Major Incident Framework
MAJOR INCIDENT FRAMEWORK
Major Incident Framework
Lead Directors:
Lou Patten (AVCCG), Annet Gamell (Chiltern CCG)Cathy
Winfield (West Berkshire CCGs) and Alan Webb (East Berkshire
CCGs)
Date:
July 2013
Version:
001
Author:
Catherine Hartz Emergency Planning Liaison Officer –
Buckinghamshire and Berkshire CCGs
Review date:
Changes ratified by:
Date:
July 2014
Bracknell & Ascot CCG
Governing Body
November 2013 (TBC)
Slough CCG Governing
Body
November 2013 (TBC)
WAM CCG Governing
Body
2nd October 2013
EXTERNAL DISTRIBUTION LIST
Berkshire Healthcare FT
Bracknell Forest Council
Buckinghamshire County Council
Buckinghamshire Healthcare NHS Trust
Buckinghamshire Urgent Care Services
Burns and critical/trauma network
Central Southern Commissioning Support Unit
Environment Agency
Health Protection Agency (Thames Valley Health Protection Unit)
Heatherwood & Wexham Park Hospital FT
Milton Keynes Hospital NHS Foundation Trust
NHS Blood and transplant
NHS England -South
NHS England- Thames Valley
Nuffield Orthopaedic Centre NHS Trust
Oxford Health NHS Foundation Trust
Oxford University Hospitals NHS Trust
Oxfordshire Clinical Commissioning Group
Public Health
Reading Council
Royal Berks Hospital FT
Slough Council
South Central Ambulance Service NHS Foundation Trust
South Oxfordshire District Council
Southern Health
Thames Valley Emergency Access
Thames Valley Health Protection Unit
Thames Valley Police
Vale of White Horse District Council
West Berkshire Council
Windsor & Maidenhead Council
Wokingham Borough Council
Major Incident Framework
Foreword
The overarching Major Incident Framework for Buckinghamshire and Berkshire
Clinical Commissioning Groups describes how the Clinical Commissioning Groups
working in collaboration with NHS England -Thames Valley and NHS funded
providers will respond to a major incident, significant incident or emergency. It
comprises of two parts, the Framework and the On Call Incident Response Plan. The
Major Incident Framework and the Incident Response Plan aim to bring coordination
and professionalism to the often unpredictable and complicated events of a major
incident, significant incident or emergency.
The purpose of planning for emergencies is to ensure that as organisations, the
Clinical Commissioning Groups can fulfil their responsibilities under the Civil
Contingencies Act 2004 and support the NHS funded providers and NHS England Thames Valley to provide an effective response to any major incident or emergency
and to ensure that the organisations can return to normal services as quickly as
possible.
The overall aim of the Major Incident Framework is to achieve an effective response
to any emergency regardless of the cause. This framework is sufficiently flexible to
deal with a range of situations. It is therefore necessary for all members of Clinical
Commissioning Groups to become acquainted with these procedures and, through
training and exercising, become fully aware of their individual responsibilities.
This framework has been put together in collaboration with our partner organisations
across Thames Valley including NHS England -Thames Valley, Oxfordshire CCG,
emergency services, local authorities and emergency planning experts. I commend
this document to you and thank you for your cooperation.
Lou Patten
Annet Gamell
Cathy Winfield
Alan Webb
Chief Officer, Aylesbury Vale CCG
Chief Clinical Officer, Chiltern CCG
Chief Officer, West Berkshire CCG Confederation
Chief Officer, Bracknell and Ascot CCG, Slough CCG
and Windsor, Ascot and Maidenhead CCG
Major Incident Framework
CONTENTS
1
Executive Summary ...................................................................................................... 1
2
Introduction ................................................................................................................... 2
3
Major Incident, Significant Incident or Emergency ......................................................... 3
4
NHS Standard Contracts and NHS England Emergency Preparedness Framework ..... 4
5
Legal framework and decision making framework ......................................................... 8
6
Principal Organisational Roles and responsibilities........................................................ 9
7
Command and Control Structure ................................................................................. 14
Table 1 NHS England incident alert and response levels ............................ 14
8
Multi-agency Command and Control ........................................................................... 17
9
NHS England Thames Valley Area Team - Response to a major incident, significant
incident or emergency ......................................................................................................... 18
10
Recovery ..................................................................................................................... 21
11
Communications ......................................................................................................... 21
12
Training ....................................................................................................................... 23
13
Testing and exercises ................................................................................................. 23
14
Assurance ................................................................................................................... 24
15
Appendix 1a ................................................................................................................ 25
16
Appendix 1b ................................................................................................................ 26
1 Executive Summary
1.1 The NHS needs to be able 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 infectious disease outbreak 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. This programme of work is
referred to in the health community as emergency preparedness resilience and
response (EPRR).
New arrangements for local health EPRR commenced on1 April 2013 as part of
the changes that the Health and Social Care Act 2012 made to the health system
in England. The key elements are that:


EPRR responsibilities of strategic health authorities (SHAs) and primary care
trusts (PCTs) were transferred to the NHS Commissioning Board (NHS
England) and to Clinical Commissioning Groups (CCGs);
Local health resilience partnerships (LHRPs) are the forum for coordination,
joint working and planning for EPRR across all relevant health bodies; and
organisations have accountable emergency officers in place who take
executive responsibility and leadership at service level for EPRR.
NHS England emergency preparedness resilience and response guidance can be
found at http://www.commissioningboard.nhs.uk/eprr/
1.2 EPRR remains a key priority for the NHS as detailed in the Operating Framework
for the NHS in England 2013/14. Specific requirements for EPRR are set out in the
NHS Commissioning Board planning framework (‘Everyone Counts: Planning for
Patients’), “Putting Patients First”, the NHS standard contract and through this the
NHS Commissioning Board Emergency Preparedness Framework (2013). Key
responsibilities for all NHS organisations are detailed in the ‘NHS Commissioning
Board Core Standards for Emergency Preparedness, Resilience and Response
(EPRR)’ from which an annual assurance process will be implemented.
