Business Continuity Policy and Plan

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1 Business Continuity Policy and Plan Policy Number: 040 Version: 2 Ratified by: V1 Approved by GB 2013 V2 update approved by OLT 26 Sept 2014 Name of originator/author: Robert Kirton Interim CFO 2013 Executive sponsor Rob Morgan, CFO Date issued August 2013 Last review date: Sept 2014 Next review date: July 2015 VERSION CONTROL SHEET Version Date Author Status Comment 1 March 2013 Amended from NHS Surrey policy version 7 April Final Agreed by the Governing Body 16 April September 2014 OLT Approved Update with current information, legislation and data (reference to Distribution: North East Hampshire and Farnham CCG Surrey Heath CCG staff and Governing Body members Surrey Heath CCG Website Surrey Heath Borough Council Page 1

2 Equality Analysis This Policy is applicable to the Governing Body, every member of staff within the Surrey Heath CCG (SHCCG) and those who work on behalf of the CCG. This document has been assessed for equality impact on the protected groups, as set out in the Equality Act This document demonstrates SHCCG s commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote positive practice and value the diversity of all individuals and communities. An equality impact assessment was completed by Rob Morgan, CFO in Sept 2014 (appendix 4). If you have identified a potential discriminatory impact of this procedural document, please contact the Corporate Office, Surrey Heath CCG, Surrey Heath House, Knoll Road, Camberley, Surrey GU15 3HD. Telephone Alternative formats To help ensure that this policy is as accessible as possible, this document is available in alternative formats and languages. To request a copy of this policy in large print, audio, Braille (or another format) or in an alternative language please call the Corporate Office on Page 2

3 Business Continuity Policy and Plan Contents: 1. Introduction 2. Definitions 3. Roles, Duties and Responsibilities 4. Outcomes of the Plan 5. Testing and Review 6. Monitoring Appendix 1 Business Impact Assessment Appendix 2 NHS Surrey Heath Business Continuity Plan Appendix 3 List and details of Stakeholders Appendix 4 Equality impact assessment Page 3

4 1. Introduction The Civil Contingencies Act 2004 and the NHS Emergency Planning Guidance 2005 requires Clinical Commissioning Groups to have a Business Continuity Policy which will ensure that, in the event of a significant service interruption, critical day to day functions can be maintained whilst timely recovery and restoration of key services, systems and processes is also achieved. This policy has been updated in 2014 to reflect guidance from NHSE with specific reference to It is the policy of NHS Surrey Heath CCG (SH CCG) to take all reasonable steps to ensure that in the event of a service interruption, the organisation will be able to maintain essential services 1 and restore normal services as soon as possible in the circumstances prevailing at the time. This document combines the general principles and corporate framework of a Business Continuity Policy together with the initial plan which the CCG will follow in the event of need to mobilise a response to an incident threatening business continuity. The business continuity management procedures described are separate from, but may operate in conjunction with, the Frimley System Emergency Prepardness Resilience Response Plan (EPRR). It also operates in conjunction with the CCG s Risk Management processes. This policy does not address or represent the CCG s responsibilities relating to emergency planning and response nor as a responder to mobilisation of a local emergency. This is an overarching policy for SH CCG and should be read in conjunction with the shared Oncall arrangements with North East Hampshire and Farnham CCG; and the information governance business continuity policies for finance; operations & performance; and quality teams. 2. Definitions The following definitions apply to terms used in this document, in accordance with governing standards, British Standard for Business Continuity Management, BS2599-1:2006 and International Standard 23001: Business As Usual : Pre-defined acceptable levels of service delivery 1 Quality Management; public engagement; oncall (if applicable at the time); finance transactions; medicines management (ref Business Continuity Plan Appendix 2). Page 4

5 Business Impact Assessment: The process of analysing business functions and the effect that a business disruption might have upon them Business Continuity Management: Holistic process to identify potential threats, accesss the impact of those threats, including protecting patients and stakeholders interests and achieving strategic directives. Disruption: Any event, planned or unplanned, which causes an interruption to the CCG s ability to continue business as usual. Service Recovery Objective: The desired level to which essential services will be restored and the desired maximum time between loss of service and recovery. Further guidance on the wider subject Business Continuity can be referenced at Page 5

