NHS NEWCASTLE GATESHEAD CLINICAL COMMISSIONING GROUP

NHS Newcastle Gateshead Clinical Commissioning Group NHS NEWCASTLE GATESHEAD CLINICAL COMMISSIONING GROUP Business Continuity Plan (including Emergency Planning Response and Resilience, Surge Management and Pandemic Arrangements) Version Control Ratified September 2015 Status Issued September 2015 Approved by NHS Newcastle Gateshead Governing Body Consultation N/A Implementation date September 2015 Core Standard reference Equality Impact Assessment Distribution ISO22301, PAS2015, NHSE Emergency Preparedness Framework 2013, NHSE Core Standards for Emergency Preparedness, Resilience and Response 2013, NHSE Command and Control Framework 2013. YES Review September 2016 Author Marc Hopkinson Version 2 Reference No Location All Newcastle Gateshead CCG staff 1

NHS Newcastle Gateshead Clinical Commissioning Group Contents Page Section 1 1. Introduction 4 2. Business Continuity Management 5 3. Purpose and Scope 5 4. Categorisation and Prioritisation of Services 6 5 Organisational Culture 7 6. Accountable Emergency Officer and Oversight of Business Continuity 8 Management Policy Section 2 1. Service Priorities 9 Section 3 1. Emergency Planning, Response and Resilience (EPRR) Statutory and 10 Legal Obligations and Requirements 2. Surge Management Arrangements 10 3. Pandemic Influenza Arrangements 11 Section 4 1. Activating the Business Continuity Plan (BCP) 13 2. Key Personnel in BCP 14 3. Plan Activation Phases 15 4. Business Continuity Incident Room 15 5. Designated roles 15 6. Communications 16 7. De-escalation of BCP 16 8. Debrief 16 9. Business Continuity Management Plan Holding, Maintenance and 17 Review procedure 10. Training and exercises 17 Appendices Appendix 1 Adverse Weather/Fuel Shortages 18 Appendix 2 Business Impact Analysis Forms 19 Appendix 3 Action Checklist for Senior Manager in charge 29 Appendix 4 Incident Assessment and Situation Report 30 Appendix 5 First Meeting Agenda 32 Appendix 6 Generic Debrief Template 34 Appendix 7 Key Contact List 37 Appendix 8 CCG Surge Management Plan 38 2

NHS Newcastle Gateshead Clinical Commissioning Group Definitions The following definitions apply to terms used in this policy in accordance with ISO 22301 and PAS 2015 Framework for NHS Resilience: Activity: Processes or sets of processes undertaken by the CCG, or on behalf of the CCG, that supports delivery of services. Business As Usual: Pre-defined acceptable levels of service delivery. Business Continuity Management (BCM): Process to identify potential threats, assess the impact of those threats on the CCG, and building a framework to support CCG resilience to those threats, including protecting patients and stake-holders interests and achieving strategic objectives. Includes strategic and tactical capability of the CCG to plan for and respond to business interruptions in order to support continued delivery of business as usual. Critical Activities: Those activities carried out by the CCG which are most time sensitive and important for ensured continued delivery. These will be mainly those services essential for immediate life and death of patients. These activities will typically suffer if delayed by more than one hour. Desired Activities: Those activities carried out by the CCG which can be postponed or delayed most easily. These activities will begin to suffer if delayed by more than 7 days. Disruption: Any event, planned or unplanned, which causes an interruption to the CCG s ability to continue business as usual. Essential Activities: Those activities carried out by the CCG which are sensitive and important, but not critical to life and death of patients. These activities will normally suffer if delayed by more than one day. Major Incident: An event classified as a major incident according to the CCG Business Continuity Plan. Necessary Activities: Those activities carried out by the CCG which support business delivery on a daily basis and are not critical or essential. These activities will typically start to suffer if not restored within a week. Service Recovery: The process through which business as usual is reached, following an interruption or disruption event. Vital Activities: Those activities carried out by the CCG which support business delivery. These activities need to be restored within 3 working days. 3

NHS Newcastle Gateshead Clinical Commissioning Group SECTION 1 1. Introduction 1.1 This Business Continuity Plan (BCP) describes how Newcastle Gateshead CCG will discharge its functions in the event of a major incident or outbreak that causes or threatens to cause serious interruption of business operations. 1.2 As Category 2 responders under the Civil Contingencies Act 2004, CCGs are required to have a Business Continuity Plan in place to manage the effects of any incident that might disrupt its normal business 1.3 This plan also details the procedures that will be implemented to ensure that the CCG is also able to plan for and respond to emergencies and surges in accordance with the NHS Emergency Planning Risk and Response (EPRR) guidelines and the Civil Contingencies Act 2004 and successfully discharge its duties as Category 2 responder. 1.4 Clinical Commissioning Groups are designated as Category 2 responder organisations in an amendment made to the Civil Contingencies Act (CCA). The CCA prescribes specific emergency planning and response duties for a range of organisations. As a Category 2 responder the CCG has a duty to: Cooperate with other responders Share information with other responders. 1.5 The NHS England Core Standards for EPRR (Emergency Planning Response and Resilience) adds: Category 2 Responders, such as Clinical Commissioning Groups, are seen as cooperating organisations. They are less likely to be involved in the heart of planning, but they will be heavily involved in incidents that affect their sector. Although Category 2 Responders have a lesser set of duties, it is vital that they share relevant information with other responders (both Category 1 and 2) if EPRR arrangements are to succeed. The intent of these duties is to ensure that CCG and other Category 2 organisations can fulfil the responsibilities imposed by other legislation, such as the Health and Social Care Act, in a way that is integrated with the work of other organisations that are usually more involved in planning for and responding to emergencies. 2. Business Continuity Management 2.1 Business Interruption can be defined as; An unwanted incident which threatens personnel, buildings, operational procedures, or the reputation of the organization, which requires special measures to be taken to restore things back to normal 4