During times of severe pressure and when responding to major incidents,
significant incidents and other emergencies, NHS organisations need a structure
which provides:
 clear leadership;
 accountable decision making; and
 accurate, internal and external communication strategies
This structured approach to leadership under pressure is known as “command,
control, communication and co-ordination”.
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1.3 The Buckinghamshire and Berkshire CCGs Major Incident Framework is built on
the principles of risk assessment, cooperation with partners, emergency planning,
communicating with the public, and information sharing.
1.4 This plan is sufficiently flexible to deal with a range of situations and is comprised
of two parts. The first part is the overarching major incident framework itself which
sets out the role of the Buckinghamshire and Berkshire CCGs, NHS funded
organisations and NHS England -Thames Valley in a major incident and explains
how their roles fit together with those of other NHS organisations and the
emergency services. This is the strategic part of the plan and is designed to be
read by all staff, especially those on call staff when they first join the on call rota.
1.5 The second document is known as the on call incident response plan. This
document is designed to be used by the on call director / manager. It summarises
the practical steps that need to be taken in the event of a surge capacity issue,
major incident, significant incident or other emergency. The incident response
plan also has key contacts and information for each county area (Buckinghamshire
and Berkshire) and other partner agencies within the Thames Valley.
2 Introduction
2.1 Buckinghamshire and Berkshire CCGs Major Incident Framework follows a set of
general principles that guide all NHS organisations in developing their ability to
respond to major incident, significant incidents and other emergencies and to
manage recovery locally within the context of the requirements of the Civil
Contingencies Act 2004 (CCA 2004).
This document should be read in conjunction with:
 NHS England Business Continuity Management Framework (Service
Resilience) (2013);
 NHS England Emergency Preparedness Framework (2013); and
 NHS England Core Standards for Emergency Preparation, Resilience and
Response (2013).
 NHS England Command and Control Framework
 Thames Valley Local Resilience Forum multi agency plans
 Clinical commissioning group major incident frameworks and incident
response plans
 Public Health England Centre(PHEC) major incident frameworks and incident
response plans
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3 Major Incident, Significant Incident or Emergency
3.1 This section describes various definitions of major incidents, significant incidents
and emergencies as they may apply to NHS organisations and providers of NHS
funded care and the varying scale of these incidents.
3.2 There may be times of severe pressure such as winter periods, a sustained
increase in demand for services (surge) or an infectious disease outbreak.
3.3 A significant incident or emergency is any event that cannot be managed within
routine service arrangements. It requires the implementation of special procedures
and may involve one or more of the emergency services, the NHS or a local
authority.
3.4 Within local NHS organisations these emergencies are often referred to as Major
Incidents.
The term ‘emergency’ is used as defined in the Civil Contingencies Act 2004:
‘To describe an event or situation that threatens serious damage to human
welfare in a place in the UK or to the environment of a place in the UK, or war
or terrorism which threatens serious damage to the security of the UK. The
term ‘‘major incident’’ is commonly used to describe such emergencies.
These may include multiple casualty incidents, terrorism or national
emergencies such as pandemic influenza.’
For the NHS, a significant incident is defined as:
‘Any occurrence that presents serious threat to the health of the community,
disruption to the service or causes (or is likely to cause) such numbers or
types of casualties as to require special arrangements to be implemented by
hospitals, ambulance trusts or other acute or community provider
organisations.’
3.5 Individual NHS organisations can self-declare a significant incident when their own
facilities and/or resources, or those of its neighbours, are overwhelmed. What is a
significant incident or emergency to the NHS may not be a significant incident or
emergency for other local agencies and the reverse is also true.
A major incident, significant incident or emergency may arise in a variety of ways:
 big bang: a serious transport accident, explosion, or series of smaller
incidents
 rising tide: a developing infectious disease epidemic, or a capacity/staffing
crisis
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





4
cloud on the horizon: a serious threat such as a major chemical or nuclear
release developing elsewhere and needing preparatory action
chemical/nuclear release, dangerous epidemics, armed conflict
headline news: wave of public or media alarm over health issue or perceived
threat
internal incidents: fire, breakdown of utilities, equipment failure, hospital
acquired infections, violent crime
deliberate release of chemical, biological, nuclear or explosive materials
mass casualties
pre-planned major events that require planning such as demonstrations,
sports fixtures, air shows.
NHS Standard Contracts and NHS England Emergency
Preparedness Framework
Underpinning requirements and principles of EPRR
4.1 The Civil Contingencies Act 2004 delivers a single framework for civil protection in
the United Kingdom. Part 1 of the Act establishes a clear set of roles and
responsibilities for those involved in emergency preparation and response at local
level.
4.2
The Act divides local responders into two categories, imposing a different set of
duties on each. Category one responders are those organisations at the core of
the response to most emergencies. Category one providers include all Acute
Trusts and Ambulance NHS Trusts, Public Health England and NHS England.
They are subject to the following civil protection duties: assess the risk of emergencies occurring and use this to inform contingency
planning;
 put in place emergency plans;
 put in place business continuity management arrangements;
 put in place arrangements to make information available to the public about
civil protection matters and maintain arrangements to warn, inform and advise
the public in the event of an emergency;
 share information with other local responders to enhance coordination;
 cooperate with other local responders to enhance coordination and efficiency.
These six principles will be used by Buckinghamshire and Berkshire CCGs
4.3 Primary care, community providers, mental health and other NHS organisations
(NHS Blood and Transplant, NHS Logistics and NHS Protect) are not listed in the
Civil Contingencies Act 2004. However, Department of Health (DH) and NHS
England guidance expects them to plan for and respond to incidents in the same
way as category one responders.
