National Ambulance Commissioners Group briefing March 2013 Issue 261

Emergency preparedness, resilience and response A guide for ambulance commissioners

Key points Ambulance services play a critical role in the national infrastructure for emergency preparedness, resilience and response (EPRR). They are at • The NHS needs to be fully the heart of civil contingency planning for both the NHS and the wider prepared and able to respond effectively to a wide range emergency preparedness network. They play a key role in ensuring public of major incidents, and the confidence in the ability of the public services to effectively manage ambulance service is at the core the impact and aftermath of a major incident. It is essential that those of NHS emergency preparedness, commissioning ambulance services are aware of the statutory requirements resilience and response (EPRR). and responsibilities of their providers, and are able to assure themselves that effective preparations are in place. • Commissioners of ambulance services need to be aware of relevant statutory obligations and This Briefing supports commissioners by outlining the scope and importance be confident in assessing their of EPPR and their own role in it, key questions and answers regarding providers’ plans and preparations EPRR, and sources of further information and guidance. It draws on the for a major incident. national specification for ambulance emergency preparedness, published • The Core standards for EPRR in 2012 by the National Ambulance Resilience Unit (NARU), and the NHS define the minimum standards Commissioning Board’s newly published core standards for EPRR, and with which all NHS organisations references the supporting assurance framework and guidance documents. and providers of NHS funded care are expected to comply. The role of ambulance of significant incidents and • A national specification for commissioners in EPRR emergencies that could impact ambulance EPRR has been upon health or patient care.” From developed by NARU with support Everyone counts, planning for April 2013, all NHS organisations from the National Ambulance patients 2013/14 emphasises the are required to contribute to Commissioners Group (NACG). importance of EPRR nationally: coordinated planning for both every NHS trust must “maintain emergency preparedness and service preparedness to respond safely resilience through their local health and effectively to a full spectrum resilience partnerships (LHRPs). briefing 261 Emergency preparedness, resilience and response

Specifically, commissioners must ensure that they “maintain Examples of major incidents the current capability and Major health incidents – for example, the impact of a national flu capacity of existing hazardous pandemic or the business continuity effects of an outbreak of area response teams (HARTs) seasonal flu. in ambulance trusts.” Natural disasters – for example, major flooding events and severe The essential nature of this winter weather. activity, the impact of a major incident on the delivery of routine Transport events – for example, train crashes (Grayrigg, 2007 and Uffton emergency and urgent services Nervet, 2004), plane crashes (Kegworth, 1989), or multiple motorway and the decentralisation of incidents (Taunton, 2011). funding for emergency planning Multiple firearms incidents – for example, Derek Bird (, 2010) all make it vital that those or Raoul Moat (, 2010). responsible for commissioning ambulance services have an Terrorist attacks – the coroner’s report into the London bombings (2005) understanding of the scope and recommended inter-agency major incident training, the use of protocols importance of EPRR. They should in declaring a major incident, a review of be aware of their own roles in training in multi-casualty triage, and a review of the capability and emergency preparedness, and funding of London’s mobile emergency response incident team (MERIT). know where to look for further information and guidance. And they should feel equipped to Ambulance services have always Core standards for EPPR planned for major incidents act as informed customers in The NHS Commissioning Board’s and seen preparedness as an assessing the preparedness of Core standards for EPRR define essential part of their day-to- their ambulance service providers the minimum standards and day business. In recent years to respond effectively should the level of care with which all NHS their capabilities and skills worst occur. organisations and providers of NHS have increased enormously. funded care are expected to comply. The role of ambulance The introduction of HARTs; the In addition to the standards that services in EPRR development of skills in handling apply to all NHS organisations, terrorist attacks, biochemical The ambulance service is at the there are specific standards for hazards and environmental centre of EPRR. The public expects ambulance service providers. disasters; and increasingly strong the ambulance emergency service These include the requirement cooperative relationships with to be on the frontline of any major to maintain a HART and a mobile the other emergency services incident. The response provided emergency response incident team have all helped to create a by ambulance crews is expected (MERIT). These standards closely highly professional cadre of to be immediate, well organised, reflect the National Ambulance emergency planning teams professional and effective. Resilience Unit (NARU) service within the ambulance service. specification and quality assurance This is more than just an framework. expectation though. The However, because it is traditionally treated as part of the routine ambulance service has obligations NARU service specification under the Civil Contingencies work of the ambulance service, Act 2004 and the Department such preparation and planning and quality assurance of Health’s emergency planning is not always especially visible framework to those commissioning guidance which identify The NARU service specification for ambulance services. ambulance providers as ‘Category NHS Ambulance Services EPPR and 1 responders’. the supporting Quality assurance framework is the first publication to

