This plan should be read in conjunction with the following:

• NHS Emergency Preparedness, Resilience and Response Framework
• NHS England Incident Response Plan (National)
• Operations for the management of mass casualties: burns annex
• NHS England Regional Mass Casualty arrangements and Incident Response Plans (Regional)

1. Introduction and definitions

This document sets out how NHS England plans to respond to a mass casualty incident. It should be read alongside NHS England’s national and regional incident response and mass casualty plans.

1.1 Purpose

This is a framework detailing how NHS England may respond and direct NHS resources in the event of a mass casualty incident in England. This concept of operations applies when local and regional health systems require:

• external support to manage the number of casualties
• specialist resources to treat casualties
• national co-ordination of assets

Elements of this framework may be used if NHS England’s support is required for the NHS response to a mass casualty incident in Wales, Scotland or Northern Ireland.

When a mass casualty incident occurs, whatever the cause, a comprehensive and integrated healthcare response must be activated immediately. This will enable the spectrum of healthcare provision (from the pre-hospital space to the management of patients in secondary and tertiary care, and subsequent recovery or rehabilitation) to rapidly mobilise available resources, ensuring the highest quality patient care is delivered to the greatest number of people possible.

1.2 Definitions

The Cabinet Office and the Joint Emergency Services Interoperability Principles define a major incident as an event or situation with a range of serious consequences that require special arrangements to be implemented by one or more emergency responder agency.

In the NHS, this applies to any event that presents a serious threat to a community’s health, or results in casualties of a scale or nature that require special arrangements to be put in place.

A mass casualty incident is defined as:

• an incident or event where the location, number, severity or type of live casualties requires extraordinary resources
• an incident or event (or series of incidents or events) where available healthcare resources are overwhelmed, against the casualty demand

See section 7.3 for examples of previous mass casualty events.

For the purposes of this document, a mass casualty incident is most likely to be the result of a rapid onset incident and may be a result of:

• man-made disasters or emergency incidents such as transport or industrial incidents
• terrorism
• hazardous materials (HAZMAT) or chemical, biological, radiological or nuclear (CBRN) incidents

Declaring a mass casualty incident

The following criteria should be considered before declaring a mass casualty incident:

• a major incident has been declared by a healthcare organisation
• the incident should be identified as a rapid onset event
• responding healthcare providers’ resources are exceeded by casualty demand from the incident
• a mass casualty incident may involve hundreds or thousands of casualties with a range of injuries, the response to which will be beyond the capacity of normal major incident procedures to cope and requires further measures to appropriately deal with the casualty numbers

A mass casualty incident should not be declared when:

• a hospital’s emergency department resources are exceeded due to systemic operational pressures in the healthcare system
• the incident is the result of a rising tide event, requiring standard operating procedures and local plans to be implemented to ensure the casualty demand is addressed using the available local, regional or national resources

Similarly, several small incidents may combine and require a larger response. Additionally, the incident may be geographically diverse requiring a mass casualty activation due to many simultaneous casualties.

For specialist services such as burns, the trigger for mass casualty arrangements to be activated will be lower due to the limited availability of resource for incident response.

Casualties are likely to fall within multiple categories. These include:

See casualty labelling following triage for more information.

1.3 Scope

This document focuses on the national response led by NHS England and is supported by regional and local arrangements for managing mass casualties.

2. Roles and responsibilities ​

This section describes the roles and responsibilities of those functions required to deliver a response under NHS England’s national incident response plan.

2.1 NHS England

2.1.1 NHS England: national

During a mass casualty incident, NHS England will ensure its response arrangements are activated. National NHS England will be responsible for:

• appointing and briefing a national NHS England incident director
• establishing national strategic priorities, in addition to those in the national incident response plan, and communicating these throughout NHS England and the NHS
• establishing briefing arrangements for NHS England senior staff
• informing regional emergency preparedness, resilience and response on-call teams of the incident and any required reporting arrangements
• establishing an incident management team
• activating a communications cell
• co-ordinating mutual aid and the mobilisation of national assets
• co-ordinating any cross-border mutual aid or military aid requests with the Department of Health and Social Care (DHSC). The military support in an emergency on an assistance basis is known as ‘military aid to the civil authorities’ (MACA) 
• briefing DHSC to support central government arrangements as required
• establishing a national recovery cell to co-ordinate with the response and manage the recovery efforts of NHS England and the NHS in England

2.1.2 NHS England: regions

The NHS England region where the incident occurs will be the lead region and all other regions are referred to as supporting regions.

The region will be responsible for:

• liaising with the national incident management team
• appointing a regional incident director
• implementing appropriate response arrangements in line with the EPRR framework
• establishing regional strategic priorities, in line with national ones, and communicating these to the region and the region’s ICBs
• leading the NHS response in local strategic co-ordinating groups. This may be undertaken by the ICB or NHS England region as appropriate.
• supporting regional communications
• supporting regional decision-making in line with national and regional priorities
• leading and directing ICBs to ensure an adequate response
• providing timely and accurate incident situation reports to national NHS England

2.1.3 NHS England: emergency preparedness, resilience and response clinical reference group

NHS England’s emergency preparedness, resilience and response clinical reference group (CRG) may be called on during a mass casualty incident to provide clinical advice to NHS England’s national incident director. In line with the CRG’s terms of reference, NHS England’s national incident director may ask the chair to convene the group along with additional specialist advisors to ensure appropriate clinical advice is available. This is most likely to be conducted virtually although an in-person meeting may be required. The CRG is responsible for:

• providing clinical advice to NHS England’s national incident director
• providing advice on adopting revised triage categories when paediatric services become overwhelmed, issuing advice on how ‘older’ paediatric patients will be managed via the ‘adult’ system
• establishing NHS England’s national incident management team clinical cell

2.2 Department of Health and Social Care

The Secretary of State for Health and Social Care (Secretary of State) will ultimately be accountable for a health emergency response, supported by the Chief Medical Officer and DHSC.

DHSC supports the Secretary of State to discharge their responsibilities for assuring a ‘whole system’ accountable response.

In fulfilling its responsibilities on behalf of the Secretary of State, DHSC will:

• ensure a whole system response to high-end risks impacting on public health, the NHS and the wider healthcare system
• support the UK government response to emergencies including by providing ministerial support and briefing
• provide a data and information conduit between NHS England, UK Health Security Agency (UKHSA) and Cabinet Office for emergency preparedness and response
• take other action as required on behalf of the Secretary of State to ensure a national health emergency is managed
• liaise with other government departments on behalf of the NHS

2.2.1 Liaison with other government departments

2.2.1.1 Ministry of Housing, Communities and Local Government

DHSC will work closely with the Ministry of Housing, Communities and Local Government (MHCLG) and other sector partners during an incident to ensure services are surged as appropriate to support the discharge of patients into social care settings. DHSC may also need to adapt standard practices to respond to increased health risks and demand.