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4.4 Category two responders are required to cooperate and share relevant information
with other Category one and two responders. Category two responders, such as
Clinical Commissioning Groups (CCGs), are seen as ‘co-operating bodies’. They
are less likely to be involved in the heart of the planning, but they will be heavily
involved in incidents that affect their sector. It is vital that they share relevant
information with other responders (both category one and two) if EPRR
arrangements are to succeed;
4.5 Category one and two responders come together to form local resilience forums
based on police areas. These forums help to co-ordinate activities and foster cooperation between local responders. Within Thames Valley the strategic forum for
joint planning for emergencies is via the Thames Valley Local Health Resilience
Partnership (LHRP). A representative for all the CCGs in Thames Valley is a
member of the LHRP. The LHRP provides the health sector’s contribution to multiagency planning through Thames Valley Local Resilience Fora (LRFs). Thames
Valley LHRP will coordinate health input and support to the Thames Valley Area
Team, CCGs, local authorities and Public Health England (PHE) in ensuring that
member organisations develop and maintain effective planning arrangements for
major incidents, significant incidents and emergencies.
Risk Management
4.6 The Civil Contingencies Act 2004 places a risk assessment duty on all category
one responders to ensure that planning is proportionate to each risk. A
Community Risk Register is compiled by the Thames Valley Local Resilience
Forum and consists of a table of hazards summarising hazard information,
outcome descriptions, risk rating and mitigation plans
(http://www.thamesvalleylrf.org.uk/riskregister.ashx).
The top five risks currently identified on the Thames Valley Risk Register are:
 flooding;
 influenza-type disease; (pandemic)
 storms and gales;
 widespread loss of telecommunications;
 constraint on the supply of fuel.
The national and community risk register has informed local health and multiagency planning and the Thames Valley Local Health Resilience Partnership
Three Year Strategy. The Berkshire and Buckinghamshire CCGs will contribute to
the annual review of the Community Risk Register via the Berkshire and
Buckinghamshire County Resilience Groups and the Thames Valley LHRP.
Requirements applicable within the Health and Social Care Act 2012
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4.7 The Health and Social Care (2012) Act embeds the requirement of NHS services
to respond effectively to incidents and emergencies. The key elements are: The NHS England and each CCG must take appropriate steps for securing
that it is properly prepared for dealing with a relevant emergency.
 The NHS England must take steps as it considers appropriate for securing that
each relevant service provider is properly prepared for dealing with a relevant
emergency
Core standards
4.8 The minimum core standards, which NHS organisations and providers of NHS
funded care must meet, are set out in the NHS England Core Standards for
EPRR. These standards are in accordance with the Civil Contingencies Act 2004,
the Health and Social Care Act 2012, the NHS England planning framework
(‘Everyone Counts: Planning for Patients’) and the NHS standard contract.
4.9 All NHS commissioning and provider organisations, non-NHS commissioners and
providers from the independent or third sectors may be responsible for health
service provision to significant parts of the population. All work undertaken by
these independent and third sector providers must pay due regard to equality and
diversity in line with the Equality Duty.
4.10 NHS organisations and providers of NHS funded care must:
 nominate an accountable emergency officer who will be responsible for EPRR;
 contribute to area planning for EPRR through local health resilience
partnerships (LHRPs) and other relevant groups;
 contribute to the annual NHS England - Thames Valley report on the health
sector’s EPRR capability and capacity in responding to national, regional and
LRF incidents. Reports must include control and assurance processes,
information-sharing, training and exercise programmes and national
capabilities surveys. They must be made through the organisations’ formal
reporting structures;
 have suitable, up to date incident response plans which set out how they plan
for, respond to and recover from significant incidents and emergencies. They
fulfil the testing schedule as detailed in the CCA 2004;
 have suitably trained, competent staff and the right facilities (incident
coordination centres) available round the clock to effectively manage a major
incident or emergency; and
 share their resources as required to respond to a major incident or emergency.
Business Continuity (service resilience) planning
4.11 The CCA 2004 places a statutory duty on organisations to develop a
comprehensive approach to business continuity. Both category one responder
and category two responders (CCGs) are required to maintain plans to ensure that
services are provided in the event of an incident so far as is reasonably practical.
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Business continuity plans have been developed in line with these requirements
and link to arrangements for the recovery phase after a major incident. This
framework follows the principles of ISO 22301 and PAS 2015. Some elements of
ISO 22301 must be done in partnership with other health organisations and this
will be led by the Thames Valley Local Health Resilience Partnership and Thames
Valley Local Resilience Forum.
Link to NHS England Business Continuity Framework 2013
http://www.commissioningboard.nhs.uk/eprr/
Local cooperation
4.12 At the local level, it is important that planning for major incidents, significant
incidents and emergencies is co-ordinated within individual NHS organisations,
between NHS funded organisations and at a multi-agency level with emergency
services, local authorities, voluntary agencies, the independent health and social
care sector and other partner organisations. Buckinghamshire and Berkshire
CCGs either individually or working in groups, will undertake the co-ordination role
for the NHS in local communities, this is a statutory responsibility covered by the
CCA 2004.
4.13 Training, exercising and testing of all EPRR plans within individual NHS
organisations, between NHS funded organisations and with multi-agency partners
is an important part of emergency preparedness and must be documented as part
of annual work programmes by each organisation.
4.14 Buckinghamshire and Berkshire CCGs are responsible through the contracting
process to establish a mechanism to ensure they receive annual assurance that all
NHS funded providers plan and cooperate appropriately. In addition the CCGs will
performance manage these organisations for this aspect of their responsibilities.
This will be supported by NHS England -Thames Valley, Thames Valley LHRP
and the annual memorandum of understanding and national assurance process.
Mutual Aid
4.15 Mutual Aid can be defined as an arrangement between Category one and two
responders, other organisations not covered by the CCA 2004, within the same
sector or across sectors and across boundaries, to provide assistance with
additional resource during any incident that may overwhelm the resources of a
single organisation. Within the Thames Valley health sector mutual aid
arrangements exist between organisations and will be regularly updated to ensure
they are in line with current service provision. NHS England - Thames Valley will
be responsible for the coordination and implementation of mutual aid requests
during a major incident, significant incident or emergency.
