Admin and Clerical 5

Supplies/

Services Other ResourcesDay Night Type No.

5 Email

Telephone 5 Internet

48+

Telephone 10+ Internet

Staff Number Technology

Building



Computer


48+

Building



systems

Supplies/


Children's Joint Commissioning Required Within

Telephone 6 InternetOffice Space Admin and Clerical 6

Finance and Turnround Required Within

Information

systems

Supplies/

Services

additional screens

x11Office Space

Computer 10+ Email

Telephone 10+ Internet

Other ResourcesDay Night Type No.

Building

Requirement Type No.

Technology

Admin and Clerical 14

Planned Care & Homelessness Required Within

Primary Care & Unscheduled Care Required Within48+

Information

systems

Supplies/

Services Other ResourcesStaff Type

Staff Number

Supplies/

Day Night

48+

Computer

Version 1 5 of 8

Central London CCG


Function

Function

Function

Function

Function

10. Functions/Services Provided to Internal or External Partners

Service/Function Provided

Telephone 6

Engagement and Corporate Affairs Required Within48+

Building



systems

Supplies/

Services Other ResourcesDay Night Type No.Office Space Admin and Clerical1 6 Computer 6

Day Night Type No.

Email

Office Space Admin and Clerical Telephone 6

Building



systems

Supplies/

Services

48+

Other ResourcesDay Night Type No.


BI 48+

Email

Admin and Clerical 4 TelephoneOffice Space

Email

48+

Other Resources

Email

Staff Type

Building

Requirement

Information

systems

Supplies/

Services

Building

Requirement

Information

systemsNo.

Provided by

Type

Staff Type


2

Computer

Internet

Main Contact NumberOrganisation Name

Internet

Supplied?

Internet


Day Night

Computer 4

Day Night Type

Computer

Contracts Team Required Within

No.

Telephone

Computer 6

Supplies/

Services

Required Within

2

8

CWHHE Quality team Required Within48+

Contact Name

Other Resources

Telephone 8

4 Internet

Corporate Required Within

Building



systems

Supplies/

Services Other Resources

Building



systems

Supplies/


Office Space Admin and Clerical1 6 Computer 6 Internet

Telephone 6 Email

Version 1 6 of 8

Central London CCG


11. Function/Team Key Contact Details (For All Staff Contact List see below)

Staff Name

12. External and Internal (outside of this service) Key Contact Details

Staff Name

13. Service Buildings

Address

07950286635

Call Sign NWLCP01

Natalie Osanquaye Corporate Affairs Manager 02033504061

Business Manager to MD & Chair

Managing Director 02033504783

Function/Team Name Role

Vice Chair

Neville Purssell Chair

Daniela Valdes Interim Deputy Managing Director02033504679

Chris Neill

07973747488

Mona Vadiya

Philippa Mardon

Interim Deputy Managing Director

Jules Martin

02033504783

Chathura Malasena

Intermin Deputy Managagi Director

NWL CCGs On-Call Director NWL CCGs On-Call Director Internal 08448222888 Paging Service

Accountable Emergency OfficerInternal

Company Role In/External Contact Number

020 3350 4504

2033504886

Internal 0203 350 4050

Clare Parker (AEO) CWHHE

Local Police MET External

Telephony NWL CCGs IT Service Desk Internal 0203 350 4764

101

0203 350 4224

0208 966 1066

Comms

Multi-occupancy Office Building

Notes/Other

3rd Floor 15 Marylebone Road, London NW1 5JD No

Jonathan Webster NWL CCGs Director of Quality and SafetyInternal

NHS Property Services External 0208 962 4000

02033504798

NWL CCGs

Mark Haggerty Emergency Planning/Business Continuity Internal

Internal

Marylebone IT Service Desk NWL CCGs

02033504692

NWL Owned

07940269270

0203 688 2244

07824 609 629

Postcode

Other Contact Number

Contact NumberOther Contact Number Other Skills

Version 1 7 of 8

Central London CCG


14. All Staff Contact ListPlease refer to current Staff Contact List

Version 1 8 of 8

Team First Name Surname Job Title Email ExtGulam Muktadir Contracts Information Analyst [email protected] 4043

Rufus Fearnley CCG Information Manager [email protected] 4518

Alison Markwell Designated Clinical Officer for SEND [email protected] 4319

Angela Caulder CAMHS Commissioning Manager [email protected] 4324

Imogen Murray Commissioning Assistant, Children [email protected] 4320

Fiona Murray Tri-Borough CAMHS Transformation Project Manager [email protected]

Robin Partridge Children's Joint Commissioning Manager [email protected] 4326Steve Buckerfield Head of Children's Joint Commissioning [email protected] 4331

Aneesh Desai Senior Contract Manager [email protected] 4070

Aoife Kirwan Senior Contract Manager [email protected] 4209

Sazia Rawat Contract Manager [email protected]

Leroy Cordle Associate Director of Contracts [email protected] 4051

Chathura (Chats) Malalasena Business Manager [email protected] 4783

Chris Neill Interim Deputy Managing Director [email protected] 4679

Daniela Valdés Head of Planning and Governance [email protected] 4063

Emma Playford Senior Corporate Affairs and Engagment manager (interim) [email protected] 4886

Jonathan Storey Engagement & Corporate Affairs Officer [email protected]

Jules Martin Managing Director [email protected] 4692

Natalie Osanquaye Corporate Affairs Manager [email protected] 4061

Neville Purssell Clinical Leader [email protected]

Sophia Malaspina Engagement & Corporate Affairs Officer [email protected] 4494

Radhika Howarth Interim Engagement Manager [email protected]

Tricia Otukoya Engagement & Corporate Affairs Officer [email protected] 4698Philippa Mardon Interim Deputy Managing Director [email protected] 4692

Mak Inayat Designated Nurse - Safeguarding Children [email protected] 4443

Molly Larkin Designated Nurse - Safeguarding Adults [email protected] 4478

Amit Shah Senior Management Accountant [email protected] 4467Beatriz Villena Financial Analyst [email protected] 4473Elke Taylor Head of Finance, CCG [email protected] 4472Fahad Farooq Financial Accounts Assistant [email protected] 4849Ian Perry Financial Controller [email protected] 4491Kelly Amadi Finance Trainee [email protected] 4399Ladan Tehrani Senior Management Accountant [email protected] 4485Lovina Coothapen Assistant Financial Accountant [email protected] 4495Mark Collinson Head of Financial & Management Accounts [email protected] 4640Nabila Ahmad Finance Placement Student [email protected] 4125Wole Ajiboye Collaborative Finance Manager [email protected] 4614

Adel Baluch GP [email protected]

Afsana Safa GP [email protected]

Alan Hakim Secondary Care Consultant [email protected]

Ben Westmancott Company Secretary [email protected] 4313Clare Parker Chief Officer, CWHHE [email protected] 4504Dominique Kleyn Lay Member [email protected]

Gail Spiller Co-opted Practice Manager [email protected]

Helen Troalen Deputy CFO, CWHHE [email protected] 4008Jonathan Webster Secondary Care Nurse Member [email protected] 4798Keith Edmunds CFO, CWHHE [email protected] 4167Maxine Radcliffe Co-opted Practice Nurse [email protected]

Michael Morton Lay Member [email protected]

Mona Vaidya GP and Vice Chair [email protected]

Nafsika Thalassis Chair of User Panel [email protected]

Niamh McLaughlin GP [email protected]

Paul O'Reilly GP [email protected]

Philip Young Lay Member and Deputy Chair [email protected]

Sheila Neogi GP [email protected] Gordon GP [email protected]

Greice Cerqueria Project Manager - London Homeless Health Programme [email protected] 4663

Jane Cook Clinical Lead, Homelessness [email protected] 4120

Susan Harrison Head of Health and Homelessness [email protected] 4238

Caroline Fry Project Support Officer - Integrated Care [email protected] 4426

Samuel Smith MDG Manager [email protected] 4994Siobhan Herron Delivery Manager - OOH Strategy [email protected] 4919

Chris Longster Project Manager, Mental Health [email protected] 4390

Robert Holman Delivery Manager [email protected] 4624

Candy Brown Project Support Officer - Planned Care & Mental Health [email protected] 4880

Colette Turner Project Manager [email protected] 4208

Jonathon Simpson Planned Care Programme Manager [email protected] 4711

Samira Shariff Project Manager [email protected] 4779Sophia Malik Programme Manager [email protected] 4017

Ashfaq Khan Assistant Director for Quality Improvement and Clinical Assurance [email protected] 4732

