Organisation objective

• Statutory item, Governance

Action required

The Board is asked to:

• note key activities and response to incidents as defined by the NHS England emergency preparedness, resilience and response (EPRR) framework during 2023/24; and
• receive assurance that NHS England and the NHS in England is prepared to respond to an emergency and is resilient to provide continued safe patient care. The Board is asked to note and comment on the information provided in the report, and to continue to support CMH transformation across all integrated care systems (ICSs) in 2023/24 and beyond.

Background

Emergency preparedness, resilience and response (EPRR) is a core function of the NHS and is a statutory requirement of the Civil Contingencies Act (CCA) 2004. Responding to emergencies is a key requirement within the NHS Act (2006) and the Health and Care Act 2022.

The role of NHS England in EPRR relates to potentially disruptive threats outlined in the National Security Risk Assessment and leading the NHS response, as required, during emergency situations. These are wide ranging and may be anything from extreme weather conditions to infectious disease outbreaks, a major transport accident or a terrorist incident.

This is the largest area of investment within the wider LTP for mental health, with additional funding in community mental health services across England reaching almost £1 billion by 2023/24. The headline aim is that by 2023/24, 370,000 people will be supported through newly integrated primary and community mental health services.

As part of the new NHS England change programme, the national EPRR team has now adopted the title NHS Resilience team to reflect its involvement in wider NHS resilience matters.

This paper updates the Board on NHS EPRR statutory requirements placed upon NHS England, including:

• summary of key activities and publications
• update on incidents and events which occurred during 2023/24
• outcome of the annual EPRR assurance process and related actions
• priorities for the 2024/25 work programme.

Key activities in 2023/24

During 2023/24, NHS England oversight of EPRR was provided by Sir David Sloman (to 31 August 2023), Sir James Mackey (1 September 2023 to 31 October 2023) and Dr Dame Emily Lawson (from 1 November 2023) as the Accountable Emergency Officer. Additional oversight has been provided by Dr Mike Prentice, National Director for NHS Resilience

The work programme for 2023/24 has delivered some key activity but there have been some significant challenges due to managing protracted industrial action which has meant some projects have been delayed or deferred. Further industrial action and other concurrent incidents will continue to impact work plan commitments and the levels of preparedness of the NHS.

Several key documents in the work programme have been developed and published over the past 12 months:

• Business continuity management toolkit – this contains a portfolio of supporting materials and aims to assist NHS organisations and providers of NHS funded care in meeting their business continuity management obligations.
• Evacuation and shelter guidance for the NHS in England – this provides a framework in the planning, preparation and response to the evacuation and shelter of patients, staff, and others from, or within, health care settings, including whole site evacuation.

Other EPRR products that have been developed and are due to be published:

• Review and update of the concept of operations for the management of mass casualties: burns annex.
• Interim refresh of the pandemic diseases operating framework.
• Introduction of new guidance for the NHS in managing equalities and health inequalities during an incident or an emergency.
• Review of NHS guidance for the management of self-presenters from incidents involving hazardous materials – this brings together several historic publications into one guidance document which will cover the full pathway of managing contaminated persons who present at healthcare facilities and other NHS branded buildings. It includes the initial operational response and the transition to the specialist operational response. The guidance will also support the implementation of new standards in relation to ambulance services chemical, biological, radiological and nuclear (CBRN) support to acute trusts.
• Lessons identification and management framework – this supports NHS organisations to develop their own supporting arrangements for identifying, recording, and sharing lessons to raise standards and support greater consistency. This will help to address variation in local practices and promote learning across the NHS to feed into continuous improvement and resilience planning activity.
• Framework for managing the response to a national energy supply chain disruption – this will ensure the service can respond to and recover from a range of power outage scenarios. NHS England continues to work with the Department of Health and Social Care (DHSC) to develop guidance and support to NHS organisations to enable them to respond and recover from long duration power outages, for example due to extreme weather events.

Additional products for internal use have also been developed and approved, including an independent provider standard operating procedure – this has been developed to help manage a potential or actual failure of an independent provider of NHS healthcare services. It captures learning to date on roles and responsibilities, risk factors, thresholds for intervention, joint decision-making approaches, and mitigations to be implemented in different scenarios.