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Networks (critical care, trauma, burns)
4.16 Clinical networks exist in many specialist areas of care and ensure that patients
can access the optimum care for their condition. Within Thames Valley there is a
Trauma network that works alongside the Critical Care networks across the region
and with neighbouring areas. The London and South East Burns Network
incorporates the Thames Valley and works alongside the other regional networks
which effectively ensure mutual aid arrangements when needed.
Information Sharing
4.17 Under the CCA 2004 local responders have a duty to share information and this is
seen as a crucial element of civil protection work, underpinning all forms of cooperation. The Buckinghamshire and Berkshire CCG Major Incident Framework
and Incident Response Plans are made available in the public domain and to all
multi agency partners. They do not include sensitive or confidential information.
The Buckinghamshire and Berkshire CCGs have considered their obligations
under the Equality Act 2010 by putting these plans in place.
4.18 The sharing of information will include, if required for the response, details of
vulnerable people. The general definition of a vulnerable person is a person
”present or resident within an area known to local responders who, because
of dependency or disability, need particular attention during incidents”.
Vulnerable persons could therefore include children and older people; Black and
Minority Ethnic (BME) communities, particularly those for whom English is a
second language, and people with disabilities, including physical disabilities and
impairments, learning disabilities and those with mental illness (see Thames
Valley LRF Vulnerable Persons Framework 2009).
4.19 The Equality Impact Assessment (EIA) process will be used when drawing up
those specific incident plans to identify and address the specific needs of
vulnerable groups.
4.20 Buckinghamshire and Berkshire CCGs have taken into consideration what
information can be made available in the context of the CCA 2004 and the
Freedom of Information Act 2000, whilst maintaining the confidentiality of, for
example, staff telephone contact numbers. It will also take into account the role of
Caldicott Guardians in supporting the discharge of responsibilities in relation to
disclosure of information.
5 Legal framework and decision making framework
5.1 Following a major incident, significant incident or emergency a number of legal
investigations and challenge can and will be made. A serious incident requiring
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investigation (SIRI) may involve contributing to a root cause analysis and the
reporting of the SIRI on STEIS. It may also include Coroners’ Inquests, Public
Enquiries, Corporate Manslaughter and Civil Action.
5.2 When planning for and responding to a major incident, significant incident or
emergency Buckinghamshire and Berkshire CCGs have procedures in place to
ensure that any decisions made and actions taken are recorded and stored in a
way that can be called upon at a later date to provide evidence.
5.3 Accurate record keeping by the decision maker is described in the NHS England
Core standards. Buckinghamshire ad Berkshire CCGs on call directors / managers
all complete a training programme which includes strategic decision making, risk
assessment and record keeping. Logs will be produced at best practice standards
and all records kept for a robust audit trail.
5.4 To support this process Buckinghamshire and Berkshire CCGs use the National
Decision Making Model (see figure 1).
Figure 1
6 Principal Organisational Roles and responsibilities
6.1 Most incidents and emergencies can be managed at local or organisational level.
However, local organisations must inform their commissioners about any internal
incidents, responses to local emergencies or cases of extreme pressure. The
commissioners will then inform NHS England -Thames Valley on call director /
manager so that both teams have a detailed understanding of local NHS demand
and capacity. This is laid out within local NHS funded providers and CCG Major
Incident Frameworks and Escalation Plans.
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Clinical Commissioning Groups (CCGs)
6.2 As category two responders under the CCA 2004, CCGs must respond to
reasonable requests to assist and cooperate during a major incident, significant
incident or emergency.
6.2 If a provider of NHS funded care has a problem either in or out of normal business
hours, they must be able to escalate the matter through the designated CCG. This
requires CCGs to draw up their own on-call rotas, escalation frameworks and
major incident frameworks.
6.3 As part of any inclusion of CCGs in NHS England command and control
arrangements, formal Memorandum of Understandings (MOUs) have been signed
within the Thames Valley, which explicitly include those relevant Core Standards
that are being delegated. Therefore the Thames Valley Area Team will hold the
CCG to account for those relevant standards
6.4 NHS England - Thames Valley may decide to include CCG members in the formal
command and control structure based on:
 the local geography;
 the number of executives on the rota; and
 CCG members’ expertise in emergency preparation resilience and response.
NHS England -Thames Valley (Area Team)
6.5 NHS England - Thames Valley provide leadership across Thames Valley. If an
incident requires a wider NHS or multi-agency response, this coordination and
leadership is provided by NHS England - Thames Valley Area Team Director. The
Director has overall responsibility for ensuring that NHS England -Thames Valley
and the local health economy are able to respond to a major incident, significant
incident or emergency.
6.6 In some cases, several NHS and partner organisations may be involved and the
need for a coordinating role may arise. In these cases, NHS England -Thames
Valley on-call director may take command and control of the situation.
6.7 If there is a Strategic Coordination Group, ‘health’ will be represented by NHS
England -Thames Valley on-call director (NHS Gold). If necessary, Public Health
England, local authority directors and the South Central Ambulance Service will
also attend.
NHS England South (Regional team)
6.8 If an incident affects two or more areas, the NHS response will normally be led by
the Area Team first affected and responding to it. If the NHS England South has to
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take command of all NHS resources across the region, the team’s on-call director /
managers will if necessary provide leadership and direction across the region.
Actions for local organisations will be actioned through the Area Teams.
NHS England (National team)
6.9 In extreme situations such as pandemic influenza, a national fuel shortage or
extreme weather, the NHS England national team may take command of all NHS
resources across England. In this situation, direction from the national team will be
actioned through the regional teams.