During a mass casualty incident, government liaison officers from MHCLG’s resilience emergency department will support Strategic Co-ordinating Groups and co-ordinate any local resilience forum requests for assistance from central government.

Any health related requests from Strategic Co-ordinating Groups requiring government support must be requested via the NHS region to the national incident director through the incident co-ordination centre or established incident management teams.

2.2.1.2 Requesting military aid

A MACA is not guaranteed and there may be a charge, unless it is requested for response to an immediate threat to life.

To activate the military assistance process, the relevant NHS trust will need to decide – in consultation with the regional NHS England EPRR team (via their local ICB) – to identify any likely or actual gaps in capability where specialist resource is needed, in addition or instead of mutual aid arrangements with other trusts. Once the need for military assistance has been agreed, the request for activation must be submitted via the regional NHS England EPRR team.

These requests are then considered by NHS England’s national resilience team before being submitted to DHSC for authorisation by a health minister. They are then submitted to the Ministry of Defence (MoD).

More information about MACAs as well as details of the process can be found here: NHS England » Guidance for the NHS in England on requesting military aid to the civil authorities (MACA)

2.2.1.3 Military support for blast and high velocity injuries

If a major incident results in blast and high velocity injuries, DHSC can ask the MoD to make uncommitted personnel with recent operational experience available from within the defence medical services (DMS). 

DMS personnel are experienced in the clinical management of blast and high velocity injuries. They can provide expert advice and guidance on treating these types of wounds, including in the fields of anaesthetics, emergency medicine, plastic and reconstructive surgery, general surgery, trauma and orthopaedic surgery, and radiology.

If the required advice and guidance is over and above what is available locally, then military support for blast and high velocity injuries should be discussed with the regional EPRR team in line with the MACA process outlined above.

2.2.2 Devolved administrations

Support from the devolved administrations may be requested by NHS England via DHSC. Support required to respond to an incident in a devolved administration by the NHS in England will be made via DHSC to NHS England’s national EPRR duty officer.

Arrangements for cross-border working, which are not covered under mutual aid arrangements, for NHS ambulance services will also be requested in this way. Cross-border working occurs under routine business, and this will continue as normal during an incident.

2.2.3 International support

If NHS capacity is exceeded in England and the devolved administrations, NHS England may request support internationally via DHSC. Consideration will need to be given to which countries are best placed to provide support, ensuring they can offer appropriate standards of care, including for infection prevention and control.  

Reciprocal arrangements are in place for receiving casualties from overseas where necessary.

2.3 NHS Supply Chain

NHS Supply Chain will provide delivery services and inventory information to support requests from the logistic cell of NHS England’s national incident management team. They will also liaise with suppliers to try and source additional products and accelerated product dispatch, as necessary, to meet the demands of the response.

It is likely that multiple trusts may make simultaneous requests for urgent resupply, and this will need to be managed to ensure all organisations can continue to effectively support casualties.

NHS Supply Chain will immediately escalate any problems relating to stock availability, delivery access and timescales, and direct requests to the logistic cell of NHS England’s national incident management team. Significant problems will be escalated to NHS England’s national incident management team.

2.4 NHS Blood and Transplant

NHS Blood and Transplant (NHSBT) will manage supplies of blood products and tissues to responding hospitals, and ensure adequate supplies remain available during the incident, making substitutions where necessary to maintain supplies. When restrictions are essential to conserve stocks, these will be implemented through the clinical cell of NHS England’s national incident management team. NHSBT may be required to form part of a national incident management team, although this depends on the nature and type of incident.

NHSBT will be responsible for ensuring the recovery of blood stocks following the return to normal business.

2.5 Specialised services’ clinical networks

Clinical networks are collaborative groups compromising clinical professionals, service users and organisations who work together across professional, organisational and geographical boundaries. They play a vital role in co-ordinating pathways of care, supporting equitable access to healthcare, and assuring and improving quality.

While they do not provide an on-call service they will support with subject matter advice to the established command and control structures during the response phase of a mass casualty incident. Additionally, they are expected to support help write guidance on load balancing and repatriation during the recovery phase.

2.6 Integrated care boards

Integrated care boards (ICBs) will discharge their statutory duties as a Category 1 responder under the Civil Contingencies Act 2004, acting in accordance with the locally agreed response arrangements. Read more about ICBs’ roles and responsibilities as Category 1 responders in the NHS EPRR Framework.  

2.7 Care Quality Commission

NHS England may ask the Care Quality Commission (CQC) to suspend its inspection regime in organisations which are responding to a mass casualty incident. NHS England will ask the CQC to take an organisations response to a mass casualty incident into account when inspecting organisations which have recently responded.

3. Response (provision of services)​

During a major incident, which results in mass casualties, organisations will be expected to deliver emergency care to those affected. In addition, it may be necessary for services to consider enhanced care or expanding these functions beyond normal service provision to deal with the surge in patients.

National planning assumptions state the likely split across triage categories will be 25% Priority 1, 25% Priority 2 and 50% Priority 3. Injuries resulting from a mass casualty event are likely to be severe blunt force or ballistic trauma, burns or acoustic injuries.

Due to the increased number of casualties during a mass casualty incident, it may be necessary to expand the established procedures and resources to accommodate individuals with specific needs, for example, those with communication difficulties or special needs. Plans should proactively account for these needs ensuring provisions are in place to support equitable access to treatment and healthcare throughout both the immediate response and long-term care phases.

Organisations are expected to always maintain appropriate safeguarding measures, and particularly during incidents involving children or persons of interest. Where individuals become persons of interest due to their connection to the incident, governance arrangements like those used for VIPs should be considered.

In addition, there may be circumstances where patients’ families are asked to assist with collecting patients from an NHS setting to aid the discharge of patients and create capacity. The voluntary sector may be asked to provide support, along with alternative transport arrangements to ensure patients are transferred safely and efficiently.

3.1 Ambulance trusts

The local ambulance trust will be responsible for the command and control of all health assets and responders at the scene led by the ambulance incident commander who will be notified using the standard alerting messages. Operations at the scene will focus on triaging, treating and transporting casualties to the most appropriate receiving care setting. The ambulance incident commander will direct conveying ambulances to these care settings as appropriate, under the advice of the strategic medical adviser.  

The strategic medical advisor is responsible for monitoring overall capacity and ensuring the tactical level has access to the clinical resources it requires, including national mutual aid if required by other parts of the NHS.