Asim Foroze Project Manager [email protected] 4927

Helena Stokes Delivery Manager - Primary Care [email protected] 4278

Jana Labovic Locality Support Manager (South) [email protected] 4697

Katasi Kironde Locality Support Manager (Central) [email protected] 4587

Cynthia Mkandawire Primary Care Project Manager [email protected]

Monika Truszczynska Primary Care IT Project Manager [email protected] 4649

Mandekh Hussein Project Support Officer - Education [email protected]

Rebecca McCaw Locality Support Manager (North) [email protected] 4429

Samar Pankanti Public Health Project Manager [email protected] 4994

Sarah Alexander Nurse Developer [email protected] 4492

Andrew Trunkfield QIPP Information Lead [email protected]

Taryn Aspelling QIPP and BI Analyst [email protected] 4599

Will Reynolds Senior Delivery Manager [email protected] 4484

Holly Mankletow Senior Delivery Manager [email protected] 4533

Melanie Foody Programme Manager - Unscheduled Care [email protected] 4687

Corporate

Team &

Engagement

and Corporate

Affairs

Governing

Body

Turnaround

Unscheduled

Care

CL CCG Staff - Telephone 0203350XXXX

Children's

Contracts

Primary Care

CWHHE

Safeguarding

Finance

Homelessness

Integrated

Care

Planned Care

Mental Health

Business

Intelligence

Quality

North West London

Clinical Commissioning Groups

Emergency Preparedness, Resilience and Response (EPRR) and Business Continuity Policy

This document is NOT intended for emergency use

In the event of a business disruption or incident then please consult the MAJOR INCIDENT RESPONSE PLAN immediately

Document Reference Information Version Three (3) Status Approved Author/Lead

Mark Haggerty

Accountable Emergency Officer BHH-Rob Larkman CHHWE- Clare Parker

Date Effective June 2016 Date of Next Formal Review June 2017

Version Control Record Date Version Action Amendments June 2014 1 New Document June 2015 2 Annual Review Removed any reference to

the CSU June 2016 3 Annual Review BC policy incorporated into

EPRR policy/ Reference to BHH/CWHHE Risk Management Strategy

To be read in conjunction with:

• Risk Management Strategy • Health and Safety at Work Policy • Security Management Policy • Media Policy • Serious Incident Reporting Policy

The CCG incorporates and supports the Equality Act 2010 and the human rights of the individual as set out in the European Convention on Human Rights and the Human Rights Act 1998

1 EPRR Policy V3 Date of Issue: June 2016 Review Date: June 2017

Contents Page Document Reference Information 1 Version Control Record 1

1. Introduction 3

2. Policy Statement 3

3. Purpose 4

4. On-Call Command and Control 5 4.1 Command and Control 5 4.2 On-Call 5 4.3 Administration of On-Call 5 4.4 On-Call Documentation 6

5. Roles and Responsibilities 6

5.1 CCG Executive Board 6 5.2 Chief Officer 6 5.3 Accountable Emergency Officer 6 5.4On-Call Director 6 5.5 CCGs EPRR Lead 6 5.6 NWL CCGs Resilience Forum 7 5.7 Local Health Resilience Partnership (LHRP) 7 5.8 Staff with Specific Resilience Roles 7 5.9 BCM Specific Role 7 5.10 All CCG Staff 7

6. Risk Management Strategy 7

7. Development of Plans 8

8. Business Continuity Management (BCM) 8

9. BCM Definitions 9

10. Business Impact Assessment 9

11. National Assurance EPRR 10

12. Training 10

13. Testing and Exercising 10

14. Dissemination of Document 11

15. Monitoring Arrangements 11

16. Audit Arrangements 11

17. Equality Statement 11

18. References 11

Appendix 1 – Equality Impact Assessment


1. Introduction The NHS needs to plan for, and respond to a wide range of incidents and emergencies that could affect health or patient care. These could be anything from extreme weather conditions to an outbreak of an infectious disease or a major transport accident. The Civil Contingencies Act (2004) requires NHS organisations, and providers of NHS-funded care to show that they can deal with such incidents while maintaining services to patients.

Under the Civil Contingencies Act 2004 North West London Clinical Commissioning Groups (NWL CCGs) are defined as Category 2 responders, meaning that there is a duty to cooperate and share information with the Category 1 responders.

NWL CCGs are also committed to implementing an integrated and robust Business Continuity Management System (BCMS) via alignment to ISO22301 and the meeting of a number of statutory duties in relation to Emergency and Business Continuity Planning, to ensure the continued delivery of safe and effective healthcare commissioning and management. In addition to meeting legislative duties, NWL CCGs are required to comply with guidance and framework documents, including but not limited to:

NHS England Business Continuity Management Framework NHS England Core Standards for Emergency Preparedness Resilience and

Response (EPRR) NHS England EPRR Framework (2015) NHS England Operating Framework – Response to Pandemic Influenza ISO 22301 – Societal Security – Business Continuity Management Systems -

Requirements; PAS 2015:2010 Framework for Health Services Resilience.

This is achieved through the publication, testing and exercising of plans for critical functions and key services in accordance with the aforementioned guidance. Furthermore this policy outlines how compliance will be achieved against NHS England’s national standards for Emergency Preparedness, Resilience and Response (EPRR) and Business Continuity (BC) across NWL CCGs, detailing the minimum requirements for planning and responding to a major incident whilst maintaining key services via business continuity arrangements.

2. Policy Statement

An integrated approach for EPRR across all 8 CCGs in North West London has been adopted. No individual CCG will need to write a plan as a single generic plan will be used across North West London. All CCGs in North West London accept their statutory duties as a Category 2 responder under the Civil Contingencies Act 2004 (CCA) and as such will cooperate with Category 1 responders in order to enhance co-ordination and efficiency and to share information as required, prior to, during and following an incident. NWL CCGs will ensure that they are capable of responding to major incidents of any scale in a way that delivers optimum care and assistance to those affected, and one that minimises the consequential disruption to healthcare services and help brings about a speedy return to normal levels of functioning.


Furthermore all CCGs will have in place business continuity and contingency plans that allow them to continue to provide their core functions during a major incident, so far as is practicable and to recover from the additional pressure that an incident may place on an organisation. In addition to its duties contained within the Civil Contingency Act, all CCGs recognise their EPRR responsibilities as detailed within section 46 of the Health & Social Care Act 2012 (H&SCA) and will in partnership with its commissioned services meet this responsibility through:

• Building upon the existing strengths of current multi-agency coordination, and co-operation which includes local NHS Trusts and other Category 1 Responders.

• Ensuring that responsibilities of the Borough Resilience Forums and North West London Local Health Resilience Partnership enhance any response to emergency arrangements, both during the response and recovery phase.

• Fully integrating with partner agencies emergency arrangements, in supporting the local health economy.

• Reviewing the state of readiness and operability to extend further, with the assistance of new and improved partnerships, the capability to handle a new kind and potential magnitude of threat.

• Ensuring that plans for business continuity are in place. • Cultivating a culture within each CCG to make emergency preparedness an intrinsic

element of management and operations. In order to achieve this CCGs in North West London operate a 24/7 On-Call Director Function. The On-Call Director will hold a pager and will receive calls and respond to:

• Major Incident Notifications • Surge Management/Capacity Issues

The on-call rota will be managed by NWL CCGs surge team, and published along with all other relevant on call information, via a weekly EPRR email circulated to all directors, and assistant directors. 3. Purpose

The purpose of this document is to ensure that all CCGs across North West London act in accordance with the CCA, H&SCA and the NHS England national policy and guidance by undertaking the duties listed below:

• To ensure that major incident and continuity plans have been established and are well communicated.

• To ensure that the plans address the consequences of all situations that might feasibly occur.

• To ensure that plans involve robust arrangements for the operational recovery from all such incidents.

• To ensure that all key stakeholders are consulted and collaborated with concerning their role in the plan and that they understand those responsibilities.

• To ensure that the plans are tested and are regularly reviewed. • To ensure that funding and resources are available to respond effectively to major

incidents and business disruptions • To ensure that all CCGs have access to up to date guidance relating to BC/EPRR. • To ensure that staff receive BC/EPRR training that is commensurate with their role

and responsibilities. • To ensure that a risk based approach to planning is undertaken, and that all risks are

assessed, mitigated and recorded.


• To ensure that indicators demonstrating emergency preparedness and/or early warning of risk are used within contracts and service specifications.

