The National Health Service (NHS) England Emergency Preparedness, Resilience and Response Framework exists to provide a structure by which NHS England and NHS-funded bodies prepare for and respond to a range of emergencies. This framework exists to ensure that in emergencies the NHS retains the capability to deliver appropriate care to patients. Rather than dealing with individual scenarios, the framework aims to maintain the adaptability and capacity to deal with a variety of emergencies, their consequences and guide recovery plans. This paper summarises this guidance and elucidates the reasoning and mechanisms by which this care will be facilitated and delivered.
- organisation of health services
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The Civil Contingencies Act (CCA) 2004 divides responders into: category 1: responders, who are responsible for core emergency service delivery, and category 2: Clinical Comissioning Groups (CCGs, who coordinate local resources.
National Health Service (NHS) England is the lead oversight body ‘ensuring the NHS is prepared to deal with an emergency’ with multiple roles.
The dominant principles of NHS Emergency Preparedness, Resilience and Response (EPRR) are: preparedness and anticipation, continuity, subsidiarity, communication, cooperation and integration and direction.
Cooperation between the CCA 2004-defined responders is a moral and legal obligation. Legal requirements are not reduced by EPRR, and significant public scrutiny may occur.
On an operational level, organisations command and control their own personnel and resources for specific tasks; these may be transferred to other organisations if needed.
The National Health Service (NHS) has a legal obligation in the Civil Contingencies Act 2004 (CCA 2004) and NHS Act 2006 (as amended) to plan and prepare to effectively respond to a range of specified and unspecified emergencies that could affect healthcare and health; this role is met through EPRR teams. This strategic guidance involves Accountable Emergency Officers (AEOs) and Emergency Preparedness, Resilience and Response (EPRR) practitioners throughout the NHS and NHS-funded organisations (including charitable and independent NHS contractors) as well as incorporating potential input from military and government sources. Each NHS funded organisation then formulates its own more focused framework.
The formal definition of emergency preparedness given is ‘The extent to which emergency planning enables the effective and efficient prevention, reduction, control, migration of and response to emergencies’. Emergencies are defined by the CCA 2004 as ‘(a) an event or situation which threatens serious damage to human welfare in a place in the United Kingdom; (b) an event or situation which threatens serious damage to the environment of a place in the United Kingdom; (c) war, or terrorism, which threatens serious damage to the security of the United Kingdom’.
Whereas the NHS has three broad categories of incidents: business continuity incidents, critical incidents and major incidents where additional support will be required. Business continuity incidents are where service delivery may be disrupted by events. Critical incidents result in an organisation becoming unable to safely perform their core functions and services. Major incidents include any CCA 2004-defined emergency, or incidents that require additional support due to their nature or quantity or threaten the ‘health of the community’. Four incident levels are used to facilitate communication through the NHS (Table 1); these levels can be used for any type of incident for which there are multiple definitions that include: mass casualty, cyberattacks, hazardous materials and rising tide events such as a ‘emerging infectious disease outbreak’.
Responders and categories
The CCA 2004 divides responders into two categories. Category 1 responders are responsible for core emergency service delivery and includes the Department of Health (DH), NHS England (at all levels), the majority of NHS Provider Organisations (eg, Acute Hospital Trusts and Ambulance Service), Public Health England (PHE) and local authorities via Directors of Public Health. Category 2 responders are the CCGs who may coordinate local resources such as primary care. Those with no formal collective responder status include NHS Blood & Transport, Mental Health Trusts, Local Health Resilience Partnerships (LHRPs), Devolved Administrations (eg, Manchester) and other NHS-funded providers that are expected to plan and respond as if they were category 1 responders, in accordance with Standard Contract (SC30). Each responder is required to have its own incident response plan.
NHS England is the lead oversight body ‘ensuring the NHS is prepared to deal with an emergency’ with multiple roles. These include representing the NHS at Local Resilience Forums (LRFs), providing oversight, monitoring and compliance for the CCGs and service providers. As such, NHS England works at a strategic and tactical level to ensure service delivery.
Principles of NHS EPRR
Preparedness and anticipation: specific and generic plans with training for these, so individuals and organisations are capable to perform and understand their distinct roles and responsibilities.
Continuity: organisations work within their existing systems and structures although with potential for larger capacity.
Subsidiarity: decisions occurring at the lowest possible level being coordinated as high as possible.
Communication: among the responders and with the public.
Cooperation and integration: ‘Active mutual aid across’ organisations.
Direction: clearly understood and agreed strategic and tactical objectives.
Cooperation between CCA 2004-defined responders is a moral and legal obligation. NHS England takes the coordination role at the LRF level and works with the NHS at the local level. Health economy EPRR planning groups and LHRPs act as enablers. Mutual aid includes prior agreements and if used effectively reduces interorganisational and intraorganisational bottlenecks. Information sharing: organisations need to plan for what information they require, need to respond to and make available to partner organisations and the public. Information governance should make provision for EPRR.