3.1.1 Role of NHS ambulance services

The response may be supported at the scene by specialist or interoperable assets such as:

• enhanced care teams
• hazardous area response teams 
• special operations response teams
• mass casualty vehicles deployed by the NHS ambulance trust

3.1.1.1 Role of emergency operations centres

Emergency operations centres (EOC) should liaise with neighbouring EOCs to allow for mutual aid and capacity usage in other ambulance areas, co-ordinating support to the incident and business as usual provision during the incident.

Within an hour of a mass casualty incident being declared the EOC should contact all its possible receiving centres and confirm their immediate receiving capacity in line with their regional mass casualty plan (noting regional plans may differ). NHS ambulance services should work collaboratively with NHS England and acute providers to pre-identify patient receiving capacity. The EOC should also liaise with neighbouring ambulance trusts to request they do the same.

Ambulance services will have established plans for casualty distribution within their area of operations and neighbouring trusts and systems, which should be enacted in the first instance. In the event of a mass casualty situation where casualty distribution is required nationally and above locally agreed plans, this will be co-ordinated by NHS England.

3.1.1.2 Casualty clearing stations

NHS ambulance services are expected to conduct the major incident triage tool at the scene before transferring a patient to a receiving care setting. The goal is to transport casualties to the correct location accurately and promptly to avoid secondary transfers. This transfer process should align with pre-agreed patient distribution plans.

The aim of the NHS ambulance service should be to ensure the right patient, right place, right time, first time to avoid secondary transfers. This will need to be in accordance with the agreed patient distribution models held by the service.

3.2 Transport options

3.2.1 Patient transport services

NHS ambulance services will make use of available patient transport services to support the response, as appropriate, in consultation with the commissioners of those services.

3.2.2 Voluntary and private ambulance services

Voluntary and private ambulance services, where appropriate, will come under the direction of the local NHS ambulance trust to ensure casualties are transported in a timely manner from the scene to an appropriate care setting. Where possible this should be done via pre-agreed memorandums of understanding.

Where voluntary ambulances are contracted directly by NHS providers, for example, intra hospital transfer and retrieval services, these will operate as required but may be redeployed if deemed necessary by NHS England’s national incident management team.

NHS requests via the strategic co-ordinating groups (SCG) must be co-ordinated and channelled via the appropriate commander representing the health sector at the SCG.

3.2.3 Public transportation

Requests for support from partners (including public transport providers) should be directed through the SCG as part of the multi-agency response to the incident.

3.2.4 Patient transfer vehicles

Secondary patient transfers may be unavoidable during the response to a mass casualty incident and may need to be provided by the NHS or independent sector ambulance providers across a wide geographical area. In addition, transferring casualties to support accelerated discharge will need to be considered.

The responding or receiving trusts may need to support the deployment of these services to support the response. Vehicles should be able to support the transfer of levels 2 and 3 care transport requirements. Some transfers may need to be multimodal to reach available capacity, especially if international transfer is required.

Retrieval transfer teams will most likely need to be provided by the receiving hospital.

3.2.5 Alternative transport options

There are alternative transport options that may be utilised. These include:

• transport via a friend and family
• local resilience forum partners
• third party providers
• Agreed local memorandum of understanding

3.3 Acute care

Receiving and supporting hospitals will be designated by the NHS ambulance service responding to the incident or NHS England as appropriate.

3.3.1 Immediate response

Major trauma centres, trauma units and local emergency departments should work with their NHS England region and NHS ambulance trust to predetermine the number of casualties in each priority they can take during the initial distribution of casualties from the incident scene.

On receipt of a notification of a declared mass casualty incident, the hospital should confirm their casualty-receiving capacity and consider the likely impact on the organisation and those receiving units nearby.

All receiving hospitals should ensure they enact plans to enable them to free up 20% of their total bed base, 10% of which should be in the first 6 hours, and a further 10% within 12 hours of the incident being declared, allowing casualties from the incident scene to be rapidly placed and to ensure effective patient flow.

In addition, hospitals with level 3 intensive care capability should prepare to surge to double their normal level 3 ventilated bed capacity and maintain this for a minimum period of 96 hours.

Trauma units should be prepared to manage casualties for longer periods than would normally be expected prior to transfer, while also maintaining the capacity to receive repatriated patients from Major Trauma Centres.

It may be necessary for receiving hospitals to expand their emergency capacity into areas not typically used for emergency care. This will require business continuity measures to be activated.

Receiving (and supporting) hospitals may need to reconfigure their services to enable them to respond to the incident. These surge arrangements should be clearly documented in their major incident and mass casualty plans, with appropriate governance and safeguards in place for activation.

Organisations will need to consider activating their lockdown arrangements to support site security and protecting access to healthcare facilities to those in need of treatment.  

Trusts should have arrangements in place to provide updates on their receiving capacity for the duration of the incident and as outlined in regional mass casualty plans.

3.3.2 Hospital reporting

Trusts should be prepared to provide the information required on NHS England’s national incident situation report template, or a specific incident template issued during the incident, within an appropriate timeframe.

Critical care centres, burns centres, burns units and extracorporeal membrane oxygenation (ECMO) units are required to update their position within an hour of the incident declaration on NHS Pathways Directory of Service Capacity Management System.

3.3.3 Supporting hospitals

Those hospitals not directly receiving casualties from the scene will be considered a supporting hospital for the incident.

Nominated supporting hospitals are also expected to maximise available capacity in their bed base to a maximum of 20% of their total bed base within 12 hours of the incident being declared.

When nominated, a supporting hospital with level 3 intensive care capacity should be ready to surge to double their normal capacity for level 3 beds for general use and supporting the decant of patients from other receiving medical centres.

In addition, supporting hospitals may have to support patient transfers by providing suitably skilled transfer teams for each patient needing to be moved. All hospitals with critical care capacity should have plans in place to support the retrieval or transfer of patients.

Where hospitals routinely have retrieval teams, they will be asked to support these transfers as long as this does not cause a reduction in the response at the scene or responding hospitals.

3.3.4 Urgent treatment centres

These units should be prepared to receive casualties who self-present from the incident.  This is particularly important for units located close to the scene, which may be at risk of becoming overwhelmed. All units and centres should have plans to treat lower priority casualties and have holding areas for higher priority casualties who require onward transportation to trauma centres and emergency departments.

3.4 Community care (NHS-funded)

3.4.1 Immediate actions and considerations

• Identify patients suitable for discharge to make beds available for acute discharge support.
• Identify resources to support accelerated discharge assistance, assessment and discharging of rehabilitation patients and physiotherapy patients.
• Identify staff who can support care delivery in acute settings without negatively impacting on the capacity to maximise community based care or support rapid discharge from acute settings.