• To ensure that the whole system is monitored and audited regularly. 4. Command and Control (including On Call) 4.1 Command and Control An integral element of command and control is a clear chain of command from the top of the organisation to the lowest level, and across agencies as required. Every person involved in the response to an incident must exactly know their role and responsibility. All Civil Contingencies Act responders follow the nationally recognised ‘Strategic, Tactical, Operational’ framework. Furthermore each CCG has an individual Business Continuity Plan which in the event of a business continuity disruptive incident outlines the response and recovery arrangements to facilitate the resumption and restoration of activities and to mitigate the impacts of the business disruption on the CCG’s operations and reputation. 4.2 On Call In order to fulfil our EPRR requirements CCGs in North West London operate a 24/7, 365 day On-Call Director function. Each On-Call Director holds a pager and is on-call for a seven day period commencing at 10:00 on a Tuesday morning. The Director On-Call:

• Is the nominated first point of contact for all Major Incident notification; • Will initially assume the role of Incident Director; • Will activate the appropriate Incident Management Team(s) and the

appropriate staff to respond to the incident; • Must carry their Director On-Call pager at all times (not to be turned off at

any time); • Chief Operating Officers / Accountable Emergency Officers must always be

briefed in the event of a major incident; • Must be able to respond in person to a call-out; • Must be able to attend an incident coordination centre preferably within a

two hour of a call-out; • Must carry their Identity Card at all times; • Must carry the on-call Directors Procedures pack & action card; • Must make themselves familiar with the Action Card for their role.

4.3 Administration of On-Call The On-Call Coordinator will manage the rota, which covers a four-month period and will be circulated with the on-call email weekly on Fridays. A separate rota for the Christmas and New Year period will be issued. Directors who rearrange their allocated rota dates should advise the On-Call Coordinator accordingly.


4.4 On-Call Documentation There are a number of documents available to assist the on-call staff. These documents include:

• On Call Major Incident Pack • On Call Director Action Card • Incident Response Plan • EPRR Contact Directory • Loggist Pack • Surge plans

All of these documents are available within the PageOne Documents and have been circulated to On-Call Staff via the aforementioned weekly EPRR On-Call email. 5. Roles and Responsibilities

5.1 CCG Executive Board The CCG Executive Board are accountable to the public and NHS England for ensuring that the EPRR/BC framework is in place to ensure effective responses to incidents and to safeguard that in the event of a disruption to services the public continue to receive the best quality and range of services it is reasonable practical to deliver and that key services are maintained. 5.2 Chief Officer The Chief Officer has overall responsibility for ensuring there are effective arrangements for EPRR and Business Continuity management in place within BHH/CWHHE and for meeting statutory requirements and guidance. 5.3 Accountable Emergency Officer The Accountable Emergency Officer (AEO) as required under the H&SC Act 2012, is responsible for the strategic implementation of major incident and business continuity planning in accordance with the aims as detailed within section three (3) of this policy. Furthermore the AEO or a nominated deputy has a duty to attend the NHS North West London Local Health Resilience Partnership. 5.4 On-Call Director The On-Call Director is responsible for handling the initial response to an incident, responding to any NHS England (London) resource requests and is responsible for providing NHS England (London) with situation reports. The on-call Director is responsible for briefing and updating the AEO and Chief Operating Officers of the incident response. 5.5 CCGs EPRR Lead The CCGs EPRR Lead is responsible for all aspects of operational implementation of the aims contained within section three of this procedure and reports to the Accountable Emergency Officer. Specific responsibilities include:

• Ensuring CCGs fulfil their responsibly as a Cat 2 responder under the CCA and other associated guidance

• Ensuring that the CCG jointly plans with NHS England London, Acute Trusts, Community and Mental Health Providers, Primary Care, Local Authorities, and other category 1&2 responders as required.

• Chairing the North West London CCGs Resilience Forum. • Developing and continuously monitoring the BC/EPRR arrangements.


• Ensuring that staff are appropriately trained and have the necessary skills to carry out their role.

• Providing regular updates and reports as required to the Accountable Emergency Officer and CCG board/governing body.

• Overseeing the audit and fit for purpose requirements for both EPRR and business continuity.

• Represent the CCG at Borough Resilience Forums, NHS EPRR Network meetings and multi-agency EPRR events.

• Providing guidance, advice and support for health emergency preparedness to the NWL CCGs.

5.6 North West London CCGs Resilience Forum This group is made up of representatives from BHH/CHHWE. Members of this Group will have responsibility for their operational area and will have responsibility for ensuring that the resilience policies and procedures and emergency plans are adopted and that appropriate staff are trained and made aware of their roles and responsibilities. The Resilience Forum shall also be responsible for ensuring that exercises are undertaken and that improvements are implemented where required. 5.7 NWL Local Health Resilience Partnership (LHRP) The AEO or a nominated representative have a duty to attend the North West London LHRP. The LHRP will provide a strategic forum for NHS organisations to facilitate health sector preparedness and planning for emergencies. 5.8 Staff with Specific EPRR Resilience Roles Members of staff identified in EPRR arrangements have a responsibility for attending training and responding to any incidents as detailed within the appropriate plans. It shall be the responsibility of each member of staff to identify a suitable substitute representative and ensure they are trained in accordance with the relevant EPRR functions. 5.9 BCMS Specific Roles Chief Operating Officers/Heads of Departments/Business Continuity Leads The aforementioned staff have a responsibility to ensure the provision of

• Maintained and reviewed Business Impact Analysis; • Maintained and review local Business Continuity Plans in response to the outcomes

of Business Impact Analysis and Risk Assessment; • Promote a preparedness and resilience culture within their team; • Ensure an appropriate response is made during an emergency or

business continuity event.

5.10 All CCG Staff All staff are responsible for co-operating with the implementation of this Policy and any relevant plans as part of their normal duties and responsibilities. 6. Risk Management Strategy In implementing an effective resilience system CCGs will ensure that the BC/EPRR processes are integrated within the Risk Management Strategy allowing consistent risk identification, assessment, mitigation and escalation to Governing Bodies. Risk and Hazard assessments will relate to both internal and external potential threats and will take into consideration risks outlined on the LHRP, National and Community Risk registers.


All high and extreme risks will be escalated to the risk management corporate governance lead in each CCG to ensure inclusion of these risks in the individual CCG Corporate Risk Registers as deemed necessary. The EPRR Lead with the Chief Operating Officers/Heads of Departments/Business Continuity Leads will be responsible for implementing risk mitigation to reduce likelihood and/or impact of risks identified (For further information please refer to BHH/CWHHE CCGs Risk Management Policy). 7. Development of Plans EPRR arrangements will be developed to enable all CCGs to respond to the identified risks

At present specific plans include:

However the above list will be kept updated in accordance with NHS England’s EPRR Core Standards. Multi agency plans will be developed through the Borough Resilience Forums (BRF) and Health Protection Forums (HPF). Assurance in respect of EPRR arrangements will be regularly provided to the CCG Board/Governing Body. 8. Business Continuity Management NWLC CCGs Business Continuity Management System (BCMS) provides a structure through which:

• A comprehensive BCMS is established and maintained; • Business impact analysis and risk assessment is applied to key services and their

supporting prioritised activities, processes and resources; • Key services, together with their supporting prioritised activities, process and

resources are identified; • Risk mitigation strategies are applied to reduce the impact of disruption to key

services in line with the Risk Management Strategy; • Plans are developed to ensure restoration of key services to a minimum acceptable

standard following disruption; • Invocation of business continuity plans can be managed; • Plans are subject to ongoing exercising and revision.

Benefits of Effective BCMS Effective BCMS will enable CCGs to;

• Continue to provide key services in times of disruption; • Make best use of personnel and other resources in times when both may be scarce; • Reduce the period of disruption to CCGs and their users, partners and stakeholders; • Resume normal working more efficiently and effectively after a period of disruption; • Comply with standards of corporate governance; • Improve the resilience of the CCGs infrastructure to reduce the likelihood of

disruption; and • Reduce the operational, financial and reputational impact of any disruption.

• Major Incident Response Plan • Fuel Plan • Severe Weather • Flu Pandemic Plan • Heatwave Procedures • Infectious Outbreak Plan • Cold Weather Plan • Recovery Plan • Bomb Threat Plan • IT Disaster Recovery Plan


9. BCM Definitions 9.1 Business Continuity The strategic and tactical capability of the organisation to plan for, and respond to incidents, and business disruptions, in order to continue business operations at an acceptable pre-defined level. 9.2 Business Continuity Management (BCM) Business Continuity Management (BCM) is a tool which enables organisations to safeguard their business operations against threats by ensuring that in the event of a business disruption or incident, regardless of cause, essential services can be maintained and normal service restored as soon as possible.

