Appendix 30
To the PCT Emergency Plan
WANDSWORTH PCT
BUSINESS CONTINUITY PLAN
This Business Continuity Plan is based on the organisational structure and
physical distribution of PCT services across Wandsworth as of the date of issue.
In the event that the PCT is restructured or there are changes in facilities or
locations where services are delivered then the Business Continuity Plan will be
amended to reflect such changes.
Documentation Control
First issued
5 December 2005
2nd issue
18 October 2007
3rd issue
4 August 2009
4th issue
5th issue
1
Author: E Checkley
Author: E Checkley
Author: E Checkley
Version 1.0
Version 2.0
Version 3.0
TABLE OF CONTENTS
No
Section
Page number
1
Introduction
3
2
Business continuity principles
3
3
Aim of the plan
3
4
Activation of the business continuity plan
3
5
Business continuity action cards
3
6
Business continuity management process
4
7
Definition of essential and non essential services
5
7.1
Levels of service
5
7.2
External Agencies and Contractors
6
8
Risk analysis
6
9
Business continuity planning structure
6
9.1
Business continuity planning structure – services
7
9.2
Business continuity planning structure – sites
8
10
Business continuity planning template
8
11
Business continuity service to site matrix
9
12
Business continuity contact list
9
App 1
Business continuity action cards
On call Director
On call manager
App 2
Service to Site Matrix
App 3
Business continuity template
For services
For sites
2
1.
INTRODUCTION
A business continuity (BC) crisis is a problem which has not overwhelmed our capability to deliver health
services to the community, and is therefore not a major incident, but does require special arrangements
within the PCT to maintain or restore services, and needs action to ensure that essential services continue,
and if the problem continues over time, to take actions to continue normal business.
The Civil
Contingencies Act 2004 places a duty on the PCT to have and maintain a business continuity plan. BC is
also embodied in the DoH Emergency Planning Guidance 2005, is common sense, good business practice,
and fundamental to our capability to support the health of our community during emergencies, for example
during a flu pandemic. Business continuity planning takes into account the risks to the PCT and our areas of
vulnerability, and identifies which are the essential services and activities that the PCT must maintain.
The critical aspects of the PCT that are essential to the running of the PCT and fulfilling our obligations to
protect the health of the community are:
a) the people we employ – our core asset is our staff
b) the services we provide – health care to our community
c) Some of our facilities – Queen Mary’s Hospital and the Tooting Walk-in Centre
2.
BUSINESS CONTINUITY PRINCIPLES
The PCT’s business continuity plan is based on four principles
1. Immediate action must be taken in the event of a problem or crisis
2. Actions must first focus on keeping defined essential services going
3. Business continuity at the service and site levels is the responsibility of the designated business
Continuity coordinator.
4. There should be no single point of dependence.
3.
AIM OF THE PLAN
The objective of Business Continuity Planning is to enable planning and reaction in a coordinated manner.
The business continuity plan falls within the overall framework of the PCT Emergency Plan. The BC plan
follows the NHS Resilience and Business Continuity Management Guidance (September 2008) which allows
a unified and cohesive approach to BCM which parallels the new British Standard BS25999- parts 1&2
The aim of the business continuity plan is to identify, as far as possible, the actions that are necessary and
the resources that are needed to enable the PCT to manage an interruption to the PCT’s business, whatever
the cause, as a minimum to maintain essential services, and return to normality. The business continuity
plan addresses the effects of a crisis and the possible solutions, and provides guidance on how services can
be continued.
4.
BUSINESS CONTINUITY ACTION CARDS
Business continuity action cards will be available as part of the PCTs Emergency Plan and cover the roles of
the On-call Director and On-call Manager. Copies of these action cards are attached as appendix 1 to this
plan
5.
ACTIVATION OF THE BUSINESS CONTINUITY PLAN
The business continuity plan is a sub-set of the PCT emergency plan and will be activated either by the line
Director if in working hours or the on call manager out of hours or should the crises have a wide impact such
as severe weather. A list of contact details for business continuity coordinators and their deputies will be
available in the on call managers bag and in the incident control room cabinets. The following management
process will be followed.
3
6.
BUSINESS CONTINUITY MANAGEMENT PROCESS
Activation of the business continuity plan may be necessary either within working hours or out of hours.
Based on the principle that immediate action must be taken in the event of a problem or crisis, action will be