NHS Newcastle Gateshead Clinical Commissioning Group 2.3 Newcastle Gateshead CCG will maintain a specific Business Continuity Plan (including EPRR and Surge Management arrangements) which outlines their critical functions and services, and provides details of how it is intended that business continuity is maintained when faced with loss of premises, staff and other resources 2.4 Business continuity management (BCM) is a business driven process that establishes a fit-for-purpose strategic and operational framework to Proactively improve the organisation s resilience against severe interruption; Provide a rehearsed method of restoring the organisation s ability to supply its key services to an agreed level within an agreed time after a interruption; Deliver a proven capability to manage a business interruption and protect the organisation s reputation and brand 2.5 BCM can be defined as: A holistic management process that identifies potential threats to an organisation and the impacts to business operations that those threats, if realised might cause, and which provides a framework for building organisational resilience with the capability for an effective response that safeguards the interests of its key stakeholders, reputation, brand and value creating activities. (BS 25999 Business Continuity Management Part 1 2006: Code of Practice, British Standards Institute) At the heart of business continuity planning are four key areas: Damage/denial of access to premises; Non availability of key staff; Loss or damage to other resources; Loss/damage to IT or data. 2.6 Business continuity is complementary to the risk management framework that sets out to understand the risks to operations or business, and the consequences of those risks. Reference should be made to the organisation s risk management strategy and risk register which relate to corporate and directorate risk assessments that may be considered in conjunction with this continuity planning process. 3. Purpose and scope 3.1 The purpose of this Plan is to ensure business continuity arrangements are in place which: identify and maintain critical activities during and after any interruption; restore them to full functionality; promote recovery as quickly as possible. 5

NHS Newcastle Gateshead Clinical Commissioning Group The plan also describes how the Newcastle Gateshead CCG maintains a good standard of preparedness to respond safely and effectively to a full spectrum of threats and hazards, outbreaks and disruptive events as part of a multi agency response. 3.2 To perform its duty on a day-to-day basis, Newcastle Gateshead CCG depends upon a wide range of complex systems and resources, and seeks to maintain a good reputation. Inevitably, there is potential for significant interruption to normal business or damage to the organisation s reputation through loss of those systems and resources. Newcastle Gateshead CCG priorities when faced with a significant interruption (whether actual or impending) will always be to: Ensure the safety and welfare of its personnel and visitors; Endeavour to meet its obligations under legislative requirements; Secure replacement critical infrastructure and facilities; Protect its reputation; Minimise the exposure to its financial and reputational position; Facilitate a return to normal operations as soon as practicable. 3.3 The scope of this BCP will centre on conformity with BS 25999, legislative requirements within the Civil Contingencies Act (CCA) 2004 and NHS England guidance. 4. Categorisation and prioritisation of services 4.1 Successful business continuity planning includes the ability to define the essential business services of the organisation and must be identified at all levels. These can be broken down into critical, vital, necessary and desired. Determining and categorising services in this way is the responsibility of heads of service within the organisation. CRITICAL VITAL NECESSARY Services must be provided immediately or the loss of life, infrastructure destruction, loss of confidence and significant loss of revenue will result. These services will require continuity within 24 hours of interruption. Services are those that must be provided within 72 hours or loss of life, infrastructure destruction, loss of confidence and significant loss of revenue or disproportionate recovery costs will result. Services must be resumed within 7 days 6

NHS Newcastle Gateshead Clinical Commissioning Group DESIRED or considerable loss, further destruction or disproportionate recovery costs could result. Services could be delayed for 7 days or longer, but are required in order to return to normal operating conditions and alleviate further disruption or disturbance to normal conditions. 4.2 This is a list of the possible interruption factors that represents the potential impact for the organisation; Loss of life or inacceptable threat to human safety; Disruption of essential services; Loss of public/stakeholder confidence; Loss of vital records; Loss of expertise; Significant damage or total loss of infrastructure; Significant loss of revenue or public funds; Disproportionate recovery costs. 4.3 Within the organisation the interruption factors may include; Access to or the ability to operate normal services from a site which can be either fully or partially interrupted due to an incident occurring e.g. fire, loss of utilities; IT systems are interrupted or the network fails, causing significant disruption to either a single or more department; Failure of service provision arising from a key 3 rd party supplier or provider organisation; Greatly reduced staffing levels e.g. severe weather conditions, fuel shortages (Appendix 1) or flu pandemic; Loss of telephone communications. 4.4 And as a result there is impact upon Health and safety Possibility of either adverse Financial or reputational damage. A requirement to relocate to alternative working premises or service delivery resources. 5. Organisational Culture 5.1 To be successful, this Business Continuity Plan must be owned by everyone within the organisation as many disruptions to critical services and organisations are caused by internal failures. All staff must be convinced that business continuity is a serious issue for the organisation and they have an important role to play in maintaining the delivery of critical services for patients. 7