9.3 Business Disruption An event or incident that disrupts personnel, buildings or the operational procedures of one or more services, requiring the implementation of continuity measures to restore normal function. Essential services must be maintained and normal services restored as soon as possible.

9.4 Business Continuity Plan (BCP) Documented collection of procedures and information that is developed, compiled, and maintained; in readiness for use in an incident, to enable an organisation to continue to deliver its critical activities at an acceptable pre-defined level. 9.5 Business Impact Analysis (BIA) The process of analysing activities and the effect that a business disruption may have upon them. 9.6 Maximum Tolerable Period of Disruption (MTPOD) The time it would take for adverse impacts, which might arise as a result of not providing a product/service or performing an activity, to become unacceptable.

9.7 Minimum Business Continuity Objective (MBCO) The minimum level of services and/or products that is acceptable to the organisation to achieve its business objectives during a disruption.

9.8 Recovery Time Objective (RTO)

The period of time following an incident within which; • Product or service must be resumed; or • Activity must be resumed; or • Resources must be recovered.

The Recovery Time Objective must be less than the Maximum Tolerable Period of Disruption.

10 NWL CCGs Business Impact Analysis Process (BIA) BIA documentation provides the framework by which BIAs will be undertaken by NWL CCGs to establish:

• Prioritised activities • Locations for prioritised activities • Resources required for prioritised activities


• Dependencies for prioritised activities • Service level risk assessments.

Business impact analysis also determines the impact of a disruption to the prioritised activities, which support key services by;

• Assessing over time the impacts that may occur if the activity was disrupted • Establishing the MTPOD identifying;

- The maximum time period after the start of the disruption within which the activity needs to be resumed,

- The minimum level at which the activity needs to be performed on its resumption,

- The level of time within which normal levels of operation need to be resumed or Recovery Time Objective.

Business impact analysis should be reviewed every three months or after any major changes to the service or any of the teams. 11. National Assurance Emergency Preparedness, Resilience and Response The EPRR National Assurance Process developed in 2013 is to ensure that NHS organisations are working towards meeting the requirements for EPRR, as set out in the NHS England Core Standards Matrix and the NHS England planning framework. The EPRR team will ensure that the CCGs meet the timescales outlined in the EPRR assurance process year on year and ensure:-

• CCG self-assessment against the NHS England Core Standards for EPRR. • Ensure CCG Boards (or equivalent) are sighted on the level of compliance achieved,

the results of the self-assessment and the action/work plan for the forthcoming period • Ensure that any additional assurance, e.g. ‘Deep dive’ into Pandemic Flu

preparedness, is undertaken as required.

12.Training Those individuals undertaking roles and responsibilities within Business Continuity/EPRR must undertake appropriate training for their function, including in line with the competencies for their role/function provided in NHS England’s EPRR Framework and ‘National Occupational Standards’.

Training will be undertaken in line with the annual training and exercise schedule agreed by CCG Executive Boards, and should occur regularly to familiarise staff with command and control procedures and to ensure there is no erosion of skills. Senior managers are responsible for ensuring that all staff within their department are aware of the training available and encourage attendance on recommended courses. 13.Testing & Exercising Plans developed to allow organisations to respond efficiently and effectively, must be tested regularly using recognised and agreed processes such as table top or live exercises. Roles within the plan (not individuals) are exercised to ensure any specific role is fit for purpose and encapsulates all necessary functions and actions to be carried out during an incident.


Through the exercising process, individuals have the opportunity to practice their skills and increase their confidence, knowledge and skill base in preparation for responding at the time of a real incident. Testing and exercising will be undertaken in line with the annual Training and Exercise Schedule agreed by CCG Executive Boards and in line with NHS England’s EPRR Framework 2015 which defines the process and timescales for exercising. This includes a minimum expectation of a communications exercise every 6 months, a table top exercise ever year, and a live exercise every three years, in addition to any activation. 14. Dissemination, Implementation and Access to this Document This policy will be available to all staff on the internet or from the Governance department if requested. Awareness will be raised to managers of this policy via the Global Email system and other relevant corporate communication channels. Each department is required to disseminate this policy through normal governance procedures. 15. Monitoring Arrangements To ensure effectiveness, efficiency and compliance, the Accountable Emergency Officer with the assistance of the EPRR Lead, will carry out bi-annual reviews of this policy to ensure that is remains in line with current employment law and NHS guidance. 16. Audit arrangements The policy will be audited throughout the year both internally and externally. The EPRR Lead will also ensure that any appropriate external audits tools and assurance processes are conducted on a regular basis, examples of external audit tools include:

• Civil Contingencies Secretariat assurance; • Provision of assurance to NHS England; • ISO 22301; • Cabinet Office Civil Contingencies Secretariat National Capabilities Survey.

17. Equality Statement CCGs are committed to treating every individual equally and will not discriminate any groups of people or treat them differently because of their race, gender, disability, age, religion or belief systems or their sexual orientation (Appendix 1 Equality Impact Assessment Screening Tool). 18. References For further more detailed information regarding the contents of this policy please refer to the following documents:

• Civil Contingencies Act 2004; • The NHS England EPRR Framework 2015; • NHS England Business Continuity Management Framework (service resilience)

(2013) ; • NHS England Core Standards for Emergency Preparedness Resilience and

Response; • ISO 22301 – Societal Security – Business Continuity Management Systems –

Requirements.


APPENDIX 1- Equality Impact Assessment Tool DOCUMENT AUTHOR: Mark Haggerty

DIRECTORATE: EPRR Team

EPRR Policy

Annual Review

DATE June 2016 Aim/Status

[a] What is the aim/purpose of the policy/strategy/procedure? The aim of this policy is to provide a strategic framework which will ensure, as far as reasonably practicable in the event of a major incident will provide a response and support to partner organisations.

[b] Who is intended to benefit from this policy/strategy/procedure and in what way? All staff in the event of a major incident [c] How have they been involved in the development of this policy/strategy/procedure? As outlined above in the policy [d] How does it fit into the broader corporate aims? This policy provides assurance that a strategic and tactical frameworks exist within the organisation, to enable it to identify and respond to major or significant incident, in accordance with legislative an national guidance [e] What outcomes are intended from this policy/strategy/procedure? Adherence to this policy will improve EPRR in accordance with the aforementioned legislation and national guidance. [f] What resource implications are linked to this policy/strategy/procedure? During the initial response from an incident additional costs may be incurred either through the procurement of additional supplies and services. The Incident Director has authority to authorise these costs and it is the responsibility of this individual to maintain adequate logs and records of all activity undertaken in respect of the response to an incident.

Impacts [a] what is the likely impact [whether intended or unintended, positive or negative] of the initiative on individual users or on the public at large? The policy will have a greater impact and increased vulnerability for those staff with a disability. If staff are to be relocated to other locations, reasonable adjustments will need to be taken into account (e.g. access for wheelchairs) [b] Is there likely to be differential impact on any group? If yes, please state if this impact may be adverse and give further details [e.g. which specific groups are affected, in what way, and why you believe this to be the case] As mentioned above, the training on the implementation of the policy should consider the needs of the above groups so that staff are aware. If the policy is unlawfully discriminatory it must go to a full impact assessment (please Contact the Equality, Diversity & Human Rights Advisor – Human Resources Directorate) NO

Persons conducting EqIA

Signed

Date:


Business Continuity Procedures-Version 4 Date of Issue: February 2017 Review Date: February 2018

1

North West London Clinical Commissioning Groups

NWL CCGS BUSINESS CONTINUITY

PROCEDURES

BUSINESS CONTINUITY PROCEDURES V4.0

About this Plan:

CCGs are not expected to continue to deliver all functions in the event of a major incident or major business disruption. Therefore, CCGs have these business continuity procedures to allow some functions or services to be scaled up by scaling down or even suspending some non-critical functions. Please Note: The procedures documented in this plan should be used in conjunction with the Local

Business Continuity Plan in APPENDIX A.