Community care organisations may be asked to support medically at survivor reception centres or establish treatment centres for low priority casualties in spaces close to the incident scene. These services may be augmented by voluntary services via local authority arrangements, or other commissioned clinical providers.

3.4.2 Medium term actions and considerations 

Invoke medium-term business continuity measures to support the management of casualties requiring ongoing care in an alternative setting and create capacity to support the local acute hospital.

Establish links from urgent treatment centres to the nearest acute hospital to manage deteriorating casualties. Liaise with mental health providers and other referral systems to ensure patients are cared for appropriately.

Hospitals may need to provide respite care for some hours for those clinically discharged but unable to leave the hospital as they may be waiting for issues to be resolved (for example, waiting for family members to arrive, living further afield from the treating hospital, friends and family being treated at the same hospital).

3.4.3 Longer term actions and considerations 

Recover services to normal business as soon as possible and identify specific patient groups and support services that may continue to have surges of casualties.  

3.5 Mental health

3.5.1 Immediate actions and considerations 

Make adequate mental health-liaison resources available to responding care settings. Ensure the discharge areas are supported with staff able to give advice on where to seek treatment and support and issue the post incident leaflet. Additional information on coping with trauma is available on gov.uk.

Receiving providers should ensure they are supported by staff who are able to:

• offer advice to everyone who visits the care setting on where to seek support and psychosocial care for distress. Advise on the appropriate method to make referrals to specialist mental health services for people who require immediate assessment and treatment immediately after events:
  • targeted offer – getting help. Some people may continue to experience distress despite the support offered above. They may require referrals to appropriate services and more targeted but low-level interventions
  • specialist offer – getting more help. People who experience moderate to severe symptoms may require referral to specialist services. They should have been seen already in talking therapies / early help services and their risks, symptoms and strengths should already be known. It is important to note all interventions with children and young people should be systemic and wherever appropriate should involve their parent or carer
• provide psychosocial education for expected responses to a traumatic event and access to advice and support through universal services
• universal offer – getting advice. Acknowledging that everyone in our communities may be affected by this incident, however many will require support from the networks already around them and not from specialist services (for example, family, trusted adults, friends, school)

Responding providers should liaise with NHS England’s regional teams or ICBs to ensure arrangements for psychosocial care and mental healthcare are made, co-ordinated and signposted across agencies to both casualties and staff.

They should ensure adequate mental health liaison resources are made available to those care providers that have responded to the incident.

Organisations have a responsibility for their own staff under the Health and Safety at Work Act (HSAW) 1974. Under the Act, the overarching duty of employers is to protect the health, safety and welfare of their employees and others who may be affected by their work activities, taking all reasonably practicable steps to minimise risk.

3.5.2 Medium term actions and considerations 

Following a mass casualty event, individuals involved may benefit from social support. Mental health service providers should work with local agencies to design an appropriate mechanism for identifying people who continue to need support and welfare arrangements beyond what their families can provide. It should signpost them to agencies and facilities that can offer the enhanced psychosocial support they require.

Where specialist mental health services are needed to support those affected by the incident, local systems should assess the specific organisations who may be involved and the projected number of people who are likely to need specialist assessment and treatment. They should work with commissioners to agree funding and commissioning to meet those needs, and to identify processes to support recovery of both routine and bespoke services impacted by the incident response.

3.5.3 Long term actions and considerations 

People who develop new episodes of mental health illness and psychological distress may require specialist care in the medium and long-term. If someone has an existing mental health illness, they may be more likely to require additional support. People who have previously experienced trauma may experience a higher level of distress. A small number of people may need support for several years; this would be managed and supported through local services.

Mental health service providers should work with commissioners to build referral, assessment and treatment processes for people who need further or extended care and consider the potential needs over the course of the individual’s life span. They should identify methods to continue to deliver assessment and treatment for casualties in the long-term before these facilities are absorbed into their ordinary business.

Additionally, they will work with local partners and local and borough resilience forums through recovery co-ordinating groups to consider and implement multi-agency plans and processes effectively. These groups will maintain a focus on the affected community and consider the longer-term needs of the public across several areas, including health, welfare and humanitarian needs.  

Mental health service providers should also work across sectors of care to identify casualties who require monitoring or may present later as needing specialist care. They should consider likely triggers for casualties who might need intervention during similar or subsequent events, or at specific times of the year (for example, anniversaries, inquests and memorials). Some of these services may be provided by other mental health organisations and these should engage with local primary care teams.

The NHS 111 “Press 2” service is a dedicated mental health support option available nationally in England. This option connects you directly to a local mental health team, offering support and advice and, where appropriate, referral to a local service or home visit.

Incident and emergency plans must include provisions for psychosocial and mental healthcare for people who are affected. Read more about responding to the needs of people affected by incidents and emergencies (Futures collaboration platform requires a log in).

3.6 Primary care

3.6.1 Immediate actions and considerations 

Primary care services – general practice and community pharmacy services – may be asked to support the treatment of patients who are of a lower priority in care settings and assist in managing patients triaged away from emergency departments (ED).

Community pharmacy independent prescribers may also be utilised in general practice if lower acuity patients are directed there following ED triage. Community pharmacies will be able to offer support and advice to those self-presenting with minor injuries or health concerns following an incident.

Support may also be requested for NHS 111 and integrated urgent care services and allow for online consultations and the supply of medication to the scene or to treatment centres.

General practitioners and community pharmacy contractors can support messaging being issued to the public to give reassurance following the incident. Using out of hours providers’ clinical services and other resources should be considered as well as providers that can support a response for primary care services.

Available nursing and medical care capacity may be utilised to augment other services where patient presentation is greatest.

3.6.2 Medium- and long-term actions and considerations 

Primary care services will play an important part in ensuring those involved in the incident receive appropriate mental health support and can triage those who are emotionally traumatised to the appropriate support and response services.

Commissioning organisations will need to ensure the appropriate pathways for these services are available and known to primary care services.

3.7 NHS Supply Chain

NHS Supply Chain will provide:

• delivery services – emergency deliveries can be made within 5 hours of order receipt
• inventory information
• product sourcing support, where a product is exhausted or held in insufficient quantities to meet the exceptional demands created by the incident
• call handling services to manage enquiries from the NHS on stock and deliveries

3.8 NHS Blood and Transplant

NHS Blood and Transplant (NHSBT) will ensure blood products and tissues are managed based on the demand. To achieve this, they will work closely with NHS England’s incident management team’s logistics co-ordination cell to monitor hospital response and ensure any directions to the NHS are reflected in the management of blood and tissue products. Where possible NHSBT will be represented in the logistics or clinical cell to inform product utilisation and help maximise the effective use of available resources.