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put EPRR on the same footing as other elements of the ambulance The NARU quality assurance framework commissioning package such The NARU quality assurance framework gives commissioners a tool to as the National Ambulance review the readiness of their ambulance providers for a major incident Performance Standards and against minimum standards and standard operating procedures. National Ambulance Quality Indicators. Its development Commissioners should be aware of the full scope of the framework. However, some elements are of particular note. was prompted by the National Ambulance Commissioners Group Emergency operations centre (NACG) (see back page). This is critical to the successful management of EPRR. Commissioners should assure themselves that their ambulance provider has the Why have core standards capability and capacity to effectively manage a major incident through and a national specification their operations centre. been developed? Emergency logistics Every ambulance provider will have vehicles and equipment held Ambulance services have developed in reserve for a major incident and as part of the critical national their own individual, albeit infrastructure. Commissioners need to build this capacity into their similar, approaches to emergency plans and ensure that the appropriate central funding is drawn down for preparedness. However, public maintenance and replacement when needed. bodies risk criticism (or worse) if they fail to deliver the quality National mutual aid of service expected of them, Mutual aid arrangements ensure that resources can be drawn from particularly in the assessment of neighbouring ambulance services to support the provider managing a major incident. These arrangements may apply at regional or national the effects of a major incident. level. Commissioners should ensure that appropriate arrangements and triggers for regional and national mutual aid are in place. The aim of the NHS Commissioning Board’s core Business continuity management standards is primarily to define Ambulance providers are required to ensure they, and their agency the minimum EPRR standards suppliers, have effective business continuity arrangements in place. expected of each NHS organisation Event management and provider of NHS funded care. Large sporting or entertainment events have the potential to become The standards will enable agencies major incidents. Ambulance providers are required to have plans in place across the country to share a for event management. purpose and coordinate activities, and will provide a consistent Training framework for self-assessment, Training is essential to the effective management of a major incident. In peer review and more formal times of increased activity or financial constraint this is an area that can control processes. be neglected. Commissioners will want to assure themselves that it is being prioritised appropriately. Similarly, the NARU service Partnerships and exercising specification provides a consistent Good working relationships, joint planning and exercising between national approach to ambulance ambulance providers and the wider EPRR community are key to effective emergency planning, built on preparedness. Commissioners should assure themselves that such events shared best practice, and helps are taking place in line with the minimum requirements laid down in the commissioners and ambulance EPRR Core Standards, and that the right stakeholders are involved. services manage the corporate risk Occupational health and human resources of failing to prepare appropriately The NHS generally and ambulance trusts individually have a duty of care for a major incident. to their staff and must have in place robust arrangements to protect staff health during and after a major incident. This should include arrangements The rest of this Briefing addresses for counselling, supporting and advising on long-term clinical care. some of the issues around EPRR.

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Key questions and answers

What is EPRR? partnerships (LRPs), directed by with compensation and the NHS The Civil Contingencies Act (2004) local resilience forums (LRFs). Litigation Authority costs requires NHS organisations, and These involve all relevant public • the reputational risk of criticism providers of NHS funded care, bodies and are mapped to through public enquiry, media to show that they can deal with police authority areas; so any coverage or complaints from single ambulance service may a wide range of major incidents patients and relatives. while maintaining services to have several LRPs within their patients. This programme of boundaries. What role do local commissioners work is referred to as emergency play in the preparation for and preparedness, resilience and From 1 April 2013, local health management of major incidents? response (EPRR). resilience partnerships (LHRPs) will play a key role in EPRR. The The NARU national specification for ambulance emergency NHS Commissioning Board area What is a ‘major incident’? preparedness suggests that team will take on the overall A major incident for NHS trusts is: commissioners should: leadership of the local NHS in terms of planning and response. “Any occurrence that presents • commission EPRR requirements An identified area team director serious threat to the health of as laid down in the specification and a local director of public the community, disruption to to enable the ambulance service health will co-chair the LHRP services or causes (or is likely to provider to meet their obligations cause) such numbers or types of and will be members of the LRF. casualties as to require special Clinical commissioning groups will • work cooperatively with their arrangements to be implemented be involved in planning through ambulance service provider, other by hospitals, ambulance trusts or the LHRPs. emergency services and other primary care organisations.”* Category 1 and 2 responders, Ambulance commissioners need including participating in the A major incident can be predicted, to ensure that they maintain planning and exercise testing such as severe weather or a flu relationships with area team EPRR processes colleagues and assure themselves pandemic, or unpredicted, such • work cooperatively with their that they are being kept in the as a major motorway accident or ambulance service provider local and regional communications a firearms incident with multiple and the Home Office National loops. casualties or a terrorist attack. Interoperability programme. The government departments Where are the risks of failing to A ‘major incident’ requires a major involved in the programme commission EPRR effectively? incident plan to be implemented, are the Home Office, the For commissioners and providers, detailing command and control Department of Health, and the the risks are: structures, decision-making Department for Communities processes, and staffing and and Local Government, looking at • the risk to patients in the case resourcing plans. collaborative working with police, of a failure to respond or treat fire and ambulance services. How is emergency preparedness effectively managed across the NHS, other • the financial risk of potential What is the legal obligation on emergency services and other legal action in the case of ambulance services for emergency Category 1 responders? failure of effective response or preparedness? Emergency preparedness is management of an incident, Ambulance service NHS trusts and managed through local resilience as well as any cases associated ambulance service foundation

* Department of Health (2005) NHS emergency planning guidance.