Legal requirements are not reduced by EPRR and significant public scrutiny may occur; hence, loggists and scribes are essential in management teams as notes may be required for coroner’ s inquests or criminal or judicial inquiries among others. Decisions taken and resultant actions must be recorded in an auditable fashion.
Roles within NHS England’s EPRR
Accountable Emergency Officers
All NHS and NHS-funded organisations including NHS England have AEOs who are board-level directors appointed by the individual organisation’s chief executive with statutory responsibility for EPRR. Together with another board member they ensure the organisation is meeting legal and policy requirements and provide assurance that the organisation has the capacity and capability to fulfil them. This role involves compliance against core standards and providing assurance to the board and liaising with other organisations or working groups such as LRFs or LHRPs.
Providers of NHS services
In addition to providing EPRR services and supporting category 1 or 2 responders, providers need to have assured, exercised plans for operational requirements internally and in conjunction with other bodies. These must fit the principles outlined for providers and may involve board level representation at partnerships and forums and appropriate input to local health economy planning groups (Figure 1).
The ambulance service provides subject matter experts capable of giving advice on scenes or to the ambulance tactical or strategic commander. They must also be able to advise ambulance staff and management when faced with unusual incidents. Mental health service providers ensure they can provide appropriate psychosocial support following an incident and must have a secure evacuation and relocation plan for service users.
CCGs as category 2 responders have a commissioning, assurance, compliance, EPRR and service continuity duty. Like other providers, they must ensure that information can cascade up and down, act in local forums and partnerships and support NHS England. Additionally, in alert levels 2–4, they enable health economy tactical coordination.
Local Health Resilience Partnerships
LHRPs ‘support the health sectors contribution to multiagency planning through the LRF’. They lead multiagency strategic planning across a geographic area and are cochaired by the local lead Director of Public Health and NHS England, coordinating NHS-funded providers and commissioners. Together with local public health input and NHS provided services, the cochairs allow the LHRPs to plan for incident and continuity management in geographic areas and local health economies. LHRPs provide input to Public Health England and local government planning for incidents.
LHRPs are strategic forums for joint planning but are not statutory. thus each constituent organisation retains their individual legal accountability for preparedness. The LHRPs’ input is part of the health sectors’ contribution to LRFs multiagency planning. Hence, LHRPs and LRFs exchange minutes and may coordinate subgroups to avoid duplication.
Local Resilience Forums
LRFs are multiagency partnerships, geographically corresponding to police force areas, comprising category 1 responders; emergency services, local authorities and county councils; the Environment Agency; and acute hospital trusts. They are supported by category 2 responders such as transport companies (eg, Network Rail and Highways England), utility companies, CCGs and LRF subgroups. They also deliver training and exercising programmes.1
NHS England ensures there is a strategy and an assured system in place for EPRR delivery for itself and the DH while working with PHE. If an incident occurs, it will lead the mobilisation of the NHS and fulfil its own statutory, including category 1 responder, roles. On a local level, these roles include LHRP and LRF representation, ensuring integrated and unified plans while seeking assurance from these forums. On a national level, NHS England represents the NHS to DH and ensures Health Service compliance with National Risk Assessment (NRA) requirements. NHS England submits requests for military assistance on behalf of NHS organisations to the DH.
DH takes the lead at a government level in providing assurance to ministers, the cabinet office and other departments for national and international emergencies and ensures adequate risk quantified plans are in place for the NRA. Policy requirements are formulated and promulgated to NHS England, PHE and local government. DH works with national administrations and international governments to plan for and respond to emergencies.
Public Health England
Nationally PHE ensures the public health component to EPRR plans and works with the NHS at all levels as well as providing specialist input and has a category 1 responder role. Regionally, PHE provides support to PHE centres and aims to deliver plans across more than LHRP area up to nationally while facilitating public health responses to emergencies. Locally, PHE provides representatives to LHRPs and the LRFs as well as ensuring coordinated local plans are in place.
Department of Communities and Local Government (DCLG)
The DCLG ‘Provides the platform for multi-LRF co-operation and planning in emergency preparedness’.2 This subnational tier facilitates communication and coordination between local and national responders. DCLG ensures areas are prepared in the event of an LHRP area being overwhelmed. DCLG has a Resilience and Emergencies Division who can provide a government liaison officer to facilitate communication with LRFs particularly for multiarea/high-impact incidents. DCLG or other government agencies can independently create a multistrategic # coordinating group to respond to and co-ordinate local strategic coordinating groups.