Incident response

The COVID-19 response continued into 2023 as a level 3 incident as part of the transition to recovery. On 18 May 2023, the incident response was stepped down, although it is recognised that COVID-19 and the wider long-term impact of the pandemic will be significant for years to come and learning from the pandemic response is key.

During 2023/24, incident response arrangements have been activated for several incidents requiring notification to NHS England. These have been managed with regional or national oversight.

Incident management arrangements were implemented to bring national coordination to the NHS contribution to the Coronation of King Charles III in May 2023. Regional teams led the local coordination of health input into the events which took place in the London and Windsor event footprints, reporting to the national team and key government departments.

In June 2023 NHS England co-ordinated the NHS response due to a marauding knife incident in Nottingham.

Also, in June 2023 a technical fault at BT led to a national outage preventing callers accessing emergency 999 voice call services. It was reported that 11,500 calls were impacted before BT were able to switch to a back-up system. During the outage media messaging directed callers to 111 where their needs could be assessed and if required an ambulance could be dispatched. Ofcom has since undertaken an investigation into BT to establish the facts surrounding the incident and identify learning.

In September 2023, a change in Department for Education guidance for reinforced autoclaved aerated concrete (RAAC) resulted in a wider focus on RAAC in all public buildings. NHS England had already undertaken a significant amount of work in this area, through our established RAAC Programme Board with mitigation plans in place for sites where RAAC has been identified.

In October 2023, a car park fire at Luton Airport resulted in 6 casualties being treated for smoke inhalation. Also in October, a suspected hijacked aircraft landed at Stansted Airport, requiring a pre-determined ambulance response. The incident was stood down and Police operation successfully implemented shortly after landing.

In November 2023, a major incident was declared in the Guildford area due to a disruption to water supply. Two hospital sites were impacted for several days and required water tankers on site to maintain supply.

In January 2024, the United Kingdom Health Security Agency (UKHSA) declared a standard national incident due to the increase in measles cases reported across the UK. A national campaign to boost the uptake of MMR vaccine that protects against measles has been launched. Updated infection prevention and control guidance for risk assessment of measles in healthcare settings has been cascaded, along with communications and public advice jointly issued by NHS England and UKHSA.

A number of other notable incidents occurred during 2023/24 including:

• Carbon monoxide poisoning at a venue in Lincolnshire resulting in a number of patients self-presenting at Emergency Departments across 2 regions.
• Health input to support the evacuation of residents within a cordon following the discovery of an unexploded World War II bomb at a property in Plymouth.

Industrial action

The NHS has been navigating continuous industrial action and recovery involving a wide range of health professionals, including nurses, ambulance workers, physiotherapists, hospital dentists, junior doctors, and hospital consultants.

Each period of action has presented unique challenges, dependent on different factors including demand; staff groups affected; derogations; and length of strike action. No period of industrial action is exactly the same.

NHS England has led the national operational response to industrial action working with trusts and integrated care boards (ICBs) to set out key actions to manage and plan these incidents, minimising disruption and supporting patient care. Throughout the last 15 months, the national incident management approach has been continuously revised to minimise the reporting burden on regional and trust/ICB teams, and to consider staff fatigue, health inequalities and other impacts.

NHS Resilience has also worked with patient safety teams and national clinical directors to identify areas of highest potential risks to patient safety during industrial action, reporting to the Quality and Performance Committee, and worked with regions and trusts/ICBs to undertake rapid reviews of the patient safety mitigation process. Data collection and reporting arrangements for industrial action (participation rates and elective impacts) have also been continually iterated to ensure our decision-making is evidence-based, and accurate and transparent information is available on the impacts of industrial action. These processes illustrate our commitment to continuous learning, with changes informed by both clinical and operational risk perspectives.

Localised industrial action, due to local disputes and in some cases relating to the local implementation of the 2023-24 Agenda for Change pay deal are ongoing in various trusts. These are being managed by trusts and ICBs, with support where necessary from NHS England regional teams.

Governance

In line with good management and governance practices, NHS Resilience has reviewed and significantly strengthened its risk management arrangements over the last year. This has resulted in greater oversight, reporting and accountability thereby supporting delivery of key priorities and outcomes. These arrangements will be reviewed annually for effectiveness.