NHS Newcastle Gateshead Clinical Commissioning Group 5.2 All Newcastle Gateshead CCG Job Descriptions will therefore include a description of the expected role and responsibilities of the employee as part of this business continuity planning and management process. In order to assist staff in being able to discharge these duties, regular updates and awareness raising programmes will be established as part of the overall implementation of the Business Continuity Plan. 5.3 Each individual employee will also be responsible for ensuring that he/she is familiar with the BCP and his/her role within it (when specifically named in the plan) or aware of how they may contribute to the achievement of the organisation s business continuity objectives. 6. Accountable Emergency Officer and Oversight of Business Continuity Management Policy 6.1 The Accountable Emergency Officer for the Newcastle and Gateshead CCG is the Newcastle Gateshead CCG Chief Officer. 6.2 The Executive Director of Nursing, Patient Safety and Quality is the Executive Lead with senior level responsibility for Business Continuity Planning and Management (including Pandemic Influenza). The Executive Director of Nursing, Patient Safety and Quality seeks advice from and provides reports to the Governing Body as required. Formal oversight of the CCG Business Continuity Management arrangements is the responsibility of the CCG Quality, Safety and Risk Committee. The Executive Director of Nursing, Patient Safety and Quality and the Service Reform Manager will prepare a formal report on Business Continuity for that committee at least annually. The Executive Director of Nursing, Patient Safety and Quality will be supported by the Service Reform Manager. 8

NHS Newcastle Gateshead Clinical Commissioning Group SECTION 2 1. Service Priorities 1.1 All functions of the organisation have been designated a level of priority based upon the completion of the Business Impact Assessment tool (Appendix 1). This assumes IT functionality is maintained, in line with IT business continuity and disaster recovery plans. PRIORITY AND DEFINITION CRITICAL An essential function needing to be restored within 0-24 hours VITAL An important function needing to be restored within 3 working days NECESSARY A function needing to be restored within 7 working days DESIRED A function which can be restored progressively after 7 working days NHS Newcastle Gateshead CCG CCG activities Patient safety Safeguarding Senior leadership function Corporate Communication, Media and PR Management of a major surge, pandemic or Incident. Complaints handling Payroll function (time sensitive to payroll schedule) Financial systems Contract management All these functions are administered by NECS on behalf of the CCG but require CCG input Freedom of information requests Individual treatment requests Serious Incidents All other functions 9

NHS Newcastle Gateshead Clinical Commissioning Group SECTION 3 1. Emergency Planning, Response and Resilience (EPRR) Statutory and Legal Obligations and Requirements 1.1 The operating framework for the NHS in England 2015/16 requires EPRR to remain a core function for NHS organisations in line with the Civil Contingencies Act 2004. All organisations are required to maintain a good standard of preparedness to respond safely and effectively to a full spectrum of threats and hazards and disruptive events such as: - Pandemic influenza - Mass casualty - Potential terrorist incidents - Effects of severe/adverse weather - Chemical, biological, radiological and nuclear (CBRN) incidents - Fuel and supply chain disruption - Public health incidents 1.2 Whilst NHS England bears the majority of responsibilities in preparing for and responding to incidents and emergencies as the Category 1 Responder, Newcastle Gateshead CCG as a Category 2 Responder will effectively discharge its duties and: - Carry out Risk Assessments of its own operations - Prepare emergency plans and participate in exercises - Communicate with the public when required - Cooperate with other responders through the Local Resilience Forum - Share information with other responders as and when appropriate - Undertake a debrief and provide support to staff where required - Assist with recovery to normal services where appropriate Depending upon the type and nature of the incident and the response required, it may be necessary to activate this Business Continuity Plan. 2. Surge Management Arrangements 2.1 Newcastle Gateshead CCG is supported by the North East Commissioning Support Unit (NECS) in its management of surges and winter preparedness. NECS on behalf of the CCG s works directly with the Emergency Departments, the North East Ambulance Service, other providers such as the Local Authorities as well as NHS England on a daily basis to do this. The aim is to assist health and care providers to be more effective, by ensuring that they are able to manage patients safely and effectively within their capacity on a day to day basis and in times of increased demand which cause significant pressures. 2.2 The NECS Surge Team have a regional footprint and provide an overview of pressures, manage demand through the facilitation of mutual aid and ensure 11