Providers of NHS funded Care
6.10 Providers of NHS funded care will fulfil relevant legal and contractual EPRR
requirement, including the Civil Contingencies Act 2004 (CCA), and ensure a
robust and sustainable 24/7 response to emergencies and:
 provide the resilience to manage incidents and emergencies that affect only
them, with escalation where necessary;
 provide an Accountable Emergency Officer to take executive responsibility and
leadership for EPRR at service level;
 collaborate with local multi-agency partners to facilitate inclusive planning and
response;
 ensure preparedness to maintain critical services in periods of disruption; and
 facilitate NHS EPRR assurance, including business continuity.
Public Health England Centres
6.11 Public Health England (PHE) provides expert advice to the DH, Regional Directors
of Public Health and the NHS on health protection policies and programmes. It
also provides specialist emergency planning advice to NHS organisations to:
 ensure that PHE has plans for emergencies in place across the local area;
Where appropriate, these will be joint emergency plans with the NHS and local
authorities, through the LHRP;
 discharge the local PHE EPRR functions and duties;
 have the capability to lead the PHE response to an emergency at a local level.
 ensure a 24/7 on-call rota for emergency response in the local area;
 comprise staff with the appropriate competencies and authority to coordinate
the health protection response to an emergency.
PHE Regional Offices
6.12 The Regional Office provides strategic EPRR advice and support to PHE Centres
and maintains PHE’s capacity and capability to coordinate regional public health
responses to emergencies 24/7.
PHE National Level
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6.13 At a national level they provide leadership and coordination of PHE and national
information on behalf of the PHE during periods of national emergencies. They
support the response to incidents that affect two or more PHE regions and will act
as the national link on EPRR matters between PHE, DH and NHS England.
Local Authorities
6.14 Through the Director of Public Health (DPH), the local authorities within Thames
Valley will take steps to ensure that plans are in place to protect the health of their
populations and escalate any concerns or issues to the relevant organisation or to
the LHRP as appropriate. Local authorities in the Thames Valley have delegated
overall leadership to the DPH of Oxfordshire County Council. The DPH will cochair the LHRP alongside the Director of Operations and Delivery for the Thames
Valley Area Team.
6.15 Each DPH will provide initial leadership with PHE for the response to public health
incidents and emergencies within their local authority area. The DPH will maintain
oversight of population health and ensure effective communication with local
communities. PHE will deliver and manage the specialist health protection
services.
6.16 In addition they fulfil the responsibilities of a Category one responder under the
CCA 2004 (see section 3.2).
Science and Technical Advice Cell (STAC)
6.17 The Scientific and Technical Advice Cell (STAC) provides technical advice to the
Strategic Coordinating Group. The STAC would be expected to advise on issues
such as the impact on the health of the population, public safety, environmental
protection, and sampling and monitoring of any contaminants.
6.18 In the event of a major incident the STAC is activated by the Police Gold
Commander through the cell lead or relevant duty officer. However, a senior public
health professional (i.e. Director of Public Health or the PHE Director) may
recommend to the Gold Commander that a STAC needs to be established due to
the potential impact on the health of the local population from an actual or evolving
incident.
Department of Health
6.19 The Department of Health (DH) Emergency Preparedness Division advises
Ministers on the development of policy and promulgates agreed policy. It
oversees and ensures planning and preparedness in the NHS and coordinates the
overall NHS response to major incidents where necessary. The division also
supports the Central Government response through the Cabinet Office Briefing
Room (COBR).
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7 Command and Control Structure
7.1 This section describes how the NHS will respond when a major incident,
significant incident or emergency has been formally declared and the NHS has
been asked to activate its major incident plans. It is important that all health
services respond to each incident in a coordinated and consistent manner.
7.2
The NHS response to an incident needs to be:  Proportionate: Different approaches are necessary both to the varying size of
incidents and also to the health implications of an incident.
 Flexible: The implications of incidents can change rapidly during their course.
The NHS needs to have flexible systems which ensure that it has a response
appropriate to the incident at any time.
 Clear: In particular, it must be clear at any time both to NHS organisations and
to partner organisations which part of the NHS has taken overall command and
control in a particular geographical area. The taking of command and control
does not preclude other organisations from establishing their incident
operations centres for their own organisations.
7.3 At all times during the course of an incident, it is the responsibility of the NHS
England to ensure that there is clarity about which organisation is leading the NHS
response.
Escalation
7.4 Table 1 describes the three broad levels of escalation and provides broad
parameters for decision making. It is the responsibility of the senior manager
leading the NHS response at any particular time to decide, in conjunction with
colleagues, what level of command is appropriate for the local NHS.
Table 1 NHS England incident alert and response levels
Activity
Action
NHS England Incident levels
Dynamic
Risk
Assessment
Declaration
of Incident
level
0
A health related incident that can be responded to and managed
by local health provider organisations within their respective
business as usual capabilities supported by the CCG.
1
A health related incident that requires the response of a number
of health provider organisations across an NHS England Area
Team boundary and will require an NHS England Area Team to
co-ordinate the NHS local support.
2
A health related incident, that requires the response of a number
of health provider organisations across and NHS England Area
Teams across an NHS England region and requires NHS
England Regional co-ordination to meet the demands of the
incident
3
A health related incident, that requires NHS Engalnd National
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co-ordination to support the NHS and NHS England response
The ‘NHS England Incident Response Plan (National) (IRP(N))’ (see Table 1)
describes the incident alert and response levels within the NHS ENGLAND and
the mechanisms for escalation within the NHS ENGLAND.
7.5 The establishment of a Strategic Coordinating Group (SCG) has been excluded
from Table 1, as this is at the discretion of the Chief Constable of Thames Valley
Police and the NHS follows these arrangements. Thames Valley Area Team will
provide NHS input to the SCG if required. In some circumstances the NHSCB
South may provide the NHS input to a SCG, but this will be the exception rather
than the rule.