6 3. Roles, Duties and Responsibilities 3.1 Legal and Statutory The following general (statutory) duties apply: The Civil Contingencies Act 2004 places a duty on public bodies to have business continuity plans in place to ensure that they can continue to exercise their functions in the event of an emergency so far as is reasonably practicable. The duty relates to all functions, not just emergency response functions. Healthcare Standards require healthcare organisations to have documented procedures which dictate how they will be able to continue essential routine work during an incident or an emergency situation and to provide essential supplies. 3.2 Specific duties and responsibilities within the CCG The following specific duties and responsibilities apply within the CCG Accountable Officer (AO): The AO has overall responsibility for the strategic and operational management of the CCG including ensuring that the CCG has in place robust arrangements for business continuity management and service recovery. CCG Governing Body (GB): The GB is responsible for setting the strategic context in which business continuity and service recovery procedures are developed, and for the formal review and approval of the BCM policy and plan. This function may be delegated to the Audit Committee. The GB is also responsible for gaining assurance that providers commissioned by the CCG have adequate BCM systems and processes in place to ensure service continuity. Business Continuity Management Lead Officer: This role has been delegated to the Chief Financial Officer: The Lead Officer is responsible for ensuring that business continuity plans to support core business functions are completed and updated as necessary. The Lead Officer has responsibility for advising on business continuity in the event of the need to mobilise being declared. The Lead Officer will lead test exercises. Page 6

7 4. Outcomes of the Business Continuity Management (BCM) Plan All BCM plans will be written in accordance with this policy. The anticipated outcomes of the BCM plan are: Identification of the activities of the CCG Prioritising those activities in response to a disruption Minimising the effects of any disruption and allowing return to business as usual as fast as possible Increased staff awareness of BCM principles and processes Supporting the achievement of CCG strategic objectives Ensuring legal compliance with emergency planning obligations As BCM plans are developed, the BCM policy may be adjusted as required and resubmitted to the GB for approval to the changes. 5. Testing and Review The Business Continuity Policy and Plan will be reviewed by the Operational Leadership Team and resubmitted to the Governing Body at least every two years. The Plan will be tested through a mock mobilisation, followed by a debriefing session to establish if any changes need to be made to the plan. When actual incidents or disruption occur the Corporate Office will record the event and lessons learned will be shared with staff. The record will be kept with the policy to establish if any changes need to be made to the plan at its next review. 6. Monitoring When there is a major incident that requires the CCG to take significant action (eg move staff to Aldershot centre for health) the CCG will produce a post incident report and hold a debrief the Operational Leadership team (OLT), to identify lessons learned. When there has been repeated disruption or disruption to IT services has lasted more than a day the CCG will record the event and details. The Business Continuity Management Lead Officer (CFO) will review the incident log shown in table 1 and escalate issues to OLT as and when required. Page 7

8 Table 1 Record of incidents and disruption: Period of disruption What Impact Half day 21 st July Full working day 22 nd July Half day 23 rd July Lack of IT for and internet connection. AT informed. Disruption to normal work. Office still had access to SH Y drive and telephones. Senior staff able to access s on phones. Working from home option made available. Page 8