initiated either by any director (in working hours) or the on-call manager and director (out-of-hours) under the
PCTs Emergency Plan. The business continuity management process detailed below will be followed.
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7.
DEFINITION OF ESSENTIAL AND NON ESSENTIAL SERVICES
The services which would have most impact on the business of the PCT are defined as essential services
and are those services that we must continue to provide to our community. Other services are defined as
non essential and could be deferred for periods of time if our capacity is diminished. The PCT’s essential
services are defined as those services needed to provide health care to people in ‘Beds or Bed Equivalents’
and for whom health services must be continued in the event of a crisis or lives may be at risk.
ESSENTIAL
SUPPORTING
Intermediate care
Community nursing
In-patient care
Tooting Walk-in Centre
Minor Injuries Treatment Unit
IT & Telecom services
SWL SSP
7.1
Communications
Safeguarding children
Children’s nursing
Children’s therapies
Family planning
Haemoglobinopathies
Refugees and asylum services
Older peoples therapies
Rehab and physical disability
Adult therapies
QMH out-patient diagnostics
Community dentistry
Clinical governance
Public health
Human resources
Finance
Commissioning & Contracts
Planning
LEVELS OF SERVICE
The business continuity plans prepared by each business continuity coordinator are graded against the
following level of service.
1
2
3
4
5
7.2
Critical and essential service – cannot be shut down
Needs to be your priority for service resumption the next day
Can be deferred for 2 to 4 days
Can be deferred for up to 1 week
Can be deferred for more than 1 week
EXTERNAL AGENCIES & CONTRACTORS
The PCT’s business continuity plan cannot exist in isolation. It shall be a contractual condition with any
external organisations where their services impact the delivery of PCT services that they have business
continuity plans in place.
EXTERAL AGENCIES & CONTRACTORS
St Georges Hospital
Kingston Hospital
Health Protection Unit (HPU)
SWL SSP: Estates on call, Catering, Cleaning, Transport
SODEXHO QMH: Switchboard, Maintenance On call, Portering, Cleaning, Catering,
GP Independent contractors
Harmoni OOH GP services
Community Pharmacists
Community Dentists
Community Opticians
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8.
RISK ANALYSIS
The following local risk statement as it applies to business continuity should be reviewed for each area of
responsibility. BC coordinators are not expected to produce a risk analysis for those risks where PCT plans
or the plans of other organisation are in place in their department or unit, such as fire, IT failure, power
failure, telecoms, etc, but they are expected to confirm that they have been correctly implemented in their
areas of work and that BC plans take these into account. The following are the standard risks for which the
PCT or other organisations have developed specific policies for PCT managers and staff to follow.
Risk
Standard risk mitigation in place
Fire
Fire Policy available on PCT web site:
http://www.wandsworthpct.nhs.uk/work/policies/default.asp?expid=29
Fire Monitor appointed. Fire alarms fitted and tested
Evacuation plans in place. IT data backed-up off site
Business continuity plan in place.
Thames flood watch managed by ‘Flood Line’ 0845 988 1199 who
would provide alerts to the media for areas under threat.
Environment Agency flood plain map and details on web site:
http://maps.environment-agency.gov.uk/wiyby/mapController
Business continuity plan in place.
Site specific policy provided by organisation responsible for estates.
Business continuity plan in place
Site specific policy provided by organisation responsible for estates.
Where estates are not responsible contact the telecoms provider.
PCT policy under development
Guidance available on the PCT web site:
http://www.wandsworthpct.nhs.uk/work/policies/default.asp?expid=37
PCT policy
Flood
Power
failure
Telephone
failure
CBRN
Infection
Suspicious
package
Bomb
threat
Battersea
COMAH
9.
Additional
Mitigation
PCT policy
Guidance leaflet issued by TRANSCO gas works operator to areas
under threat. Guidance leaflet readily available.
BUSINESS CONTINUITY PLANNING STRUCTURE
Business continuity planning needs to cover both physical sites and services provided from those sites.
Business continuity needs to be considered from the perspective of the officer identified as being responsible
for delivering services. The diagram below shows the relationship between services and facilities/sites
which should be considered when completing individual business continuity plans.
Business continuity planning structure
Over-arching business
continuity plan
Service managers or
Clinical Team Leaders
can better understand
the business continuity
implications of the
locations where their
services are provided
Service based
business continuity
plan
On call management team can understand
the implications of a business continuity