Buckinghamshire and Berkshire CCGs local command arrangements
7.6 The on call director / senior manager for a CCG will provide a route by which
issues in provider organisations are escalated to the most appropriate level for
action. In most cases, as commissioners of the local services this will be the CCG.
The on call director / manager for the relevant CCG will give local leadership and
support as required to the NHS funded provider ( see local incident response plan
for local information, divert policy, escalation framework and action cards). The on
call director / manager will take an executive decision in the light of best available
information and obtain input from all relevant sources of expertise and agencies to
support the NHS funded provider or lead a local response.
7.7
Issues that require initial escalation by NHS funded providers to CCGs include
those relating to:

working with local commissioned organisations to support local demand,
capacity and systems resilience issues

supporting local commissioned organisations to manage incidents and
emergencies

liaising with relevant partner organisations including requesting ambulance
divert

mobilising commissioned resources

cascading information to relevant service level providers

informing and maintaining dialogue with neighbouring CCGs when
appropriate

coordinating the response in liaison with neighbouring Thames Valley
CCGs
7.8 Issues requiring the implementation of a wider command and control system will
be escalated via the CCGs to the Thames Valley Area Team.
7.9 In the event of a major incident, significant incident or emergency that requires
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resources from across Thames Valley the local CCG will support Thames Valley
Area Team in the mobilisation of these local resources. If an extended incident or
one requiring particular expertise or local knowledge a CCG on call director /
manager may be asked to strategically support the local response. The CCG on
call director
may be required to attend a local county multi agency silver
command.
Individual NHS Organisation Command
7.10 Each NHS Organisation in the Thames Valley region will establish an incident
coordinating centre (often called control room in Acute Trusts) if they are affected
by an internal major incident or supporting an external major incident, significant
incident or emergency. The role of the Incident Coordinating Centre is to:






manage the operational response to the incident
report to the local CCGs
handle media issues/enquiries
coordinate with other NHS providers (and other partner agencies if required)
manage the return to normality
ensure liaison with a Consultant in Communicable Disease Control (CCDC)
from the Thames Valley Health Protection Unit (HPU), as required
NHS England -Thames Valley Command
7.11 The on-call director for the NHS England -Thames Valley will lead the NHS
response supported by a tactical advisor.
7.12 If required, the on-call director responding to the major incident, significant incident
or emergency will convene an incident management team with relevant expertise
from within and external to the NHS England -Thames Valley to direct and
coordinate the management of the major incident, significant incident or
emergency. The team will take executive decisions in the light of best available
information and obtain input from all relevant sources of expertise and agencies
and convene quickly.
7.13 The incident management team will take responsibility for communication with the
NHS England Thames Valley on call Director, the NHS England South and other
external organisations.
7.14 NHS England - Thames Valley Incident Coordinating Centres (ICC) will be set up
at the headquarters of NHS England -Thames Valley.
7.15 The main role of the NHS England -Thames Valley ICC is to:
 draw together information regarding the operational/tactical response across
the NHS within Thames Valley;
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




gather information from wider sources relating to the incident;
make sure information flows efficiently between the chain of command and
partner organisations;
link with individual CCG on call directors and NHS ICCs if in operation;
report to NHS England South;
coordinate communications and media management across the Thames
Valley.
7.16 The ICC will have direct contact with all responding NHS providers and must keep
the local CCG informed. Its role is to remain informed of their current status and
provide relevant information to the SCG Health Gold representative.
NHS England South Regional Command
7.17 An NHS England South ICC will normally be based at the offices in Reading. The
role of the ICC will be:
 strategic management of the incident and return to normality;
 reporting to the NHS England National;
 downwards links with Area Team Incident Coordinating Centres;
 communications and media management.
8 Multi-agency Command and Control
8.1 There are three commonly accepted levels within emergency management
command and control (Table 2) and adherence to these by all organisations
ensures a coordinated response to a major incident, significant incident or
emergency.
Table 2 Levels within command and control structures.
Level
Role
Colour
Strategic
Establish strategic objectives and overall
management framework. Ensure long-term
resourcing/expertise.
Gold
Tactical
Determine priorities in obtaining and allocating
resources. Plan and coordinate overall
response.
Silver
Operational
Manage front line operations.
Bronze
8.2 The multi-agency response to a major incident, significant incident or emergency
is described below.
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




The DH will be the source of information regarding the NHS for the Cabinet
Office Briefing Room at national level;
NHS England South will represent the NHS at national level;
NHS England -Thames Valley will attend the Strategic Coordinating Group led
by Thames Valley Police. Public Health England Centre will provide the Public
Health Consultant to attend and chair the Scientific and Technical Advice Cell
(STAC). Refer Appendix 2b for detailed information explaining how NHS
England -Thames Valley will represent health at the Strategic Coordinating
Group;
NHS England -Thames Valley may attend multi-agency silver and interact at a
bronze level;
Local CCGs may attend county wide silver and interact at a local bronze level.
Internal and external communications
8.3 Responders’ duties to communicate with the public under the CCA 2004 are
based on the belief that a well-informed public is better able to respond to an
emergency. It is also imperative that communications’ messages are circulated
within responding NHS organisations to ensure that there is an equally informed
internal workforce.
8.4 The CCA 2004 gives distinct legal duties to responders:
 in planning terms, warning and informing the public of the likely risks and
threats that NHS organisations are preparing to address and examples of the
types of responses planned;
 in responding, communications arrangements should be appropriate to the
message being released and the type of audience;
8.5 Based on the principles of the Ten Step Cycle of Communications NHS EnglandSouth has a Communications Plan to include media liaison.