NHS Newcastle Gateshead Clinical Commissioning Group appropriate diverts are implemented where and when necessary. Depending upon the level of pressures being experienced, NECS chair a teleconference between providers and CCG s. 2.3 Under certain circumstances, it may be necessary for Newcastle Gateshead CCG to activate the locally agreed Surge Management Policy and/or this Business Continuity Plan when and where sustained pressures are being experienced (Appendix 8). 2.4 During any sustained surge or the Winter period (November until March), the level of surge along with any relevant information will also be posted daily on the visibility wall, within the Newcastle Gateshead CCG premises. 3 Pandemic Influenza Arrangements 3.1 Pandemic influenza is recognised by the Government as the single most disruptive event facing the UK today. As such this remains at the top of the UK Government National Risk Register. The 2009/10 A(H1N1) influenza pandemic has not altered the likelihood of a future pandemic. Additionally the general mild nature of the 2009/10 pandemic must not be taken as an indicator of the potential severity of future such events. 3.2 Influenza pandemic planning in the UK has been based on an assessment of the reasonable worst case derived from experience and a mathematical analysis of seasonal influenza and previous pandemics. This suggests that up to 50% of the population could experience symptoms of pandemic influenza during one or more pandemic waves lasting 15 weeks, although the nature and severity of the symptoms would vary from person to person. Analysis of previous influenza pandemics suggests that we should plan for up to 2.5% of those with symptoms dying as a result of influenza, assuming no effective treatment was available. 3.3 The UK Influenza Pandemic Preparedness Strategy 2011 recognises that the combination of particularly high attack rates and a severe disease is also relatively (but unquantifiably) improbable, and consequently suggests planning for a lower level of population mortality is sensible. While the profile of the next pandemic remains by its very nature unknown, it is prudent to continue to plan and prepare using modelling assumptions based on experiences of previous pandemics. 3.4 Although all parts of society will be affected by a pandemic, the NHS is likely to be particularly impacted due to an increase in demand for services from patients coupled with a potential reduction in staffing (due to a variety of factors including personal illness and caring responsibilities). 3.5 NHS England is therefore responsible for leading the mobilisation of the NHS in the event of an emergency or incident and for ensuring it has the capability for NHS command, control, communication and coordination and leadership of all providers of NHS funded care. Locally the Local Health Resilience Partnerships (LHRP) will oversee health pandemic preparedness and act as a conduit for health to engage with the Local Resilience Forum (LRF) - wide preparedness arrangements 3.6 Newcastle Gateshead CCG has a role in supporting NHS England and providers of NHS 12

NHS Newcastle Gateshead Clinical Commissioning Group funded care in planning for and responding to an influenza pandemic (Primary Care will be co-ordinated by NHS England as the current contract holder). The primary role of Newcastle Gateshead CCG will be to: - Before a pandemic: participate in relevant planning groups to discuss, plan, exercise and share best practice; - During a pandemic: support the national pandemic response arrangements, lead the management of pressure surge arrangements with locally commissioned services as a result of increased activity as part of the overall response and support NHS England in the local coordination of the response. - After a pandemic: contribute to local, regional and national health post-pandemic debriefs and consider the implementation of recommendations and assess the impact of the pandemic on the provision of commissioned services and ensure that the ongoing service level is sufficient to meet the demands of the system. 3.7 Should a Pandemic be declared, the Executive Director of Nursing, Patient Safety and Quality will liaise with NHS England to determine Newcastle Gateshead CCG s response, which may result in the activation of this Corporate Business Continuity Plan (BCP). 13

NHS Newcastle Gateshead Clinical Commissioning Group SECTION 4 1. Activating the Business Continuity Plan (BCP) Notification of a business interruption may originate from any source, during working hours or out of hours. When a business interruption occurs it is the responsibility of the most senior manager on duty to decide the relevant response. Activation of the business continuity plan is likely to be needed when something has happened that impacts on critical business functions, for example: All or a substantial part of the CCG office building a Riverside House or other satellite sites are unusable for a period of time exceeding 7 hours; Less than one third of staff from the organisation are available for work; Major incident in or around geographic area (mass casualties, flu pandemic, adverse weather etc.); The need for additional internal/external resources; Increased severity of the business interruption; Increased demands from government departments, the service or commissioned service; Heightened public or media interest. 1.1 An alert can be raised by any member of staff to the Newcastle Gateshead CCG Director on Call. The Director on Call will inform the Chief Officer or deputy and the assigned BCP/EPRR Lead (Detailed in Section 4.2) who will consider the appropriate response and whether to activate this Business Continuity Plan. Details of the Director on Call will be displayed at all times on the information wall at Newcastle Gateshead CCG headquarters at Riverside House, Newburn. 1.2 An alert may also be raised to the Director on Call by NHS England or other organisations such as the Local Authority, North East Ambulance Service or a local Foundation Trust when a Major Incident has been declared or when organisations are at standby and are preparing to declare a major incident. Again the appropriate response will be considered and whether the Business Continuity Plan is to be activated. 1.3 During the out of hours period an alert would be made to the designated officer on call from the Northern Clinical Commissioning Groups Out of Hours On Call Rota. This person would manage the incident and then hand over to the Newcastle Gateshead CCG Director on Call at 9.00am on the next working day. 1.4 The Newcastle Gateshead CCG Director on call will activate the business continuity plan, taking charge of the situation to establish the extent of the interruption and organise the appropriate response. 14