To support internal operations and following the organisational merger, NHS Resilience has produced and implemented a EPRR policy. This policy sets out how NHS England will meet its statutory duties with regard to the function. It provides standardised processes in relation to emergency preparedness, resilience, and response to ensure they are carried out in line with best practice and within a controlled management system across the organisation.

NHS England also maintains a strong relationship with DHSC through the weekly Health Delivery Group and the quarterly Strategic Emergency Preparedness Board.

National Ambulance Resilience Unit

The National Ambulance Resilience Unit (NARU) continues to work on behalf of NHS England to maintain the specialist capabilities provided by NHS ambulance services in response to major and highly complex incidents to improve patient outcomes in a variety of challenging environments.  NARU provides specialist advice and guidance in relation to the capabilities and sets standards and safe systems of work alongside the delivery of training to ambulance staff to ensure interoperability across England. The NARU function is currently hosted by West Midlands Ambulance Service University NHS Foundation Trust.

The current NARU contract ends on 31 March 2024 and following successful open procurement the contract to host the service from 1 April 2024 has been awarded to London Ambulance Service NHS Trust.

Emergency Preparedness, Resilience and Response Clinical Reference Group

The clinical reference group (CRG) for EPRR assesses the clinical appropriateness of emergency preparedness arrangements being developed by NHS England for the NHS. The CRG continues to meet on a quarterly basis with wide representation from key clinical groups and specialties including Royal Colleges, Ministry of Defence and the NHS provider sector.

A programme of work has been established to review the end-to-end process of the clinical response to major incidents as part of the response to the recommendations from Volume II of the Report of the Public Inquiry into the attack on Manchester Arena on 22 May 2017.

Annual assurance

The annual assurance process for 2023/24 built on experiences from last year’s process following the introduction of the Health and Care Act 2022 which established ICBs as category 1 responder organisations in line with the CCA (2004) and as local health system leaders.

Following key themes and common health risks identified as part of last year’s assurance process, a deep dive was also undertaken focussing on EPRR responder training. The outcome of the deep dive was used to identify areas of both good practice and further development whilst seeking additional assurance in this particular area of the core standards, and guide organisations in the development of local arrangements.

The 2023/24 annual assurance process was undertaken through local self-assessment of providers against the core standards. ICBs were asked to work with their commissioned organisations and local health resilience partnerships (LHRP) to obtain organisational level assurance ratings, agree a process to gain confidence with organisational ratings, and provide an environment to promote the sharing of good practice.

Regional EPRR teams were then required to work with ICBs to obtain organisation level assurance ratings before submitting assurance ratings for each of their respective organisations and description of their regional process to national EPRR. These submissions were reviewed by the NHS Resilience team in confirm and challenge meetings. In turn, the South West region undertook a review of the national NHS Resilience team self-assessment.

In the last 2 years, some regions have piloted additional levels of scrutiny to their methodology of gaining confidence with organisational self-assessments. This has led to a contrast between levels of compliance in different regions. This has demonstrated the need to ensure that the local process is led by ICBs. A workshop has been held with all regions to develop a single standardised methodology for the 2024/25 assurance process to reduce the variation in approach.

It should be noted that although some levels of compliance have reduced due to changed methodology, no region has reported that providers are unable to respond to an emergency or major incident.

The assurance exercise identified the following:

• A sustained response to concurrent incidents and industrial action had impacted on preparedness activity and EPRR staff welfare/wellbeing.
• Capacity to test and update mass casualty arrangements and implement national guidance was compounded by operational pressures and high bed occupancy across the NHS.
• Response to the operational impact of cyber security and IT related incidents such as access to technical expertise, supporting procurement of resilient systems, longevity and complexity of response and recovery are to be further developed.
• New and emerging pandemics remain the highest risk on the national security risk register, and progress was made nationally in the development of a disease agnostic framework to manage the response to pandemic diseases.
• Concerns associated with the variation and condition of ageing CBRN equipment, in particular clinical decontamination units exacerbated by the availability of specialist PPE and the withdrawal of central funding for its future replacement are to be addressed
• Focus is needed on collaboration between regional teams and ICBs to gain assurance of third-party providers of NHS services.
• NHS England Corporate Business Continuity team should align and revise legacy business continuity arrangements following the organisational change programme.

This work will be incorporated in the NHS Resilience business plan and work programme from 2024/25.