9 Appendix 1 Business Impact Assessment In order to construct a Business Continuity Plan, the starting point is to undertake a Business Impact Assessment which identifies the essential functions and services which define the organisation and assesses, based on impact and risk, the maximum time (Recovery Time Objective) the organisation can be considered to be sustainable without the ability to deliver those functions and services. Purpose of activity Financial Management Financial Transactions Activity and Contract Management Quality Management Actual Activity Budgeting & Reporting Payroll Sales ledger Purchase ledger Cash management Data capture & analysis Handling complaints Monitoring SUIs Safeguarding Carried out by Finance team FPHnhsft CSS Finance Team CSS D of N & Q Medical Director Resources needed Network access to IFSE PC access Network access PC access Network access PC access Internet access PC access Dependencies (other teams, other agencies) Impact Recovery Time Objective Current Contingencies Proposed Contingencies CSS Significant 1 month Home working Aldershot FPHnhsft CSS SBS Bank Crucial 1 week FPH, CSU(S) and SBS business continuity plans Providers data Major 1 month CSU(S) B.C. Plan Providers reports Crucial 3 days Access to space at Aldershot Centre for Health Dependent on FPH & CSU business continuity plan Dependent on CSU business continuity plan Aldershot Medicines Management Manpower Management Commissioning Public Engagement Procurement Benchmarking Best practice Monitoring prescribing Recruitment Appraisal Defining need for care services System change Website Press relations Surveys FOI requests Securing goods and services Director of Operations Chief Officer Director of Operations Director of Operations Director of Operations CSS Finance Team Prescribing data Surrey Downs CCG Crucial 1 month Surrey Downs Dependent on Surrey Downs CCG continuity plan Telecomms FP HR team Moderate 6 weeks FPH FPH continuity plan Network access PC access Internet access Network access Lead CCGs Moderate 2 months Home working Aldershot CSS Moderate Major Minor Crucial 1 month 1 day 6 weeks 3 days CSS Moderate 6 weeks CSU CSU(S) use Media on call Dependent on CSU business continuity plan Page 9

10 Cont./ Purpose of activity Governance & Compliance Actual Activity Maintenance of risk and baf Conducting Boards & Committees Carried out by CFO CO/Chair/ Admin team Resources needed Network Access Dependencies (other teams, other agencies) None Available meeting facilities (St Pauls/St Cross) Impact Recovery Time Objective Current Contingencies Significant 1 week Homeworking Local facilities Proposed Contingencies Aldershot Alternative local facilities Performance Monitoring & reporting QIPP AT/SHA liaison and performance regime Director of Operations CFO Network access CSS AT/SHA Major 1 week Homeworking Aldershot Impact: Minor (1), Moderate (2), Significant (3), Major (4), Crucial (5) Recovery Time Objective: Immediate, 1 day, 3 days, 1 week, 2 weeks, 1 month, 6 weeks, 3 months. Surrey Community Risk Register Copies of the Surrey Community Risk Register are available at Risks on the very high category: Severe weather Flooding Human Health - Influenza type diseases Pandemic of infectious disease e.g. Flu Industrial technical failure electricity disruption/ supply. Surrey Heath CCG Risk Register has identified risks that may affect the contiuity of business at Surrey Heath CCG. Loss of access to office due to severe weather Flooding, fire or loss of power. Loss of key managers due to severe weather or fuel disruption. Loss of access to IT which may be affected by local office disruption or as a result on an event at the South CSU. Page 10

11 Appendix 2 Business Continuity Plan There are a number of threats to the continuity of business at Surrey Heath CCG. The major ones are: Loss of access to office Loss of key managers Loss of access to I.T. Office: Loss of access to the Head Office (Surrey Heath Borough Council Offices, Knoll Road, Camberley) may occur due to the building being unavailable for use ( fire damage, flood damage, loss of power) or access being denied to the building and immediate vicinity (security alert). If the loss of access is expected to be short term (less than 2 working days), most staff can work from home or utilise space in a GP practice. If the disruption is likely to be longer than 2 working days, the CCG has agreed with North East Hampshire & Farnham CCG that it can have access to desk space for three core staff (more with hot-desking) at Aldershot Centre for Health (ACH). This is a reciprocal arrangement under which NEH&F staff can have access to desks at Surrey Heath House. (action: check that the landlords liability insurance remains valid). If a temporary relocation to ACH takes place, an alert will be placed on the CCG website by the Administration Manager informing the public of the relocation and predicted length of disruption. Due to unforeseen circumstances, Surrey Heath CCG have temporarily moved headquarters to Aldershot Centre for Health. It may be possible to divert telephones to ACH, but it is likely that an enforced move would happen without sufficient notice to action this (e.g. incident in the building out of hours). The essential staff to relocate are: Administration Manager, Director of Nursing & Quality, and Business Continuity lead (CFO). Other staff would be asked to work from home and report to the director at Aldershot Centre for Health for a daily update on work required and possible date to return to normal work. Maintenance and access of the shared drive is critical as it may not be possible to move paperwork to ACH, or that paperwork may be destroyed in fire or flood. Excess travel costs to Aldershot will be met if claimed. Page 11