NHS Newcastle Gateshead Clinical Commissioning Group Role of senior person in charge Take charge of the situation Undertake service impact analysis and take/direct any immediate remedial actions (e.g. making an area safe) Identify a room to use as the incident room Arrange and chair the first meeting of the business continuity team Lead the organisation through the period of interruption and restoration Stand down the incident room and the team at the end Prepare final report and debrief, highlight lessons learned Appendix 3 is the action checklist for senior manager in charge Appendix 4 has the pro forma Appendix 5 gives an agenda for this meeting Appendix 6 2. Key Personnel in Business Continuity Team ROLE Senior Manager in charge EPRR and BCP Lead AND Business continuity incident room coordinator Business continuity support Any other role as designated by the senior manager in charge which may include: - Communications lead - Estates and facilities lead - HR lead - Finance lead - IT lead - Administration/Loggist lead Personnel Chief Officer OR Director on Call Head of Corporate Affairs PA to Chief Officer As determined by Senior Manager in charge 2.1 This is the minimum membership. The nature of the disruption may mean additional support is required for example from staff within the Newcastle Gateshead CCG or specific colleagues at North East Commissioning Support, particularly when an incident, outbreak or disruption is likely to be prolonged and last for more than 24 hours. This will be as determined by the senior manager in charge. 15

NHS Newcastle Gateshead Clinical Commissioning Group 3. Plan Activation Phases The following activation sequence will normally be used when informing staff of the activation of this plan: Standby phase, Implementation phase, Stand Down phase Standby will be used as an early warning of a situation which might at some later stage escalate and thus require implementation of this Plan. This is particularly important if an interruption occurs towards the end of office hours and staff may need to be asked to stay at work until the situation becomes clear. Implement is the immediate activation of this plan. Stand Down will be used to signify the phased withdrawal of the activation of the plan e.g. the standing down of the incident room. 4. Business Continuity Incident Room The purpose of the incident room is to provide a place where the CCG can implement and co-ordinate the organisation-wide initial response and recovery operations; to provide a single point of contact for requests for assistance allowing the business continuity team an immediate overview of the organisation-wide response and to provide an area for information collation and preparation of any briefings The business continuity incident room will be the Boardroom, Newcastle Gateshead CCG Clinical Commissioning Offices at Riverside House. In the event that Riverside House is not useable and the CCG has to operate from a secondary business continuity incident room and depending upon the location of the incident there are three options available. These are: - Waterfront 4, Newburn Riverside; - Newcastle Civic Centre; - Gateshead Civic Centre. 5. Designated roles On activation of this BCM Plan in response to a Business Interruption, personnel will need to adopt specific roles in the response, as follows: 5.1 Role of the senior manager in charge This is the most senior person on duty, who takes charge. Their primary role is to formulate the overall strategic response to business interruption. An initial checklist of actions is at Appendix 2. 5.2 Role of business continuity incident room co-ordinator The primary role of the business continuity incident room co-ordinator is to support the senior manager in charge and run the incident room. 16

NHS Newcastle Gateshead Clinical Commissioning Group 5.3 Role of Business continuity support The business continuity support works as required by the senior manager and incident room co-ordinator. 5.4 Other roles outside of the Business Continuity Incident Room may be established, depending upon the nature of the incident or disruption. It may also be necessary for these roles to be discharged off site (e.g. as part of a Silver Command with another agency or provider). This will be determined by the Senior Manager in Charge. 6. Communications 6.1 Effective communications are crucial. It is essential to disseminate accurate and timely information to staff, partners, stakeholders and where necessary the public during the response to a business interruption. The business continuity co-ordinator will liaise with the communications lead as needed to ensure effective, on-going communications. 6.2 Contact details will be disseminated to relevant personnel and stakeholders to maintain effective channels of communication. This will be overseen by the senior manager in charge. A checklist is given as Appendix 5. 7. De-escalation of BCP The Senior Manager in charge will determine when the BCP will be stood down in line with the phase described in Section 8 of this plan. Criteria for de-escalation would include: Reduction in internal resource requirements Reduced severity of the incident Reduced demands from government departments, the service and commissioned service Reduced public or media interest 8. Debrief At the conclusion of the incident, the Business Continuity Lead will lead a debrief session and prepare a report on the incident (Appendix 5), to include issues identified by the debriefing process. This should take place between 24 hours and fourteen days following the incident. The report will be considered at a meeting of the Quality, Safety and Risk Committee and submitted to the Governing Body together with any recommendations and action plan for approval. 17

NHS Newcastle Gateshead Clinical Commissioning Group 9. Business Continuity Management Plan Holding, Maintenance and Review procedure The Service Reform Manager is responsible for the maintenance of the business continuity plan. This includes: Ensuring up to date copies of the plan are accessible to the Accountable Emergency Officer, Directors and all staff; Formally reviewing the business continuity plan at least annually; Advising the Quality and Safety Committee about the plan, as required, no less frequently than annually. Engaging with both the Local Health Resilience Forum and Local Resilience Forum. 10. Training and exercises 10.1 Responsibility for overseeing the relevant training, testing and exercising of the plan is delegated to the Service Reform Manager acting on behalf of the Executive Director of Nursing, Patient Safety and Quality and the Quality Safety and Risk Committee. The Service Reform Manager will work closely with colleagues from the North East Commissioning Support Unit and other Category 1 and 2 Responders. This is to support all those involved in developing and implementing the Business Continuity Plan to be competent to carry out their tasks and to support all staff to have a general awareness of business continuity management issues. 10.2 Staff from the Newcastle Gateshead CCG will also, where appropriate, participate in any exercise designed to test and improve the organisations and/or sectors preparedness. As part of this training and exercise process, Newcastle Gateshead CCG will adopt a culture which encourages staff at all levels to participate in the identification of alternate methods of working should normality ever be disrupted and where appropriate; these ideas will be incorporated into the BCP. 18