3.9 Mortuary services

National arrangements for identifying victims are likely to be invoked. These may include the activation of a designated disaster mortuary (DDM). A DDM is a mortuary that has been nominated by the coroner to act as the designated mortuary in the event of a mass casualty incident. It may be a mortuary on NHS premises but operated by the local authority through local resilience forum’ plans.

Mortuary space in NHS hospitals may need to be managed carefully and co-ordinated with the appropriate HM Coroner’s Office, police, ICB representatives or NHS England and local authority to maintain capacity. This will be important where the deceased are held for a period, and there will be delays in taking hospital mortuary bodies to the designated disaster mortuaries.

3.10 Voluntary agencies

Local resilience forum have arrangements in place to seek support from voluntary agencies and community groups. Requests for mutual aid from these groups should be co-ordinated through the ICB or NHS England to ensure resources are efficiently deployed and targeted to the organisation with greatest need in times of scarce resource.

3.11 VIP visits

During or following a mass casualty incident, there is likely to be significant interest from VIPs in visiting hospitals and meeting those affected. This may need to be co-ordinated nationally to ensure appropriate arrangements are in place.

Visits can require extensive resources and planning. Organisations need to carefully consider these demands against the need to deliver ongoing patient care.

4. Activation​

These arrangements will be activated when a mass casualty incident has been declared and informed to the national EPRR duty officer.

4.1 Initial notification

4.1.1 Declaration

A national declaration will follow the arrangements of NHS England’s national incident response plan: the incident will be declared to all regional on-call teams to establish appropriate command and control. A mass casualty incident may be declared before exact numbers of casualties or their type is known.

4.1.2 Notification

Notification of the initial declaration will be via the on-call system for the region and should be cascaded as appropriate.

4.2 NHS England incident levels

A mass casualty incident will likely result in the activation of Level 4 incident response arrangements with national command and control being established. A Level 4 incident is described as:

“An incident that requires NHS England national command and control to lead the NHS response. NHS England Incident Management Team (National) to coordinate the NHS response at the strategic level. NHS England (Region) to coordinate the NHS response, in collaboration with the ICB, at the tactical level”.

4.3 NHS England internal staff notification

Following declaration and implementation of Level 4 response arrangements the national EPRR duty officer will notify communication response colleagues and ask them to prepare a staff briefing for release once approved by the national incident director. This will be disseminated via the usual internal communications channels as well as the staff alerting system (for NHS England this should be GOV.UK notify) will also be considered as appropriate to notify staff.

4.4 Notifying external agencies

NHS England’s EPRR duty officer will notify relevant external agencies to the incident, including DHSC, UKHSA, NHS Supply Chain and NHS BT via the on-call system. Further notification to additional agencies and stakeholders will be conducted through established routes. NHS England’s regions will be responsible for notifying ICBs who in turn are responsible for notifying providers to the incident. Where organisations have a duty to inform regulators of the incident, they are expected to do so through normal routes.

4.4.1 National command and control

When a Level 4 response is activated, NHS England will take whatever steps it considers appropriate to co-ordinate the response of ICBs and relevant service providers to the emergency.

4.5 Escalation and de-escalation

Escalation and de-escalation through the incident levels do not need to occur sequentially but will be driven by the nature, scale and complexity of the incident combined with the expectations of NHS England’s response. Any level incident response can be changed following a review, including a risk assessment of the strategic direction and operational management of the incident. The level of the response may need to be escalated or de-escalated. The process for this needs to be agreed with health strategic commanders so it can be co-ordinated across all organisations.

Reasons for the level of response being escalated or de-escalated may include:

Changes in incident response can only be authorised by the national incident director. All response level changes need to be communicated both internally and externally, as appropriate. A brief description of the resource implications of the new incident response level should be included.

5. Incident response structures

5.1 NHS England’s incident management team

NHS England’s national incident management team will be formed following the national incident response plan. To support these arrangements, specific support cells will be formed to ensure appropriate clinical advice is available and logistic arrangements are co-ordinated for NHS England and the wider NHS.

NHS England will appoint a national incident director to oversee the response and ensure appropriate response structures are in place.

5.1.1 Specialist staffing

As the incident progresses specialist advice may be required to support the response and the national incident management team will request individual organisations or people join the response and indicate the specific cell they will join.

5.1.2 International support requests

Any requests for support from international agencies should be made through DHSC; this may include the use of resources overseas or the placement of medical staff and resources within England.

5.1.3 Reporting

There will be a requirement to report on a variety of issues to allow the response to be co-ordinated.

5.1.3.1 Situation reports

Situation reports will be completed for all responding organisations on the appropriate template. The national situation reporting template should be used by organisations and the regional teams to ensure shared situational awareness and common understanding.

5.1.3.2 Central government emergency response arrangements

The activation of Cabinet Office Briefing Rooms (COBR) is likely with cross government co-ordination established to ensure the response is appropriately managed at a strategic level.

5.1.3.3 Regional and local response arrangements

Local resilience forum are likely to establish multi-agency command and control as part of the response to a mass casualty incident. This will enable co-ordination of all responding agencies in line with the Joint Emergency Services Interoperability Principles. Where tactical support groups and strategic co-ordinating groups are established, it is important to recognise the geographical footprint of the local resilience forum may not align to that of the incident or to existing NHS boundaries. Therefore, participating NHS representatives should ensure their reporting and co-ordination reflect the arrangements of the relevant NHS England region and are consistent with reporting requirements.

Response co-ordinating groups may be established to co-ordinate multiple strategic co-ordinating groups.

The Ministry of Housing, Communities and Local Government is responsible for reporting on strategic co-ordinating groups through Response Coordinating Groups to COBR.

5.1.3.4 Casualty reporting

Health organisations are responsible for reporting casualty numbers, including the details of triage and treatment of casualties at scene and medical facilities. In some cases, this may not be in NHS facilities depending on the location of the incident.

The casualty bureau is a central hub where all information about an incident is collected, organised and assessed. This includes details on individuals who may have been involved in the incident. A publicly available phone line and an online tool, the Major Incident Public Portal (MIPP), is made available as part of this process, so individuals’ details believed to be part of the incident can be inputted. The MIPP also has a strand that allows the police and partner agencies to capture and input information from hospitals or survivor reception centres on the people that have been impacted by the incident. Find out more.

Regional teams should ensure processes are in place to capture this information from local ambulance services, NHS providers and primary care. The regional teams are then responsible for ensuring this information is reported through command-and-control structures.

The NHS is not responsible for reporting fatalities from an incident – this is undertaken by the police.