Cabinet Office and Cabinet Office briefing rooms
The Cabinet Office prepares for emergencies with all levels of government and facilitates central government responses (Figure 2). It is permanently at a high state of readiness and decides when to activate the central response mechanism and brings in officials and ministers to ensure situational awareness is maintained to enable rapid decision making.
Training and exercising
Training needs to cover the enhanced flows and expanded roles that staff may require, with specific needs identified by a formal Training Needs Analysis, which should include understanding working with other agencies if necessary. A Skills for National Justice Occupational Standards framework details the standards to be achieved in training.3 Once identified, training needs to be given on an ongoing basis to ensure EPRR is embedded within an organisation.
Exercising that is targeted, logged and auditable must be performed regularly to test the suitability of roles and to give individuals the chance to practice their skills, gain knowledge and confidence. Interagency exercises are encouraged. Lessons learnt from exercises are fed back into an annual validation plan and form part of organisations institutional memory.
NHS-funded organisations are require to engage in four types of exercise at minimum specified intervals. Communications exercises should be performed every 6 months and should include out-of-hours and unannounced tests. Table top exercises every 12 months work through scenarios bring together key members of staff and help validate new or revised plans and can promote knowledge or partner organisation roles. Live play exercises every 3 years involve simulated casualties with different agencies working alongside one another and multiagency bodies such as the LRF where relevant. Command post exercises every 3 years can be part of another exercise and include the setting up of an Incident Coordination Centre and the practical testing of equipment and roles in doing so.
Lessons learnt from training and exercising are fed up to through the LHRPs to ensure cohesion and cross-agency learning.
While in some incidents the normal cascade process via the ambulance service may occur, in others such as business continuity incidents or rising tide epidemics, local commissioners, NHS England may alert agencies or NHS England’s regional team. Once alerted, NHS England may assist with command, control and drawing in appropriate resources including from other CCG areas. Four standard alert message types reduce confusion. A major incident – standby allows preparation for the specified type of incident. Major incident declared – activate plan enables mobilisation of additional resources. Major incident – cancelled applies to a standby or activate plan. Major incident stand down when a scene is cleared, each organisation chooses when it individually stands down.
To promote situational awareness, the acronym METHANE is used as per Joint Emergency Services Interoperability Principles.4 Organisations declaring critical incidents generally internally use the situation, background, assessment and recommendation format.
Effective communications within the health sector and to the public ensures responses are more proportionate and reduces excessive speculation. Communications leads, often from NHS England, liaise with the LFR, DH, PHE and engage with social and regular media 24/7.
Command and control
On an operational level, organisations command and control their own personnel and resources for specific tasks within their area of operation. These may be transferred to other organisations if needed. An operational commander can advise if a tactical command is necessary.
Tactical command coordinates operational commands and engages with other agencies allocating resources including time to priorities while assessing risks of the operation and to standard the public. The NHS tactical commander is set by NHS England with input from CCGs and can advise if a strategic command is necessary.
Strategic command can view the incidents in more far reaching context, understanding the broader implications and takes ‘overall responsibility for the multi-agency management of the incident and to establish the policy and strategic framework within which lower tier command groups will work’. Individual responder agencies still retain their command authority but can be advised.
The NHS command and control is proportionate to the alert raised. At alert level 4, national coordination is employed as well as all actions needed in alert levels 1, 2 and 3. Alert levels 1 and 2 are at local health economy, CCG or individual organisation level. Level 3 requires a regional command with local organisations still having tactical control. Incidents may evolve over a prolonged timeframe so sustainability is inbuilt into command and control.
Each organisation needs to have an Incident Coordination Centre (ICC) where the incident management team can implement a formalised structure and arrangements to manage and incident, particularly where flexibility may be required in terms of time and resources. A preset ICC gives a recognised structure, reduces redundancy and can ensure focused application of organisational resources. Five broad categories required of ICCs are coordination, policy making, operations, information gathering and information dispersing internally and externally. ICCs must be sited where there is sufficient resiliency to allow operations to continue during incidents, for example, natural disasters, and equipment should be tested every three months.
Recovery and debrief
Recovery begins as soon as possible and runs parallel to response and continues until normality has been restored. Recovery may need multiagency input and can be a chance to improve service design and practice; detailed advice can be found in the national Emergency Response and Recovery Guidance.5
Debriefing gathers information from an incident and captures areas to be improved. Hot debriefs usually occur immediately post-incident but can occur during a prolonged response. Cold internal debriefs usually occur 2 weeks postincident. Multiagency debriefs should happen 4 weeks with postincident reports at 6 weeks postincident. Postincident reports should identify lessons learnt and provide auditable action plans to generate improvements. Lessons learnt will be shared through the organisation and more broadly if needed.
Contributors SM conceived the paper and drafted the manuscript. SG provided much information and contributed substantially to the paper's revision.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.