Appendix 1 Adverse Weather/Fuel Shortages staff attendance 1. The need to balance business continuity and staff availability during periods of adverse weather or fuel shortages is the responsibility of the whole staff team, led by the Chief Officer and Senior Manager Team. The safety of patients and staff is paramount. 2. It is the duty of each employee to make their own arrangements to get to work at the normal time. However it is recognized that employees may experience severe difficulties in getting to and from work. 3. Individual members of staff should make contact with their line manager (or Director on call or Chief Officer in the absence of their line manager) to discuss their options and plans. This should be at the earliest opportunity, even the evening before when adverse weather starts or fuel shortage is forecast. 3.1 The first option to consider is that the member of staff attends their usual place of work (the CCG office), taking into account any particular travel arrangements (e.g. allowing extra time, using public transport) 3.2 If the employee and manager agree that it is not practical for the employee to get to the office, then the second option is to consider going to the nearest CCG or NECS office where the employee can access the necessary IT systems. If this is agreed, the employee should speak to the senior manager in charge at that office immediately on arrival, as well as notifying their own line manager. 3.3 If the employee and manager agree that neither option 1 nor 2 is practical, then the line manager may consider option 3 - that the employee can work from home. The work to be done and how contact will be maintained whilst the employee is working at home should be clearly agreed. 3.4 If the employee and manager agree that none of these options are practical, then the employee will have the option of: - Flexible working (manager may agree revised working hours to enable the employee to fulfill their contracted hours). - Annual leave - Unpaid leave 4. It is essential that communication is maintained between the employee and manager, to keep the situation under review, maintain the safety of the employee and ensure adequate oversight of the work. As a minimum the manager should speak to the employee at the start of each working day, at least once during the day and at the end of each working day. 5. During prolonged periods of adverse weather or Fuel Shortages the Chief Officer and Senior Manager team will keep the matter of workload and office cover under daily review. 16

Business Impact Analysis Form Critical Service: Patient Safety Appendix 2 Service Function: To oversee patient safety ensuring it is included in all contracts. Gaining assurance from all providers on patient safety issues. Risk rating: Medium Maximum Tolerable Period of Disruption: Recovery Time Objective: <24 Hours Immediate Profile Pro viders Proc esses Pre mises P eople Key Staff What staff are required to carry out Can staff be contacted? Could extra capacity be built into your staffing to assist you in coping during an incident? All staff have mobile IT and Telephony which supports remote working and can be used anywhere that has access to the internet Skills / Expertise / Could staff be trained in other roles? Could other members of staff undertake other Many staff are qualified Clinicians and could Training non-specialist roles in the event of an Skills / expertise required? incident? with some support help in clinical and nonclinical services Minimum Staffing Level to support essential service? Buildings Primary site locations? What is the minimal staffing level to continue to deliver your key functions at an acceptable level? What grade of staff do you require? What measures could minimise impact? 1 member in the event of a serious incident enabling others to be mobilized to support recovery from the major incident Could you operate from more than one All staff have mobile IT and Telephony which premise? Could staff work remotely? supports remote working and can be used Could you relocate operations in the event of i b i l t if d i d? anywhere that has access to the internet Facilities Are any of your facilities multi-purpose? Could relocate anywhere in the event of a What is essential to carry out Equipment / Resources What is required? IT What IT is essential? Documentation Essential documentation and how are these stored? Systems / Communications What is required to carry out Reciprocal arrangements Any arrangements with other organizations? Contractors With whom and for what? Suppliers On whom you depend for Reputation Key stakeholders? Legal Considerations Legal, statutory and regulatory requirements? Are alternative facilities available in the event of an incident? Could alternative equipment be acquired? Could key equipment be replicated or do manual procedures exist? Is data backed-up and are back-ups kept off site? Do you have any disaster recovery arrangements? Is essential documentation stored securely (e.g. fire proof safe, backed-up or stored elsewhere)? Are your systems flexible? Do you have alternative systems in place (manual processes)? What alternative means of communication exist? Do you have agreements with other organisations regarding staffing, use of facilities in the event of an incident? Alternative contractors or reliant on a single contractor? Do your contractors have contingency plans? Do you know of suitable alternative suppliers? Could key suppliers be contacted in an emergency? How could reputational damage to your organisation be reduced? How could you provide information to staff and stakeholders in an emergency (e.g. press release)? Do you have systems to log decisions; actions; and costs, in the event of an incident? major incident provided there is access to the internet No Specialised equipment needed Data all backed up on Network All stored electronically Systems are flexible need to consider manual processes. Communications can be reestablished from any other building Not needed can work from home if necessary to fulfil function for a 24 hour period No Contractors No issues identified as all equipment is standard and available from many suppliers Mange reputational issues by maintaining serves during a Major incident. Ensure regular communication with staff is maintained using various methods. Yes records of key decisions 17