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trusts are defined as Category 1 for ambulance activity. Although ambulance crews will be drawn responders in the Civil Contingencies funding for HARTs was initially from neighbouring services to Act 2004, alongside fire, police provided centrally, since 2012 this provide cover for the home crews and acute hospital trusts providing has also been included in local being drawn towards the centre of accident and emergency care. funding arrangements. However, the incident. different commissioning bodies According to the Department fund to varying levels across the In a very large or sustained major of Health’s Emergency planning country, which brings disparity incident, this domino effect may guidance 2005: between services and affects spread to other services as each national resilience. The NARU EPRR ambulance service in turn calls on “The Ambulance Service forms specification is designed to provide its neighbours to provide additional part of the NHS response to a consistency and standardisation. cover. A national mutual aid plan Major Incident. It is principally was developed prior to the Olympics geared to the immediate clinical National funding is provided for and is now being reviewed. needs of those directly or the maintenance and replacement indirectly associated with the of vehicles and equipment All commissioners should therefore incident(s) and their subsequent required for the critical national be aware of the need for – and transportation to established infrastructure and is managed the benefit of – subscribing to the treatment centres. through a contract between the principles of mutual aid and the Department of Health and West possibility of managed impact of “The Ambulance Service is Midlands Ambulance Service NHS a major incident elsewhere in the primarily responsible for Foundation Trust (WMAS). In country on their own local service the alerting, mobilising and 2013, the contract with WMAS will provision. coordinating at the scene all transfer to the NHS Commissioning primary NHS resources necessary Board. What is the role of patient transport to deal with any incident, unless services in supporting ambulance the incident is an internal health What is ‘mutual aid’ and why is providers in a major incident? service incident.” it necessary? Patient transport services may be A major incident, particularly an used for removing walking patients Both the Core Standards and unpredicted one, will draw on a from the site of an incident, the national specification look large proportion of normal day- clearing hospital A&E departments for suitably trained, competent to-day ambulance resources. The in readiness to receive patients staff and the appropriate presence of specialised HARTs has from the major incident site, and facilities to be provided on a mitigated this impact in recent discharging patients from hospital round-the-clock basis. These years, but not entirely. to create capacity for the major will be covered through normal incident. command structures and on-call Experience has shown that a arrangements; through the specific major incident not only draws It is essential that commissioners provision of the ambulance Trust’s resource to itself but may also assure themselves that suitable hazardous area response team create a ‘wake effect’ of additional arrangements are in place with (HART) capabilities; and through emergency activity elsewhere in the patient transport services providers the robust profiling of staff and surrounding area. for communications, business facilities management. continuity and service provision on To mitigate the impact of this a 24-hour basis, irrespective of who How are ambulance providers additional pressure and resource the providers are. funded for emergency required, all ambulance services preparedness activity? have mutual aid arrangements Funding for emergency in place with their neighbouring preparedness is included in the services. This creates a ‘domino standard local allocation of funding effect’ of response, whereby

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Key recommendations for ambulance commissioners Ambulance commissioners should: • ensure that their ambulance providers are aware of the NARU National Specification and Quality Assurance Framework and NHS Commissioning Board Core Standards

• arrange to jointly review the Quality Assurance Framework with their ambulance providers

• initiate regular overviews and updates of EPRR in their normal contracting reports and discussions. It is good practice for ambulance commissioners to have a seat on their ambulance provider’s resilience board or similar group

• ensure that they are included in the communications protocols that apply in the course of a developing or actual major incident and subsequent debriefings

• consider having a CCG representative keep a ‘watching brief’ on EPRR.

Useful resources Department of Health (2005) NARU (2012) Service specification NHS emergency planning guidance for NHS ambulance services. The Cabinet Office (2010) 2005: underpinning materials. Emergency preparedness, resilience Emergency response and LINK and response. LINK recovery. Non-statutory guidance accompanying the Civil NARU. National ambulance NHS Commissioning Board (2013) Contingencies Act 2004. LINK service guidance for preparing an Core standards for emergency emergency plan. LINK preparedness, resilience and The Civil Contingencies Act 2004. response. LINK LINK NARU. NHS ambulance services.