The EPRR responder training deep dive identified:

• Continuous professional development of EPRR staff and training of EPRR responders is often deprioritised particularly in areas where there is significant operational pressure and EPRR leads become increasingly involved in supporting non-core EPRR business areas.
• Variability in what constitutes a full and effective EPRR training needs analysis (TNA). Organisations reported different levels of engagement with workforce training and development teams to support development and implementation of TNAs. This is causing challenges with monitoring and reporting on compliance, resulting in limited organisational oversight.
• Whilst some organisations report challenges with implementing commander portfolios among command staff, a number of organisations in the Midlands and other areas are adopting digital platforms to build, record and maintain accurate records of commander portfolios and monitor compliance with organisational TNAs.
• The Principles of Health Command training package developed in line with NHS England minimal occupational standards and national occupational standards continues to be rolled out by regional teams to service providers.
• Access to loggist training across the NHS previously provided by UKHSA is a challenge. The NHS Resilience Training and Exercise Working Group are supporting the development of a training package that can be used by the NHS.
• The lack of a standardised national training package for CBRN response is being addressed through a workstream commissioned by the NHS Resilience CBRN Oversight Group to the Training and Exercise Working Group.

Findings from the deep dive will be reported to the NHS Resilience Training and Exercise Working Group for consideration and to inform work plans.

Overall, assurance was gained that NHS England and the NHS in England is prepared to respond to an emergency and has resilience in relation to the continued provision of safe patient care.

Training and exercising

NHS England has continually developed and delivered Principles of Health Command (PoHC) training to over 1,600 strategic leaders over the course of 2023 ensuring they have the knowledge and skills to lead and coordinate the response to incidents and emergencies for their organisation/system. Following last year’s requirements and in support of continuous improvement, the course will be reviewed, evaluated and subsequent changes made to course content in 2024. In parallel, a new PoHC training course for tactical leaders is being developed.

NHS England is also working with DHSC and UKHSA to determine a future model for training and seeking to maximise opportunities and efficiencies ensuring that EPRR practitioners can access appropriate development to be suitably qualified and competent to undertake training and exercising activities. This approach also extends to other responder training.

All staff awareness training has been developed to support and increase EPRR knowledge and understanding across the organisation. This is a requirement of NHS Core Standards for EPRR but particularly important considering recent NHS England changes and implementation of the function’s corporate policy.

The NHS Resilience team and regional EPRR teams have routinely conducted exercises as well as participated in exercises with government and local resilience partners to validate resilience planning. These have covered a range of topics and capabilities including management of infectious disease outbreaks; managing the consequences of hospital evacuations, in relation to reinforced autoclaved aerated concrete (RAAC) and other potential risks; incident coordination arrangements; and concurrent winter issues.

NHS England intends to conduct and partake in several exercises that are planned throughout the upcoming financial year. Additionally, a revised exercise programme is being developed across the NHS and working with tripartite partners to exercise the spectrum of health emergency response capabilities, ensuring greater coordination, more systematic testing, and identification of learning. This revised programme is due to be implemented in Autumn 2024.

NHS Resilience has designed and delivered 2 communications systems exercises to test its communications arrangements in line with legal requirements. Work remains ongoing to embed lessons identified from previous exercises.

Priorities for 2024/25

The EPRR work programme for 2024/25 will include:

• Progressing areas of development that have been identified through EPRR assurance 2023/24. This will include a significant review of the annual process to ensure it aligns with the NHS England operating framework to empower and support local system partners to deliver on their responsibilities. In parallel, the tri-annual review of NHS Core Standards for EPRR will also take place.
• Embedding learning from the Industrial Action Cold Debrief “One Year On” supporting continuous improvement activity with regards to operational arrangements and wider EPRR policy.
• Supporting the NHS England Inquiry team in providing evidence to contribute to the UK Covid-19 Inquiry.
• Ongoing implementation of health recommendations from the Manchester Arena Inquiry report. NHS Resilience is due to host the NHS Clinical Response to Major Incidents Conference in April 2024 to support and share some of the outcomes of this work.
• Reviewing and updating the Concept of operations for the management of mass casualties and access to countermeasures guidance.
• Continuing to support pandemic preparedness arrangements and HMG’s catastrophic risk programme.

The Board is asked to note the content of the report and the annual assurance, to acknowledge the priorities that have been identified for 2024/25 and to support the NHS Resilience team in achieving them.