Business Impact Analysis Form Critical Service: Safeguarding Service Function: To ensure safeguarding of people is included in all contracts to provide expert advice and support to commissioning and work collaboratively with LA s and Service Providers Risk rating: High Maximum Tolerable Period of Disruption: <24 Hours Recovery Time Objective: Immediate viders Proc esses Pre mises P eople Key Staff What staff are required to carry out Can staff be contacted? Could extra capacity be built into your staffing to assist you in coping during an incident? All staff have mobile IT and Telephony which supports remote working and can be used anywhere that has access to the internet Skills / Expertise / Could staff be trained in other roles? Could other members of staff undertake other Many staff are qualified Clinicians and could Training Skills / expertise required? non-specialist roles in the event of an incident? with some support help in clinical and nonclinical services Minimum Staffing Level to support essential service? Buildings Primary site locations? What is the minimal staffing level to continue to deliver your key functions at an acceptable level? What grade of staff do you require? What measures could minimise impact? 1 member in the event of a serious incident enabling others to be mobilized to support recovery from the major incident Could you operate from more than one All staff have mobile IT and Telephony which premise? Could staff work remotely? supports remote working and can be used Could you relocate operations in the event of i b i l t if d i d? anywhere that has access to the internet Facilities Are any of your facilities multi-purpose? Could relocate anywhere in the event of a What is essential to carry out Equipment / Resources What is required? IT What IT is essential? Documentation Essential documentation and how are these stored? Systems / Communications What is required to carry out Reciprocal arrangements Any arrangements with other organizations? Contractors With whom and for what? Are alternative facilities available in the event of an incident? Could alternative equipment be acquired? Could key equipment be replicated or do manual procedures exist? Is data backed-up and are back-ups kept off site? Do you have any disaster recovery arrangements? Is essential documentation stored securely (e.g. fire proof safe, backed-up or stored elsewhere)? Are your systems flexible? Do you have alternative systems in place (manual processes)? What alternative means of communication exist? Do you have agreements with other organisations regarding staffing, use of facilities in the event of an incident? Alternative contractors or reliant on a single contractor? Do your contractors have contingency plans? major incident provided there is access to the internet No Specialised equipment needed Data all backed up on Network All stored electronically Systems are flexible need to consider manual processes. Communications can be reestablished from any other building Not needed can work from home if necessary to fulfil function for a 24 hour period No Contractors Pro Suppliers On whom you depend for Do you know of suitable alternative suppliers? Could key suppliers be contacted in an emergency? No issues identified as all equipment is standard and available from many suppliers rofile P Reputation Key stakeholders? Legal Considerations Legal, statutory and regulatory requirements? How could reputational damage to your organisation be reduced? How could you provide information to staff and stakeholders in an emergency (e.g. press release)? Do you have systems to log decisions; actions; and costs, in the event of an incident? Mange reputational issues by maintaining serves during a Major incident. Ensure regular communication with staff is maintained using various methods. 18

Business Impact Analysis Form Critical Service: Senior Leadership Function Service Function: Provision of leadership across CCG. Maximum Tolerable Period of Disruption: Recovery Time Objective: Risk rating: High <12 Hours Immediate viders Proc esses Pre mises P eople Key Staff What staff are required to carry out Can staff be contacted? Could extra capacity be built into your staffing to assist you in coping during an incident? All staff have mobile phones and lap tops/ipads. Skills / Expertise / Could staff be trained in other roles? Staff will undertake key roles identified in this Could other members of staff undertake other Training plan. Skills / expertise required? Minimum Staffing Level to support essential service? Buildings Primary site locations? non-specialist roles, in the event of an incident? What is the minimal staffing level to continue to deliver your key functions at an acceptable level? What grade of staff do you require? What measures could minimise impact? Could you operate from more than one premise? Could staff work remotely? Could you relocate operations in the event of a premise being lost or if access was denied? Senior staff identified in Section 2. Any site with teleconference facilities. Facilities Are any of your facilities multi-purpose? Network and telephone access. Work could Are alternative facilities available in the event What is essential to carry take place from home and also other NHS out of an incident? sites i e other CCG Equipment / Could alternative equipment be acquired? Mobile phones and lap tops. Could key equipment be replicated or do Resources manual procedures exist? What is required? IT What IT is essential? Documentation Essential documentation and how are these stored? Systems / Communications What is required to carry out Reciprocal arrangements Any arrangements with other organizations? Contractors With whom and for what? Is data backed-up and are back-ups kept off site? Do you have any disaster recovery arrangements? Is essential documentation stored securely (e.g. fire proof safe, backed-up or stored elsewhere)? Are your systems flexible? Do you have alternative systems in place (manual processes)? What alternative means of communication exist? Do you have agreements with other organisations regarding staffing, use of facilities in the event of an incident? Alternative contractors or reliant on a single contractor? Do your contractors have contingency plans? NECS Disaster Recovery Plan. On-line Good existing mechanisms plus support available from other NHS organisations. NECS and other CCG Buildings. Pro Suppliers On whom you depend for Do you know of suitable alternative suppliers? Could key suppliers be contacted in an emergency? rofile P Reputation Key stakeholders? Legal Considerations Legal statutory and How could reputational damage to your organisation be reduced? How could you provide information to staff and stakeholders in an emergency (e.g. press release)? Do you have systems to log decisions; actions; and costs, in the event of an incident? Loss of credibility with key stakeholders. Records of key decisions would be kept by Business Continuity Support function. 19