DOCUMENT DETAIL:

Document Name Business Continuity Procedures Version 4.0 Author Mark Haggerty

Accountable Emergency Officer

BHH -Rob Larkman CWHHE- Clare Parker

Date of Issue February 2017 Review Date February 2018

TRAINING AND EXERCISE DETAIL:

Exercised On September 2016 Exercise Type Tabletop Exercise

Ex. Requirement Annual Tabletop Exercise or Three Yearly Live Exercise Next Exercise June 2017

Staff Training Requirements

All Staff Major Incident Training

Response Staff Emergency Preparedness Training Programme


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CONTENTS

BUSINESS DISRUPTION RESPONSE FLOWCHART .................................................................................................... 4 SECTION ONE – PLAN INTRODUCTION ........................................................................................................................ 5 1. OVERVIEW......................................................................................................................................................... 5

1.1 LEGAL REQUIREMENT ..................................................................................................................................... 5 1.2 AIM OF THE PLAN ............................................................................................................................................. 5 1.3 OBJECTIVES ..................................................................................................................................................... 5

2. UNDERSTANDING THE PRIORITY RATINGS ................................................................................................. 6 3. KEY INFORMATION .......................................................................................................................................... 6

3.1 RISK ASSESSMENT & BUSINESS CONTINUITY PLAN TRIGGERS............................................................... 6 3.2 FINANCIAL MANAGEMENT .............................................................................................................................. 7 3.3 INSURANCE ...................................................................................................................................................... 7

SECTION TWO – BUSINESS CONTINUITY RESPONSE ............................................................................................... 8 4. BUSINESS CONTINUITY RESPONSE AIMS ................................................................................................... 8 5. ROLES AND RESPONSIBILITIES .................................................................................................................... 8

5.1 ALL STAFF ......................................................................................................................................................... 8 5.2 TEAM LEADERS/MANAGERS .......................................................................................................................... 8 5.3 CONTINUITY LEADS ......................................................................................................................................... 8 5.4 ON-CALL DIRECTOR/INCIDENT DIRECTOR ................................................................................................... 8

6. BUSINESS CONTINUITY RESPONSE ............................................................................................................. 9 6.1 INITIAL ASSESSMENT AND ESCALATION ...................................................................................................... 9 6.2 RESPONDING USING THE RECOVERY TIME OBJECTIVE (RTO) AND MAXIMUM TOLERABLE PERIOD

OF DISRUPTION (MTPD) .................................................................................................................................. 9 6.3 LOGGING AND SITUATION REPORTING (APPENDIX C) ............................................................................... 9

7. SPECIFIC STRATEGIES ................................................................................................................................. 10 7.1 LOSS OF PREMISES STRATEGY .................................................................................................................. 10 7.2 LOSS OF UTILITY SERVICES STRATEGY .................................................................................................... 10 7.3 LOSS OF INFORMATION TECHNOLOGY ...................................................................................................... 10 7.4 LOSS OF STAFF STRATEGY ......................................................................................................................... 10

8. LINKS WITH OTHER PLANS .......................................................................................................................... 11 8.1 MAJOR INCIDENT PLAN ................................................................................................................................. 11 8.2 OTHER PLANS ................................................................................................................................................ 11

9. EXTERNAL LIAISON DURING A BUSINESS CONTINUITY EVENT ............................................................ 11 9.1 NHS ENGLAND LONDON ............................................................................................................................... 11 9.2 LIAISON WITH OTHER PARTNER AGENCIES OR GOVERNMENT BODIES ............................................... 11

10. COMMUNICATIONS ........................................................................................................................................ 11 10.1 INTERNAL COMMUNICATIONS ..................................................................................................................... 11 10.2 MEDIA ENQUIRIES.......................................................................................................................................... 11

SECTION THREE - RESTORATION AND RECOVERY ................................................................................................ 12 11. RESTORATION ................................................................................................................................................ 12

11.1 SCALED DOWN AND SUSPENDED SERVICE AND FUNCTIONS ................................................................ 12 11.2 RELOCATION FOR RESUMPTION OF SERVICE .......................................................................................... 12

12. RECOVERY ...................................................................................................................................................... 12 12.1 DEBRIEF .......................................................................................................................................................... 12 12.2 INCIDENT DOCUMENTATION ........................................................................................................................ 13 12.3 POST-INCIDENT RECOVERY ......................................................................................................................... 13

APPENDIX A – LOCAL BUSINESS CONTINUITY PLAN ............................................................................................. 14 WHO SHOULD USE THIS PLAN ...................................................................................................................................... 14 HOW TO USE THIS PLAN ................................................................................................................................................ 14

APPENDIX B – ACTION CARDS.................................................................................................................................... 15 INTRODUCTION TO ACTION CARDS ............................................................................................................................. 15 ACTION CARD 1 – MANAGER/TEAM LEADER............................................................................................................... 16 ACTION CARD 2 – CONTINIUTY LEAD ........................................................................................................................... 17

APPENDIX C –LOGS SITREPS AND LOG SHEETS .................................................................................................... 18 SITREP REPORT ALL TEAMS ......................................................................................................................................... 18 INCIDENT MESSAGES AND ACTIONS LOG .................................................................................................................. 19


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Version Control It is the responsibility of the Business Continuity Team (BCT) to ensure that these procedures adheres to current guidance. The BCT will update and review this plan following any incident/exercise debrief or changes to the organisational structure. Furthermore, this plan will be ratified in accordance with BHH/CWHHE guidance and procedures.

Date Version Author Changes/ Reason Documents Replaced (if any)

03/2014 1.0 M.Haggerty First version PCT

02/2015 2.0 M Haggerty Implementing recommendations as a result of the 2014 EPRR Assurance Process: Incorporating CWHHE/ Removing Information which is already published within the BC Policy

Version One

02/2016 3.0 M Haggerty Annual Review Implementing recommendations as a result of the assurance process

Version Two

02/2017 4.0 M Haggerty Annual Review implementing recommendations as a result of the assurance process reflecting the new EPRR definitions

Version Three


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BUSINESS DISRUPTION RESPONSE FLOWCHART

INCIDENT or

DISRUPTION

Team

Level One – Local Management

Team Leaders/Managers assess the situation and the extent of the disruption making sure staff are safe before determining if the function(s) they provide can continue by reorganising and focusing the resources under their line management. ESCALATION

If the disruption is too great and their function(s) cannot be maintained with the resources available then the management of the disruption should be escalated to the appropriate continuity lead (or their deputy) so further resources can be sourced elsewhere. (Refer to your Local Business Continuity Plan Appendix A)

On-Call Director (Gold/Strategic)

Continuity Lead (Silver/Tactical)

Department Plan

Service

Function

Team (Bronze/

Operational)

*Incident or Disruption may affect all or some teams depending on the

location, type, and scale.

Level Two – Department Management

On the receipt of a request for assistance, the continuity lead will activate their local level Business Continuity Plan (Appendix A) and using their action card (Appendix B) will manage the allocation of

resources across their department or CCG. The overall response at a local level will depend entirely on how contained the incident is, the continuity priority of the teams or business functions involved. ESCALATION If there is an actual disruption and a HIGH PRIORITY team/function which cannot be managed with the resources available, then the management of the disruption should be escalated through the Major Incident Procedures so further resources can be sourced from within NWL CCGs (Situation Reporting Form is available in Appendix C).

Team leaders/managers who cannot continue their functions contact their continuity lead who will coordinate additional resources

Level Three – NWL CCGs Wide Management (and beyond)

Once informed of a disruption the on-call director should evaluate the situation using their on-call pack and make the decision whether to declare a critical/ major incident or put NWL CCGs at standby. Once this has been carried out then the usual major incident procedures should be followed until the declared or standby status is stood-down.

Activate Major Incident

Procedures

Refer to the Incident Response Plan/

On-Call Pack

The Continuity Lead will be of an appropriate level of seniority (Director or Assistant Director)

within their CCG or Department


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SECTION ONE – PLAN INTRODUCTION

1. OVERVIEW This plan provides procedures for managing business disruptions, regardless of cause, to ensure that, at a minuimum NWL CCGs are able to provide its key critical functions and proritise business recovery. NWL CCGs will endeavour to manage disruptions at the lowest level practicable, starting with team leaders/managers, who will escalate any additional resource requests directly to their appropriate Continuity Lead. The Business Continuity procedures will only activate the abridged Major Incident command and control structure in the event of an actual or threatened disruption which cannot be managed at a local level. However, in the event of a critical or major incident the business continuity procedures will always be activated in support of the incident response.

For ease of use this plan has been divided into the following sections:

Section One –Aims and objectives, overview of the priority rating system and risk assessments;

Section Two – Business continuity response, roles & responsibilities, links with other plans, and communications;

Section Three – Restoration and recovery arrangements, post incident debriefing, reporting and back to business as usual timeline;

Appendices – Local Business Continuity Plan, action cards, log sheets, and sit reps.