Emergency preparedness, resilience NHS Commissioning Board. Department of Health (2005) and response. Quality assurance Everyone counts: planning for NHS emergency planning guidance framework. LINK patients 2013/14. LINK 2005. LINK

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Glossary

Category 1 responders Local resilience forums (LRFs) NARU also coordinates lessons Category 1 responders (also known The principal mechanism for identified from coroners’ inquests, as ‘core responders’) are the ‘blue multi-agency cooperation in Rule 43 inquiries and other such light’ emergency services, as well resilience planning, based on inquiries, to ensure a consistent as acute trusts, foundation trusts, police areas. approach to the implementation local authorities and the Health of lessons learned. Protection Agency. Mobile emergency response incident team (MERIT) NARU provides strategic input to Category 2 responders MERITs provide advanced medical government policy on ambulance Category 2 responders support care at emergency incidents, resilience issues, and, working Category 1 responders and are including major and mass casualty with the Department of Health, mostly utility companies and incidents. This includes advanced assists with national coordination transport organisations. airway procedures, surgical and implementation of the interventions and critical care over pre-hospital health response CBRNE – chemical, biological, and above the level of ambulance to government policies that radiological, nuclear and explosives clinical practice. It also includes are designed to improve civil hazards. advice and support for emergency contingencies and national services staff already on the resilience across England. EPRR – emergency preparedness, scene. MERITs operate under the http://naru.org.uk resilience and response. direction of the ambulance service and are usually provided by acute NARU quality assurance framework Hazardous area response teams hospitals. A tool for commissioners to review (HARTs) the readiness of their ambulance HARTs provide medical care NARU (National Ambulance providers for a major incident within the ‘inner cordon’ at a Resilience Unit) against minimum standards and range of emergency incidents, Since June 2011, responsibility standard operating procedures including those involving chemical, for the delivery of emergency (see page 3). biological, radiological, nuclear preparedness policy in NHS and explosives hazards (CBRNE) or ambulance services in England has NARU service specification for NHS hazardous materials (HAZMAT), or been delegated to NARU, hosted ambulance services EPRR at incidents requiring urban search by Ambulance The specification for ambulance and rescue (USAR) in areas of Service NHS Foundation Trust, EPRR arrangements to be used difficult access or in environments by the Department of Health. by trusts and commissioners to that pose other types of hazard. gain assurance on the provision of NARU works with all ambulance these services in the NHS. HAZMAT – hazardous materials. trusts in England (and the devolved administrations) to USAR – urban search and rescue. Local health resilience support the development of partnerships (LHRPs) properly trained, equipped and From 1 April 2013, LHRPs will prepared ambulance responders provide strategic forums for joint to deal with hazardous or difficult planning for emergencies and will situations, particularly mass support multi-agency planning casualty incidents that represent a through local resilience forums significant risk to public health. (LRFs). They are not statutory organisations.

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Contacts For more information on the issues covered in this Briefing, please contact [email protected] Contact details for the lead commissioner for each ambulance service can be found at www.nhsconfed.org/NACG

The NHS Confederation The NHS Confederation represents all organisations that commission and provide NHS services. It is the only membership body to bring together and speak on behalf of the whole of the NHS. We help the NHS to guarantee high standards of care for patients and best value for taxpayers by representing our members and working together with our health and social care partners. We make sense of the whole health system, influence health policy and deliver industry-wide support functions for the NHS.

The National Ambulance Commissioners Group (NACG) The NACG brings together the individuals with responsibility for fulfilling the coordinating commissioner role for each of the NHS ambulance trusts in England, and those working within the teams providing that coordinating commissioner function and associated commissioning, contracting and service improvement activities. The NACG’s mission is to contribute to the development of high-quality, cost-effective, clinically-focused and locally integrated NHS services, by ensuring the commissioning of emergency ambulance services and emergency preparedness is carried out in the most efficient and effective way possible. The aim of the NACG emergency preparedness, resilience and response (EPRR) workstream is to support a consistent, co-ordinated approach to EPRR commissioning in England and to ensure collaboration between commissioners and ambulance providers on this issue. For more information or to get involved in the work of the NACG, please contact Mark Docherty (chair) at [email protected]

Alternative formats can be requested from: Tel 0870 444 5841 Email [email protected] or visit www.nhsconfed.org/publications The NHS Confederation © The NHS Confederation 2013. You may copy or distribute this work, but you must 50 Broadway London SW1H 0DB give the author credit, you may not use it for commercial purposes, and you may not Tel 020 7799 6666 alter, transform or build upon this work. Email [email protected] Registered Charity no: 1090329 www.nhsconfed.org Stock code: BRIO26101 Follow the NHS Confederation on Twitter: @nhsconfed