12 Loss of key managers This may be considered lower threat to business continuity as there is already a high degree of close-knit working and covering roles within the senior team. However, it would be better to formalise arrangements and ensure that each senior leader selects a shadow and invests time outlining their major objectives. It is also critical that shared drives for essential files are utilised and the file discipline shared with all staff. Loss of I.T. This is a critical risk. If there is a prolonged (greater than 1 week) lack of access to I.T. specifically related to operation from Surrey Heath House, the CCG would mobilise the same arrangements as for lack of access to the building, i.e. convene to Aldershot centre for Health. Loss of access to data/information is mitigated by existing back-up arrangements for the CCGs data, carried out by the NHS CSU (South). The CCG must seek regular assurance and evidence that these backing up arrangements re regularly undertaken. Authority to Invoke and Stand Down the Plan The following officers of the CCG have authority to invoke and subsequently stand down the plan: Accountable Officer Chief Financial Officer (as Business Continuity Lead) Director of Operations Appendix 3 Page 12

13 List of key stakeholders contact details All Providers, suppliers and partners working under NHS contracts are obliged to have business continuity plans. Clinical providers work to stringent contracts which also cover 24/7 operation and emergency / incident working. Frimley System 24/7 On Call On Call Duty Senior Manager/ Director - Frimley System joint NHS Surrey Heath CCG together with NHS North East Hampshire and Farnham CCG. NHS England Surrey & Sussex Code NHS42 NHS England Wessex Pager Code NHS43 Ambulance South East Coast Ambulance SECAmb ask for Duty Silver /7 Tactical advisor South Coast Ambulance SCAS on call tactical advisor Hospitals Frimley Park Hospital Mena Valiance Head of Access OOH ask for admin on Call Royal Surrey County Hospital NHS Foundation trust Jason Wright emergency planning manager OOH ask for director on call Ashford and St. Peters Hospital Claire Braithwaite Deputy Director of Opps OOH ask for Director on call Hampshire Hospital NHS Foundation Trust Basingstoke and North Hampshire Hospital Page 13

14 Community Care Virgin Health Cynthia Dwyer Sara McMullen Mental Health Surrey and Borders Partnership NHS Foundation Trust OOH ask for Duty Director Appendix 4 Page 14

15 EQUALITY IMPACT ASSESSMENT TOOL To be completed and attached to any procedural document as part of main document sited between version control sheet and contents page 1. Title of policy/ programme/ framework/ strategy being analysed. Business Continuity Policy and Plan 2. Please state the aims and objectives of the work and intended equality outcomes CCG is required to have a business continuity plan to ensure that, in the event of a significant service interruption, critical day to day functions are maintained. (how is this linked to the CCGs strategic equality objectives) 3. Who is likely to be affected? Eg staff, patients, service users, carers Staff And staff who are carers Service users and stakeholders 4. What evidence do you have of potential impact (positive and negative) Impact on all staff to carry out day to day critical functions. Impact on home life if staff are required to work from home. 5. Does the document/guidance affect one group less or more favourably than another on the basis of: Race N Ethnic origins (including gypsies and travellers) Nationality N Gender N Culture N Religion or belief N Sexual orientation including lesbian, gay and bisexual people Age N Yes/No N N Comments Page 15

16 Disability - learning disabilities, physical disability, sensory impairment and mental health problems 6. Is there any evidence that some groups are affected differently? 7. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? 8. Is the impact of the document/guidance likely to be negative? 9. If so, can the impact be avoided? N 10. What alternative is there to achieving the document/guidance without the impact? 11. Can we reduce the impact by taking different action? N N N N NONE N For advice in respect of answering the above questions, please contact the Corporate Office, Surrey Heath CCG. If you have identified a potential discriminatory impact of this procedural document, please contact as above. Sign off Name and Signature Date of the Assessment Name and designation of Individuals who carried out the Ann Cooper, Interim Governance Lead 21 July 2014 Assessment: Name and signature of responsible Director Rob Morgan, CFO 21 July 2014 Page 16

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