Full versions of business continuity and major incident plans have been circulated and are accessible to on-call staff via PageOne Documents and [email protected], hardcopies are also located in the Incident Coordination Centres (Control Rooms). Edited versions of the aforementioned plans are available to all staff and key stakeholders on BHH/CWHHE CCG Emergency Preparedness webpages. This plan, like all NWL CCGs resilience arrangements, will be updated on an annual basis or to reflect any changes in the organisation’s structure, or following any recommendations from internal (or external) incidents and exercises. In addition, any major changes to national guidance or legislation may also trigger a review of the plan.

1.1 LEGAL REQUIREMENT

These Business continuity procedures have been prepared with reference to the NHS England Business Continuity Framework, which itself is based on guidance in the PAS 2015:2010 Framework for health services resilience, ISO 22301 Business Continuity Management Systems – Requirements and ISO 22313 Business Continuity Management Systems - Guidance. Furthermore the Civil Contingencies Act 2004 requires responders to maintain Business Continuity Management Plans to ensure that they can continue to exercise their functions in the event of an emergency, so far as is ‘reasonably practicable’.

1.2 AIM OF THE PLAN

The aim of the plan is to address business interruption rather than incident response and to ensure:

NWL CCGs are able to cope with the effects of an emergency situation or business

disruption, be that predicted or unforeseen.

That such an event is handled in a manner that enables CCGs to continue with minimal

disruption to its services or core business functions.

1.3 OBJECTIVES

The Objectives of this plan are to ensure:

1. NWL CCGs are compliant with its legal and regulatory obligations; 2. Risk assess NWL CCGs vulnerability to disruptive events; 3. Identify its critical functions and activities, ensuring their continuity; 4. Ensure staff are properly communicated with; 5. Staff receive adequate support in the event of a disruption.

mailto:[email protected]


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2. UNDERSTANDING THE PRIORITY RATINGS In a disruption or major incident CCGs will not be expected to keep all its services operating at business as usual levels, instead CCGs will proritise service delivery to ensure the continuation of its HIGH PRIORTY business functions; to achieve this, staff and resources from MEDIUM and LOW priority functions may be utilised elsewhere. All CCGs functions and services have been priority rated at either HIGH, MEDIUM or LOW for continuity and recovery purposes. The prority rating is calculated on the impact to the CCG if that function or service was completely suspended for 4, 8, 24, and 48 hours. For continuity and recovery decision making processes the priorities are defined as -

HIGH PRIORITY (Category A) – A function or service that CANNOT be stopped safely for between 4 to 48 hours without causing a breach of statutory duty, massive financial loss or major reputational damage.

MEDIUM PRIORITY (Category B) – A function or service that COULD be scaled down for up to 48 hours without causing a breach of statutory duty, massive financial loss or major reputational damage.

LOW PRIORITY (Category C) – A function or service that COULD be suspended for up to 48 hours without causing a breach of statutory duty, massive financial loss or major reputational damage.

It is this information that will be used in the response to determine which services and functions can safely be scaled back or suspended to maintain the HIGH PRIORITY services or functions When recovering services HIGH PRIORITY functions will be recovered first before the MEDIUM and LOW priority rated functions.

3. KEY INFORMATION For further information regarding definitions and strategic framework please refer to the Business Continuity/EPRR Policy.

3.1 RISK ASSESSMENT & BUSINESS CONTINUITY PLAN TRIGGERS

The CCA 2004 requires responders to carry out risk assessment using the following three phase process (Cabinet Office March 2012).

1. Contextualisation: nature and scope of the risk 2. Risk evaluation: identifying threats and hazards that present significant risks, analysing their

likelihood and impact 3. Risk treatment: decide which risks are unacceptably high, developing plans and strategies to

mitigate these risks.


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The following list highlights the nature and scope of some locally identified business continuity risks or triggers which are likely to result in the activation of our business continuity procedures. These triggers and risks have been developed using both local and community risk registers. The triggers or risks which are likely to result in activation of this Plan include:

Non-availability of key staff;

Damage or denial of access to premises;

Loss or damage to IT systems / Backup files / voice networks / hardware / software / data;

Loss or damage to other resources including key Utilities (water, electric, gas etc);

Loss of inputs and outputs from supply chain partners and contractors.

Business Continuity Planning, and its processes focuses Continuity Leads attention to the risks

that might impact on the delivery of their services. Managers should also take notice of indicators

of risk identified through other internal mechanisms, such as:

Adverse incident reporting Security reports Fire reports Health and Safety reports Accident reports

3.2 FINANCIAL MANAGEMENT

It is acknowledged that during the initial response from a business continuity incident additional costs may be incurred either through the procurement of additional supplies and services. As a consequence of this and in accordance with our governance framework the On-Call Director or Continuity Lead has authority to authorise these costs, however it is the responsibility of this individual to maintain adequate logs and records of all financial activity undertaken in respect of the response to an incident or business disruption. Where the action has financial implications, it is essential that the records are adequate to identify:

The expenditure that has been incurred and for what item or service

When and where the item or service is to be provided

To whom the expenditure is payable – the company or organisations name and address, and a named individual as contact

The relevant terms and conditions of sale

When the bill is payable

The name of individual approving the expenditure at the time

The date of the transaction

In order to provide an appropriate audit trail. Copies of such information will be supplied as soon as possible to the Director of Finance, or an officer nominated by the Director to oversee the financial implications of the incident.

3.3 INSURANCE

In accordance with the current legal framework NWL CCGs has insurance with the NHS lit igat ion Authority.


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SECTION TWO – BUSINESS CONTINUITY RESPONSE

4. BUSINESS CONTINUITY RESPONSE AIMS The aims of the overall business continuity response (regardless of level) are to:

Alert and mobilise the relevant staff and cascade any necessary internal alerts;

Evaluate the extent of the disruption/damage and the potential consequences;

Mitigate the effects of the disruption, regardless of cause, once it has occurred;

Minimise the reporting lines to prevent miscommunication and ensure a co-ordinated response;

Ensure the continuation of critical services until the disruption is over; and Organise the return to normal working after the disruption as rapidly and efficiently as

possible.

5. ROLES AND RESPONSIBILITIES

5.1 ALL STAFF

All staff have a role to play in business continuity in raising alerts, assisting managers in keeping their departments running as normal as possible, and being flexible in their working arrangements.

5.2 TEAM LEADERS/MANAGERS

Team leaders/managers keep their business as usual role in a business disruption and are responsible for the coordination of their team for which they are usually responsible. However, all team leaders/managers need to be aware of their continuity lead and their teams critical business functions.

5.3 CONTINUITY LEADS

Continuity Lead Role

Each CCG has an identified continuity lead. The ‘continuity lead’ is a person with existing line management responsibility and seniority, and whose role to ensure business continuity arrangements are implemented within their CCG. They are also the first point of contact to manage any incident or disruption that requires extra resources or assistance.

Continuity Lead Responsibilities

The main responsibilities of the business continuity leads are to:

Ensure that teams and managers within their agreed remit complete an analysis of critical functions and risks using the Business Continuity Management proforma;

Ensure that Business Continuity Plans are completed for each risk identified;

Provide the decision making for business continuity in an emergency or disruptive event, unless support is required from the On-Call Director (see below);

Ensure that Business Continuity Planning is activated and resourced appropriately to maintain all critical functions, working towards restoration of normal services;

Ensure that Business Continuity Plans are cascaded to appropriate staff within their remit who are given appropriate training; and

Ensure that Business Continuity Management Plans are reviewed annually or sooner as appropriate.

5.4 ON-CALL DIRECTOR/INCIDENT DIRECTOR

On-call Director/Incident Director Role

The Director On-Call or in their unavoidable absence, another of the organisation’s Directors will initially take the role of NWL CCGs Incident Director. However, the initial Director On-Call can be replaced by a more appropriate Director if the situation requires it. The main responsibilities of the on-call director are to:

Activate the Major Incident Procedures if the disruption has reached the thresholds to be considered a major incident;

Feed requests for additional resources into the relevant departments or CCG.


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6. BUSINESS CONTINUITY RESPONSE

6.1 INITIAL ASSESSMENT AND ESCALATION

It is the responsibility of the business continuity lead to ensure that each area within their remit have undertaken an initial assessment of the impact arising from any event resulting in, or potentially causing, business disruption. Where resources to support business continuity cannot be found within the staff under the management of this individual, they must escalate this to the on-call director.