5.2 Logistics co-ordination cell

Mass casualty events will be resource intensive and may require some clinical and non-clinical products to be managed centrally by a co-ordination cell to ensure continued supply. This cell will be responsible for co-ordinating:

• the movement of stock by NHS Supply Chain
• with NHS Blood and Transplant  
• information about available capacity and passing it to the clinical cell and NHS ambulance services

These arrangements may need to be duplicated at a local and regional level to make best use of limited resources. The logistic co-ordination cell’s focus will be national logistics rather than local supply management between individual organisations. The logistics co-ordination cell will be established by NHS England and include representatives from NHS Supply Chain, DHSC and NHSBT as a minimum.

5.2.1 NHS Supply Chain

Co-ordination with NHS Supply Chain will be necessary to ensure adequate stock is made available to support the initial response and ongoing supply requirements at receiving hospitals.

Multiple trusts may make simultaneous requests for urgent resupply. This will need to be managed to ensure all organisations can continue to effectively support casualties.

In addition, the logistics co-ordination cell will be responsible for supporting supply of stocks to newly established areas, and arranging support to the NHS ambulance trust if specialist equipment is needed at the scene to allow for treatment outside of normal care settings where casualties are held for transport.

5.2.2 NHS Blood and Transplant

The logistics co-ordination cell will be responsible for co-ordination with NHS Blood and Transplant (NHSBT) so they can effectively manage blood products and tissue throughout the incident.

5.2.2.1 Demand management

Early in an incident it may be necessary to request a suspension of the normal blood stock management processes and ensure supplies are controlled.

Hospitals should be prepared to receive amber and red blood stock alerts, which may be issued to hospitals across the country to ensure adequate stocks remain available throughout the incident response and casualty management process.

NHSBT will remain responsible for donor management during the incident and any calls for blood donations. There will be no call for donors to self-present to any of the blood collection centres, unless otherwise indicated by NHSBT.

5.2.2.2 Stock relocation

NHSBT will be responsible for the movement of blood stock and tissues. However, NHS England may need to direct the supply to those facilities responding to the incident. Where casualties are relocated away from the immediate incident area, it may not be appropriate to transfer blood stock from processing centres to hospitals nearest to the scene.

To maintain adequate local supplies NHS England and NHSBT will work together to ensure these factors are considered when releasing products.

5.2.3 Additional staffing

It may be necessary to relocate staff to support the response or arrange for additional staff to give specific advice for treating casualties.

5.3 NHS Resilience Emergency Capabilities Unit

The NHS Resilience Emergency Capabilities Unit (ECU) may support NHS England to co-ordinate NHS ambulance resources effectively in the event of a mass casualty incident.

The NHS Resilience ECU will establish communications with the responding NHS ambulance service (s) when a mass casualty incident is declared in England, or at the request of NHS England to ensure an effective and co-ordinated response.

5.3.1 Co-ordination of NHS ambulance services

Multiple NHS ambulance services may need to respond during a declared mass casualty incident, and requests will need to be well organised and resources co-ordinated to deliver an effective response across geographical boundaries

NHS ambulance services are responsible for working together to share information on capacity and capability across the UK, focusing on national mutual aid readiness and availability. Communication channels will be open between ambulance services and NHS Resilience ECU to share information and ensure NHS England’s national incident co-ordination centre are informed and updated of developments and there is nationwide situational awareness.

During a national incident, NHS ambulance services will need to:

• analyse information and disseminate intelligence
• share feedback and national policy decisions
• manage mutual aid requests between NHS ambulance services

Requests for interoperable capabilities are co-ordinated by NHS Resilience ECU.

5.3.2 Mutual aid

NHS ambulance services nationwide can provide mutual aid across organisational geographic boundaries as well as to the devolved administrations. The mutual aid of interoperable capabilities will be co-ordinated by the NHS Resilience ECU.

Requests for mutual aid will be made and co-ordinated by the affected ‘responding’ NHS ambulance service based on the geographical location of the mass casualty incident and will be organised in accordance with the national memorandum of understanding (MoU) concerning the provision of mutual aid.

Requests outside of the MoU to NHS England and DHSC need to be agreed separately.

Additional information about MACA:

• requests for military aid to the civil authorities from the NHS in England
• UK Operations: the Defence Contribution to Resilience
• factsheet 14: Military Aid to the Civil Authorities (MACA)

5.3.3 Air ambulances

Air ambulances utilised by the NHS ambulance services in England are charitably funded by their communities and their use must therefore be carefully considered before being requested. The charities that support these assets allow the NHS ambulance service control rooms to co-ordinate their tasking. These assets may be available to support the national response to a major incident.

The NHS Resilience ECU will co-ordinate requests for air assets and liaise with the appropriate air ambulance provider’s control room as to their availability. The final decision on air asset mobilisation will always rest with the pilot and crew, subject to the operating limitations and procedures of the aircraft.

5.4 Communications cell

5.4.1 Ministerial briefing

DHSC is responsible for producing ministerial briefings. This will be done in conjunction with NHS England to ensure briefings contain the most accurate and up to date information and that it is shared with ministers at the appropriate time.

5.4.1.1 Casualty figure disclaimer and explainer

During the early stages of an incident, it is often not possible to provide accurate casualty figures. Where indicative figures are available, they should be shared, but with clear caveats that they are best estimates based on the situation emergency services are dealing with at that time.

5.4.2 Communicating with the NHS

The communications cell will ensure the NHS is communicated with regularly and will establish appropriate communications management within the responding services. The following methods may be used to communicate with the NHS.

5.4.2.1 NHS communications network

The NHS has a tried and tested method of disseminating information to organisations across the network of NHS communications staff. During an incident, information can be quickly shared for wider circulation to NHS staff via email, intranets and, if appropriate, social media and other public facing communication tools. These can also be shared with communications colleagues in other local organisations for wider dissemination if necessary.

5.4.3 Messages for stakeholders

In addition to using the NHS communications network to disseminate information quickly to NHS staff, consideration should be given to asking stakeholders such as royal colleges to share information with members, depending on the nature of the incident and the audience reach required.

5.4.4 Public messaging

Public messaging will be delivered via a dedicated incident page on an appropriate website (NHS England’s or potentially nhs.uk). This page will go live via NHS England’s Communications Response Team. It will contain commonly recognised information about the incident and will signpost the public to where they can get further information (such as the relevant police website or missing persons bureau). It will also tell people which hospitals are receiving mass casualties and where and how to obtain alternative healthcare services.

Appropriate public messaging will also be delivered through traditional and social media. Messages will be developed by the EPRR communications lead in conjunction with the national incident director and will be issued via NHS England’s national media team. All messaging should be agreed with the local strategic co-ordinating group prior to issue and should be open and transparent, reflecting an accurate picture of the situation as it is known at that time. Messaging will need to be reviewed to ensure different communication needs are met.