crisis from both the location and service
provision perspective and consider
response actions accordingly
Location based
business continuity
plan
Information
sharing
Business Continuity
Template
Business Continuity
Template
Business Continuity
Map of services
against locations
6
Office managers or key
holders can better
understand the services
provided from their
location and the
business continuity
implications
9.1.
BUSINESS CONTINUITY STRUCTURE - SERVICES
In the event of an emergency some services may need to be enhanced, reduced or suspended, depending
on the nature of the service and the emergency that is taking place. BC service coordinators, or if they are
not available, their deputies, will be responsible for taking actions to continue business depending on
circumstances at the time based on the information contained in their BC plan. Essential PCT services to
the community that must be maintained are marked in red below.
Managers in charge of services of the PCT, as detailed below, (this is not an organisation chart) will be
designated as ‘Business Continuity Coordinators’ and will be responsible for preparing their own business
continuity plan for their service. PCT Directors are responsible for approving Business Continuity Plans for
their directorate.
7
9.2.
BUSINESS CONTINUITY STRUCTURE - SITES
Many services or functions are delivered from multiple sites or many combined within sites and the question
of who is responsible for the site is often not clear. In the event of an emergency staff must be clear who is
responsible for the site itself and they must be aware if an essential service is delivered from the site.
Managers or key holders, or if they are not available, their deputies, will be responsible for taking actions to
continue business depending on circumstances at the time based on the information contained in their BC
plan.
Managers or key holders responsible for sites as detailed below will be designated as ‘Business Continuity
Coordinators’ and will be responsible for preparing their own business continuity plan for their site. PCT
Directors are responsible for approving Business Continuity Plans for their directorate.
Site
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
10
BC coordinator
Wimbledon Bridge House
Queen Mary’s Hospital
Tooting Walk-in Centre
Bridge Lane Health Centre
Balham Health Centre
Brocklebank Health Centre
Doddington Health Clinic
Eileen Lecky Clinic
Joan Bicknell Centre
St Christopher's Health Clinic
St John's Therapy Centre
Stormont Health Clinic
Tooting Health Clinic
Tudor Lodge Health Centre
Westmoor Community Clinic
Furzetown Eardley Rd
Greyswood Practice
Mapleton centre
Dawes House
Sandra Notridge
Stuart Reeves
Kate Carter
Margaret France
Margaret France
Margaret France
Margaret France
Dot Ferreira
Monica Baker
Margaret France
Sharon Walters
Margaret France
Margaret France
Dot Ferreira
Dot Ferreira
Ife Ogun-Turoti
Bev Atkins
Tasnim Bawa
Tasnim Bawa
BUSINESS CONTINUITY PLANNING TEMPLATE
The BC plan for each service or site cannot provide solutions to all problems, but guide the BC coordinator in
how to manage the implications of a crisis. For example if electronics records are lost, it is not the job of the
coordinator to repair the IT systems, but to know whom to contact to recover the data, and what to do if
electronic records cannot be retrieved.
Business continuity coordinators are required to complete a business continuity template for the staff and
functions within their area of responsibility. BC coordinators should ensure that a deputy has been identified
who should ideally be the next staff member down in seniority, the deputy can be a volunteer. An additional
alternate post or person can also be assigned as deputy if required (for example where an on-call rota exists
for their department or unit). The BC plan information should be retained at the department or unit with a
copy with the department Director, kept up to date and readily available.
Separate Business Continuity plans should be produced by the business continuity coordinators providing
services and the office manager or key holder for the location where services are provided. The business
continuity coordinators should liaise with each other in the production of their respective BC plans.
Copies of the business continuity template used for services and sites are attached as appendix 3
8
11
BUSINESS CONTINUITY SERVICE TO SITE MATRIX
Business continuity planning needs to cover both physical sites and services provided from those sites. To
aid directors and managers understand the consequences of a business continuity crisis at one or more sites
affecting services at other sites, information in the BC plans will be combined to produce a map of services
against locations.
This Service to Site Matrix is attached as appendix 2 to this plan.
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BUSINESS CONTINUITY CONTACT LIST
A list of business continuity coordinators, and their deputies, for the services and sites is placed in the
following locations:

On call managers bag

Wimbledon Bridge House Emergency Control Room

QMH back-up Incident Control Room
As this list contains confidential information and is frequently amended the list does not form an attachment
to this plan.
END OF DOCUMENT
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Appendix 1
PCT ON-CALL DIRECTOR
BUSINESS CONTINUITY ACTION CARD
If you are alerted to, or become aware of, a crisis that affects one or more services or sites across
the PCT then take the following actions:

Log the information received with contact details of the caller.

Follow the BC management process in the PCT emergency plan and BC plan (and
attached to this action card)

Call and instruct the on call manager to oversee the management of the BC crisis

Call the duty PCT comms officer and consider whether trust wide advice and instructions
are required, or whether media releases will be required

Ensure that initial actions focus on ensuring that essential services are continued:
o Intermediate care
o Community nursing
o In-patient care
o Tooting Walk-in Centre
o IT & telecom services
o MITU
o SWL SSP

Consider the wider ramifications of the crises and whether other services or sites will or
potentially be affected. (consider whether this may form a major incident). Refer to the
PCT business continuity plan for guidance and the service to site matrix.

Call meetings of directors as required to consider impact and actions

Consider whether to activate the Incident Control Room to manage the BC crisis.

Activate the PCT emergency plan should the BC crisis develop, or have the real potential to
develop, into a major incident for the PCT. Follow the action cards as for a major incident.

Arrange support for the on call manager and BC coordinators as required

Ensure that follow up reviews and debrief meetings are held and that a report is prepared
for management
10
Appendix 1 (continued)
PCT ON-CALL MANAGER
BUSINESS CONTINUITY ACTION CARD
If you are alerted to, or become aware of, a crisis that affects one or more services or sites across
the PCT then take the following actions:

Log the information received with contact details of the caller.

Follow the BC management process in the PCT emergency plan and BC plan (and
attached to this action card)

Focus initial actions on ensuring that essential services are continued:
o Intermediate care
o Community nursing
o In-patient care
o Tooting Walk-in Centre
o IT & telecom services

Consider the wider ramifications of the crises and whether other services or sites will or
potentially be affected. (consider whether this may form a major incident). Refer to the
PCT business continuity plan for guidance and the service to site matrix.

Alert the on call director (out of hours) or concerned Director (within working hours), provide
a briefing on the crisis and follow any instructions given by the Director.

Call the duty PCT comms officer and consider whether trust wide advice and instructions
are required, or whether media releases will be required

Refer to the contact list of business continuity coordinators in the on call manager bag and
contact the relevant BC coordinators for services and the sites to alert and ensure that they
are following their BC plans

Monitor and log actions taken by the respective BC coordinators

In consultation with the Director consider whether to activate the Incident Control Room to
manage the BC crisis.

Activate the PCT emergency plan should the BC crisis develop, or have the real potential to
develop, into a major incident for the PCT. Follow the action cards as for a major incident.

Arrange support for the BC coordinators as required

Support the Director as required

Arrange for follow up review and debrief meetings and ensure that a report is prepared for
management
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Appendix 2
BC SITE TO SERVICE MATRIX
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