Business Impact Analysis Form Critical Service: Corporate Communication, Media and PR Service Function: Corporate communication, media and PR Maximum Tolerable Period of Disruption: Recovery Time Objective: Risk rating: High <4 Hours Immediate esses Pre mises Pe ople Key Staff What staff are required to carry out Can staff be contacted? Could extra capacity be built into your staffing to assist you in coping during an incident? All communications staff from NECS have mobile phones and lap tops. There is a media relations on call rota, a media relations policy and local media know who to contact. Main media relations and communications systems are on-line and can be remotely accessed. Skills / Expertise / Could staff be trained in other roles? Larger at scale NECS communications team Training Skills / expertise required? Minimum Staffing Level to support essential service? Buildings Primary site locations? Could other members of staff undertake other non-specialist roles, in the event of an incident? What is the minimal staffing level to continue to deliver your key functions at an acceptable level? What grade of staff do you require? What measures could minimise impact? Could you operate from more than one premise? Could staff work remotely? Could you relocate operations in the event of a premise being lost or if access was denied? provides additional capacity and resource. One member of staff during in hours and maintain on call rota albeit major incident may require 24 hour cover. Any site with teleconference facilities. Facilities Are any of your facilities multi-purpose? Network and telephone access. Work could Are alternative facilities available in the event What is essential to carry take place from home and also other NHS out of an incident? sites i e other CCG Equipment / Could alternative equipment be acquired? Mobile phones and lap tops. Could key equipment be replicated or do Resources manual procedures exist? What is required? IT What IT is essential? Documentation Essential documentation and how are these stored? Is data backed-up and are back-ups kept off site? Do you have any disaster recovery arrangements? Is essential documentation stored securely (e.g. fire proof safe, backed-up or stored elsewhere)? On-line web based media relations and communications system On-line viders Proc Systems / Communications What is required to carry out Reciprocal arrangements Any arrangements with other organizations? Contractors With whom and for what? Are your systems flexible? Do you have alternative systems in place (manual processes)? What alternative means of communication exist? Do you have agreements with other organisations regarding staffing, use of facilities in the event of an incident? Alternative contractors or reliant on a single contractor? Do your contractors have contingency plans? Good existing mechanisms plus support available from other NHS organisations communications NECS cover the Northern region with staff deployed across each area. Pro Suppliers On whom you depend for Do you know of suitable alternative suppliers? Could key suppliers be contacted in an emergency? rofile Reputation Key stakeholders? Legal How could reputational damage to your organisation be reduced? How could you provide information to staff and stakeholders in an emergency (e.g. press release)? Do you have systems to log decisions; 20

Business Impact Analysis Form Critical Service: Management of Major Surge, Pandemic or Incident. Service Function: Responding to major surge, pandemic or incident which requires the intervention, co-ordination or management by the CCG Risk rating: High Maximum Tolerable Period of Disruption: <24 Hours Recovery Time Objective: Immediate viders Proc esses Prem ises P eople Key Staff Can staff be contacted? Staff have mobile phones and there is a CCG What staff are required to Could extra capacity be built into your staffing on call rota. NECS Winter Office would also be carry out to assist you in coping during an incident? utilised. Skills / Expertise / Could staff be trained in other roles? Knowledge of the system and local providers Training Skills / expertise required? Minimum Staffing Level to support essential service? Buildings Primary site locations? Could other members of staff undertake other non-specialist roles, in the event of an incident? What is the minimal staffing level to continue to deliver your key functions at an acceptable level? What grade of staff do you require? What measures could minimise impact? Could you operate from more than one premise? Could staff work remotely? Could you relocate operations in the event of a premise being lost or if access was denied? is required. One member of staff during in hours and maintain on call rota albeit major incident may require 24 hour cover. Any site with teleconference facilities. Facilities Are any of your facilities multi-purpose? Network and telephone access. What is essential to carry out Equipment / Resources What is required? IT What IT is essential? Documentation Essential documentation and how are these stored? Systems / Communications What is required to carry out Reciprocal arrangements Any arrangements with other organizations? Contractors With whom and for what? Are alternative facilities available in the event of an incident? Could alternative equipment be acquired? Could key equipment be replicated or do manual procedures exist? Is data backed-up and are back-ups kept off site? Do you have any disaster recovery arrangements? Is essential documentation stored securely (e.g. fire proof safe, backed-up or stored elsewhere)? Are your systems flexible? Do you have alternative systems in place (manual processes)? What alternative means of communication exist? Do you have agreements with other organisations regarding staffing, use of facilities in the event of an incident? Alternative contractors or reliant on a single contractor? Do your contractors have contingency plans? Network and telephone access. Communication methods - via other providers. Pro Suppliers On whom you depend for Do you know of suitable alternative suppliers? Could key suppliers be contacted in an emergency? rofile P Reputation Key stakeholders? Legal Considerations Legal, statutory and regulatory requirements? How could reputational damage to your organisation be reduced? How could you provide information to staff and stakeholders in an emergency (e.g. press release)? Do you have systems to log decisions; actions; and costs, in the event of an incident? Loss of credibility around ability to effectively discharge duties. Documentation and record of teleconferences 21