NHSBT will be responsible for any public messages regarding the donation of blood. NHS England will reflect this messaging in communications with the public.

5.5 Clinical cell (clinical reference group)

NHS England will form a clinical cell with the duty clinical director along with representatives of NHS England’s EPRR clinical reference group, with additional specialist representation as required.

This cell will ensure NHS England’s national incident management team has the appropriate access to clinical advice to inform the response.

NHS England may ask regional medical directors to support the clinical cell in a protracted incident or where they have specialist subject advice required for the response. In addition, NHS England may contact individual experts to offer advice based on available known staff in organisations.

5.5.1 Clinical impact assessment call

Within the first 24 hours of an incident, the lead national medical director will establish a clinical call with responding centres to ascertain the likely impact to services and patient management across all services. An agenda for this as well as an grid to manage numbers is available here: Clinical impact assessment call agenda and impact assessment grid

Where possible this call will be held virtually and facilitated by NHS England’s EPRR duty officer.

5.5.2 Medical support to NHS ambulance services

There should be 2 tiers of medical advice to pre-hospital staff. Strategic medical advice should be provided within the emergency operations centre to support co-ordination between the ambulance strategic commander, the acute hospital sites and the ambulance incident commander on scene.

In parallel senior clinical advice will be provided to the casualty clearing station to ensure accurate triage of casualties to the correct receiving units. There will need to be close liaison between this individual and the strategic medical advisor to avoid the local major trauma centre being overloaded, and to identify casualties who may benefit from transfer to major trauma centres further away.

5.5.3 Ethical decisions

It may become necessary to enact decisions relating to the ceilings of care during a mass casualty incident to ensure the greatest number of survivors possible.

This may include the decision by the clinical cell to invoke the expectant triage category at the scene. This decision will be time-limited, continually under review following appropriate advice and only used at a time when NHS resources are overwhelmed.

Read NHS England’s clinical guidelines for major incident and mass casualty incidents which covers use of the P4 expectant category. Pre-Hospital Emergency Care P4 processes are being refined as part of the current (CRMI) work programme.

5.5.4 Patient placement

If a mass casualty event requires an NHS England Level 4 response, the national clinical cell will advise on the placement of casualties who need to be transferred outside of the incident response area(s). This ensures patients receive the most appropriate care*.

*If local and regional bed management resources, particularly for specialist beds (major trauma centres, critical care burns and paediatrics) have been overwhelmed and national support is required to manage demand.

5.5.5 Clinical debrief

The clinical cell will establish a clinical debrief for the incident. The hot debrief will be held within 48 hours of the incident being stood down, with a structured clinical debrief within 28 days.

5.6 Recovery cell

A national recovery cell will be established to co-ordinate with the response and manage the recovery efforts of NHS England and the NHS in England. This cell will look at the recovery support required and liaise between recovery groups at all levels of the organisation, and out to those groups established as part of the strategic co-ordinating group’s response.

The recovery cell chair will be the (RD (N)). The recovery cell may include representation from appropriate regulatory bodies, for example, the Care Quality Commission.

5.6.1 Liaison with regional and strategic co-ordinating groups’ recovery groups

The RD(N) will be responsible for ensuring regional recovery groups (RRGs) established within NHS England are fully informed of national recovery priorities and any nationally mandated decisions about the recovery of NHS services.

This liaison may be direct through the regional recovery leads or the appropriate incident response structures.

5.7 Finance

5.7.1 NHS England

During and after a mass casualty incident, the costs associated with the response will need to be identified, monitored and recorded so relevant parties can discuss recovering them.

5.7.2 The NHS in England

All NHS trusts and commissioned services which respond to or manage patients due to a mass casualty incident should be able to track and report costs to support transparency and facilitate any subsequent financial recovery processes if appropriate.

6. Stand down and recovery​

Once it has been decided that NHS England’s national response structure is no longer required, and the agreed stand down triggers have been met, the national incident director will initiate the stand down process. This may be conducted in stages.

The recovery phase should begin at the earliest opportunity and run in parallel with the response. It does not end until all disruption has been rectified, demands on services have returned to normal and the physical and psychosocial needs of those involved have been met.

Recovery will be led at a regional level and co-ordinated with support from the RD(N) where required. The region will nominate an NHS England (RL (R)) and NHS recovery representatives.

The NHS will be represented at recovery co-ordination groups by a designated NHS recovery representative who will link with NHS England’s recovery lead and through them to the NHS England (RD(N)). Where regional co-ordinating groups are established, NHS England’s RL(N) will represent the NHS and co-ordinate with their representatives at a local level.

6.1 Recovery considerations

• The decision to stand down the incident to recovery rests with the national incident director. This may be delegated as the response evolves.
• Financial implications must be transparent and applied consistently across the service by providers and commissioners (see section 5.7).
• Recovery should be led by a senior RD(R) and co-ordinated nationally across the health systems to continually apply mutual aid principles, use resources effectively and facilitate repatriations.
• National, regional and local recovery leads should liaise with specialised services’ clinical networks at an early stage and throughout the process. These networks will provide local intelligence and advise on actions to be taken at local, regional and national level.
• Trauma cases may require multiple and prolonged returns to surgery and stays in critical care.
• Specialist services may need to be commissioned or expanded to deal with additional demand on a medium to long term basis.
• Casualties may need to be repatriated into their own health system a long way from the incident location and may require medium to long-term care and rehabilitation. Commissioners will need to agree the provision of additional resources.
• National support will be required to recover costs from overseas casualties and national arrangements should be set out in advance. Costs may be for short-, medium- or long-term care and treatment and could include:
• emergency or specialist treatment and care
• rehabilitation services and repatriation
• Discussions on the reduction, alteration, suspension or cancellation of services by organisations supporting the incident that impact on their national standards should be conducted between regulators at a national level.
• Points should be captured proactively to learn from the response and facilitate recovery.
• Welfare of both patients and staff should be considered throughout the incident response including the recovery stages.

6.2 Debriefing

All NHS organisations involved in the response will be expected to undertake a debrief in line with NHS England’s EPRR Framework and core standards. Trusts may be invited to multiple debriefs by different agencies and should attend these where possible.

6.3 Psychosocial support

Psychosocial support should be offered to casualties and staff as needed; they should also be made aware of those symptoms that are normal during the initial period following a traumatic event. NHS England has produced a post incident mental health services leaflet. Additional information on coping with trauma is available on gov.uk.