9
NHS England Thames Valley - Response to a major incident,
significant incident or emergency
9.1 NHS England-Thames Valley Director on call would be alerted to a major incident,
significant incident or emergency by Thames Valley Emergency Access on behalf
of South Central Ambulance Service or by the ambulance service directly. Each
Provider of NHS funded care can declare its own major incident, significant
incident or emergency when its own services and/or assets are affected (or
potentially) by, for example, fire, flood, major equipment breakdown, or civil
disturbance (firearms). See table 3 for alert levels:-
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Table 3 Alert levels
1. Major incident – standby
This alerts the NHS that a significant incident may
need to be declared
Significant incident standby is likely to involve the
participating NHS funded organisations in making
preparatory arrangements appropriate to the
incident, whether it is a ‘big bang’ ,a ‘rising tide’ or a
pre planned event
2. Major incident declared – activate plan
This alerts NHS funded organisations that they
need to activate their plan and mobilise additional
resources
3. Major incident –
cancelled
This message cancels
either of the first two
messages at any time
4. Major incident stand down
All receiving hospitals are alerted as soon as
all live casualties have been removed from the
site. Where possible, the Ambulance Incident
Commander will make it clear whether any
casualties are still en-route
While ambulance services will notify the
receiving hospitals(s) that the scene is clear of
live casualties, it is the responsibility of each
NHS funded organisation to assess when it is
appropriate for them to stand down
Alerting Arrangements
9.2 The ambulance service is likely to be the first NHS service to be notified of, and
respond to, a major incident, significant incident or emergency. South Central
Ambulance Service will:
 immediately notify or confirm with the police and the fire and rescue service
the location and nature of the incident, including identification of specific
hazards, for example, chemical, radiation or other known hazards
 alert the most appropriate receiving hospital(s)
 alert the wider health community
 alert voluntary area services
Buckinghamshire and Berkshire CCG escalation
9.3 The Buckinghamshire and Berkshire CCGs will follow the National NHS England
incident alert and response levels (see table 1 page 13)
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9.4 The Buckinghamshire and Berkshire CCGs will follow the local escalation
framework. If the incident only impacts on one County or CCG area the CCG may
be able to lead a response and can request additional help if required either from
neighbouring CCGs or escalate to the NHS England -Thames Valley.
NHS England -Thames Valley escalation
9.5 The NHS England -Thames Valley will follow the National NHS England incident
alert and response levels (see table 1 page 13)
9.6 Depending on the circumstances of the major incident, significant incident or
emergency NHS England -Thames Valley may be required to respond actively and
this is likely to include one or more of the following generic functions listed below.
 To escalate the use of GP surgeries as necessary, to see patients that, but
for the major incident, significant incident or emergency would normally be at
or would go to the local acute hospital e.g. patients with less serious problems
that, because of the incident, cannot be readily seen in the emergency
department.
 To mobilise support from GPs to help at a local acute hospital receiving
the casualties and/or by referring other patients to other hospitals.
 To mobilise assistance from GPs to support at a rest centre. A rest centre
is managed by the Local Authority and is for people evacuated from a scene of
a major incident.
 To coordinate and manage NHS response to the public and media.
Stand down arrangements at the end of a major incident, significant incident
or emergency
9.7 As the incident diminishes and emergency services declare ‘stand down’ a
decision will be made by the CCG or Thames Valley Area Team to disband any
staff supporting the response or manning an incident coordinating centre. Before
the CCG or Thames Valley Area Team is disbanded a hot debrief will be
undertaken and an incident report will be prepared with arrangements made to
review the incident and the outcome. The conclusions of the report and any
debriefings will help to inform future training and improve procedures
Debriefing
9.8 In order to identify lessons learned, a series of debriefs post incident are seen as
good practice. It is recommended that a debrief is attended by all staff that have
been a part of the response in order to give first and accounts of events. These will
include
 Hot debrief: Immediately after incident with incident responders (at each
location);
 Organisational debrief: 48-72 hours post incident;
 Multi-agency debrief: within one month of incident; and
 Post incident reports: within six weeks of incident.
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9.9 These will be supported by action plans and recommendations in order to update
the CCG and NHS England -Thames Valley plans and provide any training and
further exercising required.
9.10 The CCGs and NHS England -Thames Valley will also contribute to multiagency
debriefing and actions from incident reports.
Health and Safety Issues
9.11 During and after a major incident, significant incident or emergency the welfare of
staff is of paramount concern to Buckinghamshire and Berkshire CCGs. Staff
should, as under normal circumstances, pay due regard to the health, safety and
welfare of themselves and other employees at all times.
9.12 The need to regularly ‘risk assess’ during major incidents, significant incidents or
emergencies is extremely important and employees should not expose themselves
to unnecessary risks. Where a higher risk situation is identified this should be
assessed with the support of a line manager.
9.13 It is also particularly important during emergency situations, where staff may be
experiencing higher levels of stress than normal, that regular meal breaks and
periods of ‘off duty’ are observed. It is the responsibility of the on-call director /
manager to set up a rota for all staff.
10 Recovery
10.1 Recovery and the return to normal working is an important part of the
management of all major incidents, significant incidents or emergencies. In many
incidents, the aftermath of the incident becomes another role, taking stock of the
overall impact and facilitating the restoration of normal health services.
10.2 The Buckinghamshire and Berkshire CCGs and NHS England -Thames Valley
may need to work together to : renegotiate priorities
 assess and arrange for the continuing need of primary and community health
services such as psychological support and counselling
 provide care and support to staff that may have been personally affected
 consider any legal and financial risks that might ensue
11 Communications
11.1 Effective communication is paramount to any major incident, significant incident or
emergency response. Buckinghamshire and Berkshire CCGs are part of the NHS
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England -Thames Valley communications cascade system and full details are set
out in the Incident Response Plan. This cascade is tested through regular
exercises.
11.2 The communications cascade which is activated on declaration of a major
incident, significant incident or emergency includes alerting the communications
lead in the first tranche of contacts. Depending on the incident, the responsibility
for media handling lies with the NHS funded provider communications lead and
NHS England- Thames Valley communications lead. The latter represents NHS
England -Thames Valley and the Buckinghamshire and Berkshire CCGs in multiagency press briefing arrangements.