6.2 RESPONDING USING THE RECOVERY TIME OBJECTIVE (RTO) AND MAXIMUM TOLERABLE PERIOD OF DISRUPTION (MTPD)

Using the Recovery Time Objective (RTO) to inform the response

All CCGs services and business functions have been assessed to ascertain the impact to our organisation over a series of times (4, 8, 24, and 48 hours) if they were completely stopped for whatever reason. The impact is rated either ‘Minor’, ‘Moderate’, ‘Serious’, ‘Major’ or ‘Catastrophic’ depending on the likely impacts on human welfare, legal and regulatory duties, financial loss, reputation and/or environmental damages the stopping of the team would have. Ideally, CCGs would like to recover any service two hours before it is likely to have ‘Major’ impacts, this calculation is known as the Recovery Time Objective (RTO). Most services or functions have a recovery time objective of 48hours + which means the suspension of this team is highly unlikely to have a major impact on the CCGs overall functioning for at least 48hours. These teams are therefore rated at either LOW or MEDIUM priority and if required could be scaled back or suspended to support a HIGH priority team or function. Functions/teams that have recovery time objective of 2 or 6 hours may require the activation of the major incident procedures.

Using the Maximum Tolerable Period of Disruption (MTPD) to inform response

In the same way as the recovery time objective was assessed, all CCGS Services have been assessed to ascertain their maximum tolerable period of disruption (MTPD), which is the amount of time the team or function can be stopped entirely before the possibility of full recovery becomes highly unlikely or impossible. This is set as the hour the impact of the loss has been assessed as being ‘catastrophic’. The loss of the majority of the teams or services will not reach a catastrophic impact level within 48 hours, giving them a maximum tolerable period of disruption of 48 hours +. However, the few teams or functions that have been assessed of having a catastrophic impact on CCGs within 48 hours of disruption should be prioritised above all else.

Please Note: Impacts are only rated for the first 48hours of disruption, if the incident or disruption has lasted for over this then the impacts on affected teams or functions will have to be rated again for the next 48 hours. This could mean that Teams and functions that were previously considered LOW or MEDIUM priority now score higher or have specific RTO and MTPD times.

6.3 LOGGING AND SITUATION REPORTING (APPENDIX C)

When responding to a disruption continuity leads and senior managers should ensure:

Decision(s)/actions are recorded/logged;

Details/contents of phone conversations should be documented;

Completed forms/original documentation or other evidence should be kept securely as it may be required in any subsequent debrief or inquiry.

(Action logs can be found in Appendix C) External Sitreps In response to an incident, NHS England may request regular updates, via the completion of SitReps. The on-call Director will authorise all returns (For NHSE sitrep details refer to on-call pack). Internal Sitreps Furthermore, in the event of a business disruption/major incident CCGs or the relevant department(s) will be asked to complete and submit internal sitreps to the on-call/incident director (Appendix C). Please note this form must be completed in full by all Departments or CCG on the receipt of a ‘DECLARED’ Major Incident message and every hour thereafter until the incident is ‘STOOD DOWN’ OR as per request for BUSINESS CONTINUITY response purposes


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7. SPECIFIC STRATEGIES

The general actions that all staff and continuity leads should take in the event of a business disruption can be found in their Local Business Continuity Plan in Appendix A.

7.1 LOSS OF PREMISES STRATEGY

NWL CCGs operates its functions out of a range of premises across North West London, the response to loss of premises will depend on the type of premises affected.

7.2 LOSS OF UTILITY SERVICES STRATEGY

The loss of a utility service may make CCGs premises temporarily unfit for purpose and an extended long-term loss of essential utilities may require the relocation of staff.

Electricity

Electricity is the most critical of the utility supplies as the loss of power supply has the potential to be catastrophic for many aspects of the CCGs’ business. Without electricity most office-based functions will come to an immediate standstill, although standby generators are available at some sites, an extended interruption to electricity supply will undoubtedly cause impacts on service provision especially as loss of power will often result in disruptions to water and gas supplies as these may depend on electrically operated pumps or relays.

Gas/ Heating

The loss of gas or heating will depend on the weather. However, in the worst case an extended loss of heating in a period of cold weather could require the relocation of the department.

Water

Initially the loss of mains water for drinking purposes is relatively easy to address by sourcing bottled water from existing, or alternative, suppliers. However, the loss of mains water for sanitation is potentially more problematic. NHS Clinical sites are recognised as priority sites by Water Companies for restoration of services.

7.3 LOSS OF INFORMATION TECHNOLOGY

The loss of information technology, will be an hindrance to staff, nevertheless managers should ensure staff have access to paper based systems. Where non-networked IT equipment (i.e. laptops) can be used instead these should be allocated from across departments on the basis of core business outputs. Each IT Service should have in place its own Core Service Continuity and Disaster Recovery Plan. It is also recommended that all staff should have NHS.NET account in addition to their CCG email account. The system is independent of the CCGs systems and will therefore continue to operate in most business disruption scenarios, including loss of access to sites, server failure etc. Staff using NHS Mail can continue to access their emails as long as they have access to the internet.

Telephony Failure

Predominantly the telephone services within NWL CCGs are provided by Voice over IP services. However, in the event this fails NWL CCGs Premises (which should have been identified in the business impact assessment), should have a landline (BT Analogue phone line) installed for further resilience. All continuity leads, their deputies and senior members of staff should also have a mobile phone.

7.4 LOSS OF STAFF STRATEGY

Shortages of staff can happen for many different reasons - from industrial disputes to severe weather negatively affecting the transport system. However, regardless of cause, continuity leads will ensure that HIGH priority functions have adequate staffing even if that means scaling back or suspending MEDIUM and LOW priority teams or functions for up to 48 hours. If the loss of staff is widespread and continues beyond 48 hours then the Incident Director should consider activating Major Incident Procedures so that further workforce management strategies can be put in place.


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8. LINKS WITH OTHER PLANS The Business Continuity Procedures can be used on their own in response to business disruptions or incidents regardless of cause. However, they can also be used as part of the response to other specific incidents or disruptions as detailed below.

8.1 MAJOR INCIDENT PLAN

The Business Continuity Procedures will always be activated to some degree with the declaration of a Critical or Major Incident. This will ensure that the on-call senior managers and director are not overwhelmed with operational issues while dealing with the major incident but at the same time still receive assurance from the continuity leads that services or core business functions are operating effectively.

8.2 OTHER PLANS

The following plans may be partly or wholly implemented as a result of the activation of the Business Continuity Plan are:

Major Incident Response Plan Fuel Plan

Severe Weather Flu Pandemic Plan

Heatwave Procedures Infectious Outbreak Plan

Cold Weather Plan Recovery Plan

9. EXTERNAL LIAISON DURING A BUSINESS CONTINUITY EVENT

9.1 NHS ENGLAND (LONDON)

NWL CCGs will liaise with the NHS England (London) in the event of a serious business disruption or if a Major incident is declared (refer to incident response plan (IRP)).

9.2 LIAISON WITH OTHER PARTNER AGENCIES OR GOVERNMENT BODIES

NWL CCGs will liaise with other partner organisations as appropriate.

10. COMMUNICATIONS (For further information regarding communications please refer to IRP) The Communications lead will implement the communications plan and ensure that communications with other stakeholders and the media are managed appropriately. The On-Call Director will agree with the communications lead the following:

Method of communication;

Content of messages;

Frequency and timing of messages.

10.1 INTERNAL COMMUNICATIONS

It is vital that staff are kept up to date with accurate information about the business disruption , all communications with staff will be mindful of the personal, as well of the professional impact of the incident.

10.2 MEDIA ENQUIRIES

All media enquiries will be referred to the Communications Lead, On-Call Director or your Continuity Lead, no member of staff should discuss any aspect of the incident with the media.


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SECTION THREE - RESTORATION AND RECOVERY

11. RESTORATION When restoring a service or business function the following should be taken into consideration.

11.1 SCALED DOWN AND SUSPENDED SERVICE AND FUNCTIONS

When restoring functions that have been scaled down or suspended, a reassessment should be made of the recovery time objective (using impact over time) to set the order for restoration and prioritisation for resources.

11.2 RELOCATION FOR RESUMPTION OF SERVICE

If the building the CCG or department operates out of is lost, or there is a denial of access then the following options should be considered for resumption:

Budge up – share premises and resources with another CCG or department;

Displacement – Higher priority services to displace non-affected lower priority services;

Reciprocal arrangements – share premises or outsource to another NHS organisation (Mutual Aid);

Third Party Alternative – liaise with the local authority, commercial partner or social enterprise property;

12. RECOVERY

12.1 DEBRIEF

Within 48 hours of recovery, the continuity lead ending the response to a business disruption will facilitate a ‘hot debrief’. A ‘hot debrief’ is:

o A process for learning lessons from the incident; o A forum for staff to express immediate issues which may concern them; o An opportunity to thank staff.

A ‘hot debrief may help NWL CCGs identify staff who may need further support but should NOT:

o be allowed to become over-emotional or confrontational; o be used to criticise individuals; o be overly detailed; o be used to provide any form of post incident psychological support.

The hot debriefs should be minuted and last no more than an hour. Once the hot debriefs have been conducted the Business Continuity Team will organise a series of ‘Cold’ structured debriefs. These will happen no more than four weeks after the end of the incident and will consist of a facilitated session looking at what worked and did not work in the incident response and how the response could be improved in the future. The results of the debrief will feed into a full incident report by the Business Continuity Team who will gather further details about the response effort from incident logs and messages. The report will:

Summarise the sequence of events Identify the individuals involved Describe the actions of staff Provide an accurate timeline


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12.2 INCIDENT DOCUMENTATION

After an incident all documents including logs, notes, post-its, flip charts, electronic documents, memos, and message pads must be retained, and be sent to the Business Continuity Team, The Heights, Harrow on the Hill (Tele:-02089661066). It will be the responsibility of the Accountable Emergency Officer(s) for sourcing an appropriately secure premises to store the documents to facilitate any future internal or external investigations in accordance with current Department of Health’s record management codes of practice and our Corporate Record management Policy.

12.3 POST-INCIDENT RECOVERY

Recovery planning starts at the very beginning of the business continuity response, where continuity leads look at the recovery time objective for all effected teams and functions. This information is then used to assess which services can be scaled down and suspended in support of the HIGH priority business functions and services.

Within 48 hours of the hot debrief (see above) the Incident Director’s or the Continuity Lead’s management team will have an initial meeting to assess the disruption to the operational functions caused by the incident, including any long-term implications and how to return to business as usual. This assessment will include:

Effects on staffing (e.g. loss of staff through injury or sickness, impact of overtime worked by staff during the incident on staffing levels);

Support needs of staff affected by the incident (including trauma support);

Disruption caused to key business outputs;

Damage inflicted to property;

Financial losses;

Future provision of services or business functions in the short-, medium- and long-term.

The results of the aforementioned assessment will be used to formulate a post-incident recovery action plan with timescales for the return to business as usual (For further information please refer to NWL CCGs Recovery Plan.)


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APPENDIX A – LOCAL BUSINESS CONTINUITY PLAN

WHO SHOULD USE THIS PLAN

This plan should be used by the Team Leader/Managers of the listed teams or functions and the named continuity lead or their nominated deputy.

HOW TO USE THIS PLAN

This plan should be used in two ways first for the initial response to a disruption and alerting (team leaders/ managers); and secondly to support tactical decision making by listing the criticalities, recovery time objectives, maximum tolerable periods of disruption of teams and functions as well as key contact details and building addresses. If you have not yet developed a local Business Continuity Plan please refer to your existing plan to ascertain your CCGs or Departments Critical Functions.


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APPENDIX B – ACTION CARDS

INTRODUCTION TO ACTION CARDS

During a business disruption members of staff may be asked to perform a key role on behalf of the CCG, these roles might be different from their usual responsibilities so action cards have been developed to support staff in this situation. If the disruption lasts for more than 8hours then it may be necessary for another member of staff to take over the action card role (because they are providing relief, or they have more localised appropriate experience) this can only happen after a full briefing has to been given, in writing, on the actions taken to-date and outstanding issues. Until this has taken place, the member of staff originally assigned to the action card will be considered as still in place and responsible for all actions associated with the role. All staff with a specific role should:

Be familiar with the contents of their own action card;

Use it from the moment they are contacted about a disruption.


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ACTION CARD 1 – MANAGER/TEAM LEADER

BUSINESS CONTINUITY ACTION CARD

MANAGER/TEAM LEADER

As a team leader/ manager you are responsible for the same teams and functions you are on a day to day basis.

IN response to a disruption as a Manager/Team Leader you will: You will NOT:

Contact your designated Continuity Lead or nominated deputy as identified in your local business continuity plan, and complete the situation report (Sitrep) form (Appendix C)

On the request of the continuity lead scale down or suspend your service or function and release your resources to support another area of BHH/CWHHE.

Take resources from another team unless authorised by the continuity lead

Remember: Business Impact Assessments are only rated for the first 48hours of disruption, if the incident or disruption has lasted for over this then the impacts on affected teams or functions will have to be rated again for the next 48 hours. This could mean that Teams and functions that were previously considered LOW or MEDIUM priority now score higher or have specific RTO and MTPD times.

USING THE LOCAL BUSINESS CONTINUITY PLAN

The Local Business Continuity Plan is found in Appendix A. It will cover a group of teams or business functions within your CCG or department.

The continuity lead (or their nominated deputies) contact details are on the first page.

If the incident is in your area then first follow the emergency actions to ensure the safety of staff.

Finding your RTO and Priority

Check, your team or function should be contained on the list on the front. If not contact the continuity lead who will refer you to the correct lead.


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ACTION CARD 2 – CONTINIUTY LEAD

BUSINESS CONTINUITY ACTION CARD

CONTINIUTY LEAD

As a continuity lead you are responsible for co-ordinating business continuity measures across your CCG. This may involve scaling down or suspending some of the your services or functions to keep the HIGH priority rated functions running or in support the wider BHH/CWHHE wide response.

IN response to a disruption as a Continuity Lead you will: You will NOT:

Consider scaling down or suspend some services to release resources to support another area of business

If you need further resource to keep the minimum level of service then you will escalate this through the on-call director and you will need to complete the situation report (Sitrep) form (Appendix C)

Take resources from another department or CCG unless authorised by the on-call director or incident director

Remember: Impacts are only rated for the first 48hours of disruption, if the incident or disruption has lasted for over this then the impacts on affected teams or functions will have to be rated again for the next 48 hours. This could mean that Teams and functions that were previously considered LOW or MEDIUM priority now score higher or have specific RTO and MTPD times.

USING THE LOCAL BUSINESS CONTINUITY PLAN

The Local Business Continuity Plan is found in Appendix A. It will cover a teams or services within your CCG or department

The continuity lead (or their nominated deputies) contact details are on the first page.

If the incident is in your area then first follow the emergency actions to ensure the safety of staff.

Finding your RTO and Priority


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APPENDIX C –LOGS SITREPS AND LOG SHEETS

SITREP REPORT FORM TO BE SUBMITTED ON INITIAL ESCALATION (SEE PAGE 4) OR DURING A ‘DECLARED’ MAJOR INCIDENT

SITUATION REPORT (SITREP) FORM

Please note this form must be completed in full by all Departments or CCG on Initial Escalation

OR on receipt of a ‘DECLARED’ Major Incident message and every hour thereafter until the

incident is ‘STOOD DOWN’ OR as per request for BUSINESS CONTINUITY response purposes

TIME (HH:MM): DATE (DD/MM/YY): CONTACT NO.

CCG OR DEPARTMENT:

SENIOR MEMBER OF STAFF:

RECORDED BY:

CURRENT SITUATION (Briefly provide an overview of how your team/ area is functioning):

CURRENT STATUS (Delete as appropriate)

A: Unaffected, by the incident or disruption

B: Affected by the incident or disruption but with no or negligible impact on service delivery

C: Affected by the incident directly but meeting minimum service delivery requirements OR Affected by the incident indirectly as resources have been redeployed elsewhere but minimum service being maintained

D: Directly affected by the incident and not meeting minimum service delivery/ OR Suspended as part of the incident response.

Resources available to support the response (i.e. staff, buildings, IT equipment): Resources currently deployed elsewhere in support of the response (i.e. staff, buildings, IT equipment):

ACTIONS TAKEN (Actions agreed in the return phone call from on-call staff should be recoded below, and in the ‘Incident Messages and Actions Log’

ACTION UNDERTAKEN BY TIME (HH:MM) DATE (DD/MM/YY)

SIGNATURE

PASSED TO:

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INCIDENT MESSAGES AND ACTIONS LOG

Entry No.

Date DD/MM/YY

Time HH:MM

Information/Message (ingoing or outgoing)

From Contact details Action Taken Undertaken By Time HH:MM

Initials

Example 01 15/09/13 16:40 Major incident declared message

received

Gold

Command

020 4822

3070

Forwarded call on to next

areas in the cascade

Robert Smith 16:45 RS

DO NOT DESTROY – ENSURE ALL LOG FORMS ARE RETURNED TO THE BUSINESS CONTINUITY TEAM WITHIN 24HRS OF INCIDENT ‘STAND DOWN’