Additional responsibilities of the
communications lead might include:
 to agree with other NHS agencies locally the procedure for coordinating
information in an incident
 to plan facilities which can be made available at short notice e.g. rooms for the
media
 to prepare simple, easily understood information about NHS organisations.
Standard messages have been developed in collaboration with the
communications Lead
 to ensure communications leads and designated spokespersons have
appropriate training
 to produce common recognised information picture (CRIP) for the director on
call leading the response.
Media
11.3 The presence of media can be used effectively to support the coordination of a
major incident, significant incident or emergency response. Press statements will
be coordinated through Thames Valley Police when there is a Strategic
Coordinating Group established.
11.4 In the event that a scientific and technical advice cell is set up to advise the
Strategic Coordinating Group, the LA Director of Public Health and PHEC will be
responsible for agreeing clear public health messages to be given to the public.
11.5 At levels below this the director / manager on call responsible for coordinating the
incident will ensure advice/active involvement is sought from the Thames Valley
Area Team communications lead and will liaise with the Central Southern
Commissioning Support Units media / communications team (see on-call pack for
further details).
Public
11.6 Information will be required to ensure public/patients and their next of kin are
appropriately informed. Under the Civil Contingencies Act (2004) all category one
and two providers have a duty to advise the public of risks before an incident and
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then warn and keep people informed in the event of an incident. Depending on
the nature of the incident, provision of suitable facilities for the public will also need
to be provided. The provision of help lines will assist by diverting enquires away
from NHS switchboards (e.g. hospitals, GP Practices) which may already be
experiencing a high volume of calls.
12 Training
12.1 All staff who are on call and have roles and responsibilities to provide leadership
for local health economies during surges, major incidents, significant incidents or
emergencies must complete training in line with the required competencies for that
role. An example of this is the Strategic Leadership in a Crisis course. CCG on call
staff will all undergo a core skills audit and all staff will be trained as required by
the EPPR core standards.
12.2 Core standards for NHS Command Training are set out in the Skills for Justice
National Occupational Standards (NOS) Framework. An annual training and
exercising programme is in place to ensure competencies are met.
12.3 CCG on call directors / managers will receive regular training to familiarise
themselves with command and control procedures and make sure their skills and
knowledge remain current.
12.4 Those other staff required to support the on call staff in the command and control
function will also receive training to undertake their role. This includes tactical
support, loggist training and situation report writing.
13 Testing and exercises
13.1 All organisations must test their plans regularly through exercises to make sure
that they will be able to respond efficiently and effectively to a major incident,
significant incident or emergency. Roles within the plan should be tested to ensure
they are fit for purpose and include all the necessary actions to be carried out
during an incident. In accordance with emergency planning guidance, plans are
tested through regular exercises, in partnership with other partners.
13.2 Buckinghamshire and Berkshire CCGs have a training and exercising programme
in place that will enable people to be trained and practise their skills and increase
their confidence and knowledge in preparation for a real major incident, significant
incident or emergency.
13.3 Buckinghamshire and Berkshire CCGs comply with the NHS England Emergency
Preparedness Framework (2013) guidance on testing and exercising.
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13.4 Buckinghamshire and Berkshire CCGs will also take part in any programme
planned or requested by the Thames Valley LHRP and/ or Local Resilience Forum
(LRF). These exercise programmes provide organisations with the opportunity to
practise a multi-agency response. The Buckinghamshire and Berkshire CCG
Emergency Planning Liaison Officer (EPLO) will help with this process by working
with EPRR leads in individual organisations and the Thames Valley Area Team
EPRR Manager.
13.5 Details of all exercises are reported to the Buckinghamshire and Berkshire CCGs
Executive Teams on an annual basis and amendments as a result of training are
incorporated into reviews of incident plans. The Buckinghamshire and Berkshire
Accountable Emergency Officers are responsible for ensuring that plans are
regularly reviewed to ensure that they reflect legislative and/or organisational
change and the on-going risk assessment process.
14 Assurance
14.1 Organisations must ensure that their business continuity plans are fit for purpose
in line with the NHS England Business Continuity Framework 2013 and recognise
best practice. They must be able to respond to any incident as part of a
multiagency response.
14.2 The CCGs must be assured of plans and organisational resilience from all their
providers. These are listed in the NHS England Core Standards 2013.
14.3 NHS England -Thames Valley will seek similar assurance from the CCGs using
the NHS England Core Standards 2013.
14.4 Providers of NHS funded care are responsible for providing assurance to the
CCGs and NHS England –Thames Valley. These are listed in the NHS England
Core Standards 2013.
14.5 In gathering wide ranging assurances from individual NHS organisations, the
Buckinghamshire and Berkshire CCGs will provide assurance to the NHS England
-Thames Valley that all providers of NHS funded care within their area, are fit for
purpose.
14.6 Directors of Public Health will seek NHS EPRR assurance through the LHRP
processes.
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15 Appendix 1a
Planning
Structure
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16 Appendix 1b
Response Structure
Health System EPRR
Operating Model - Response
COBR
Accountability
National
SAGE
Lead Government
Department
Department of Health
Secretary of State
NHS Commissioning
Board (NHS CB)
PHE National
Office
Regional
Partnership
Government
Liaison Officer*
PHE Regions x4
NHS CB Regional Offices x4
Strategic
Strategic
Coordinating
Coordinating
Group
Group (SCG)
(SCG)
Local
Services
Local Resilience
STAC
Local
Authorities
PHE
PHE
Centres
Centres
x15
x15
Ambulance
Ambulance
Service
Service
NHS
NHS Provider
Provider
Organisations
Organisations
NHS
NHS CB
CB Area
Area Teams
Teams x27
x27
Other
Other
Relevant
Relevant
Organisations
Organisations
Clinical
Clinical
Commissioning
Commissioning
Groups
Groups (CCGs)
(CCGs)
*Normally led by DCLG RED. But can vary depending on the type of emergency
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