7. Background information and impacts for non-health agencies

7.1 Specialist services

The NHS in England provides specialist services at a smaller number of locations to ensure high quality of care and improve patient outcomes. These include, but are not limited to:

7.1.1 Major trauma centres

Adult and children’s major trauma centres

1. Addenbrooke’s Hospital Cambridge
2. James Cook University Hospital Middlesbrough
3. John Radcliffe Hospital Oxford
4. St Mary’s Hospital London
5. St George’s Hospital London
6. Royal London Hospital
7. King’s College Hospital London
8. Leeds General Infirmary
9. Queen’s Medical Centre Nottingham
10. Royal Victoria Infirmary Newcastle
11. Southampton General Hospital

Adult major trauma centres

1. Southmead Hospital Bristol
2. Aintree University Hospital Liverpool
3. Derriford Hospital Plymouth
4. Hull Royal Infirmary
5. Northern General Hospital Sheffield
6. Queen Elizabeth Hospital Birmingham
7. Royal Preston Hospital Lancashire
8. Royal Sussex County Hospital Brighton
9. University Hospital Coventry
10. University Hospital of North Staffordshire Stoke on Trent
11. Salford Royal Hospital and Manchester Royal Infirmary (Collaborative)

Children’s major trauma centres

1. Bristol Royal Hospital for Children
2. Royal Manchester Children’s Hospital
3. Birmingham Children’s Hospital
4. Sheffield Children’s Hospital
5. Alder Hey Children’s Hospital Liverpool

Total: 27 Major Trauma Centres in England (October 2016).

England is split into trauma networks with a major trauma centre and supporting trauma units, allowing the centralisation of specialist skills and resources.

7.1.2 Extra Corporeal Membrane Oxygenation

There are 7 adult and 6 paediatric Extra Corporeal Membrane Oxygenation (ECMO) centres in England providing highly specialised care within critical care capacity. It may be necessary to utilise this capacity in the event of a mass casualty incident.

ECMO centres are commissioned to provide retrieval of casualties via transfer teams. It may be necessary to use these teams to support the transfer of casualties to other facilities where they can be supported and create capacity in hospitals close to the incident location.

ECMO centre locations

Beds are available in scottish centres at Aberdeen (adults) and Glasgow (paediatrics).

7.1.3 Burn centres

There are 4 burns networks covering England and parts of Wales, which manage the treatment of burns patients. In many cases these patients will travel through a major trauma centre or trauma unit and await onward referral to a burns facility, unit or centre.

It may be necessary to establish an assessment team able to travel to the receiving hospitals to assess patients for distribution across the networks if there are large numbers of patients.

• Burns centres may need to offer advice to trauma centres and units to ensure appropriate care is received.
• Burns incident response teams may be required to provide expert assessment and advice on patient care when responding to a mass casualty incident. See the burns annex for further information.
• Parts of the network unlikely to receive patients may be asked to support assessing and distributing patients into the local network to maintain capacity.

7.1.4 Rehabilitation services

The NHS has well-established and diverse rehabilitation services. However, following a mass casualty incident, these may come under intensive pressure particularly if patients have severe and complex trauma. Supplies such as wheelchairs and other rehabilitation equipment may also come under pressure and need to be carefully co-ordinated.

The military has extensive rehabilitation experience which may be of use to the NHS to improve patient outcomes. Requests to use these services would need to be made via a MACA request; potential requests could be:

• parts of the network unlikely to receive casualties may be asked to support the assessment and distribution of casualties into the local network to maintain capacity
• use of current model for trauma and ballistic advice to the NHS but for rehabilitation
• assistance and advice from military rehabilitation subject matter experts for individual cases
• mobilisation of military rehabilitation teams in NHS settings
• using the defence medical rehabilitation centre to support casualties if the NHS cannot offer appropriate rehabilitation

7.1.5 Renal services

Specialist renal services may need to be surged depending on the nature of the incident. If renal services are required a specialist in these services will be asked to join the clinical cell.

Renal services include both specialist centres and units offering renal care supported by a specialist centre.

7.1.6 Hospitals with defence medical units known as joint hospital groups

• Frimley Health NHS Foundation Trust, Frimley Park Hospital, Surrey
• The James Cook University Hospital, Middlesborough
• University Hospitals Plymouth NHS Trust, Devon
• Portsmouth Hospitals University NHS Trust, Hampshire
• Queen Elizabeth Hospital, Birmingham

7.1.7 Reception arrangements for military patients

Reception arrangements for military patients are those agreed between the MoD, DHSC and NHS England for the movement, secondary healthcare and welfare of MoD patients who have been aero-medically evacuated from overseas to the UK (normally to the Queen Elizabeth Hospital, Birmingham).

Under normal circumstances the MoD patient transportation, admission, transfer and clinical management will be managed according to arrangements made between the MoD Royal Centre for Defence Medicine and NHS providers in the Birmingham area.

In the case of a major incident involving numbers or types of military casualties that cannot be managed by normal resources, NHS England’s national EPRR duty officer will be notified and instigate arrangements under this framework and in line with normal incident response plans to manage the situation.

Tracking and supporting MoD patients will remain MoD’s responsibility.

MoD patients may include military personnel, dependents of military personnel and government personnel posted overseas.

7.2 Anticipated impacts for non-health sectors

Any mass casualty incident could have an impact on any non-healthcare services; the impact should be considered when activating these arrangements.

7.2.1 Transport infrastructure

Extreme disruption to transport services in the localised area, especially if the transport infrastructure has been targeted for use in the incident – this includes transportation hubs.

The security services may also advise that transport is closed temporarily to prevent suspects escaping or further potential attacks from being staged. This should be considered when planning a response or choosing co-ordination centre locations.

7.2.2 Power and gas supplies

There may be temporary loss of power and gas supplies to an area where an incident has occurred, depending on the cause of the incident. Additional loading in any location where temporary clinics are established should be considered to prevent healthcare facility power supplies being overloaded.

7.2.3 Telecommunications

Locally to the incident there may be considerable disruption to telecommunications including to mobile phones and land lines. There will be high demand for these services following an incident and where large numbers of people continue to use telecommunication channels. This may be accompanied by disruption to infrastructure supporting telecommunications networks, and organisations should ensure co-ordination arrangements take this into account.

7.2.4 Environmental

Local weather and or environmental conditions can impact on the ease to access medical facilities for patients as well as casualties requiring a greater response from the hospital. Weather conditions can impact on the number of casualties in an incident and the type of treatment and staff required to respond. Extremes of temperature can increase the risk of shock and result in exposure-related illness.

7.2.5 Water supplies

Water supplies could be the cause of a mass casualty incident or be impacted by an incident. Trusts have utility disruption plans to allow services to continue in the event of a disruption or contamination to supplies. Advice should be sought from UKHSA during any incident of this nature.

Lack of water supplies may require a change in the way casualties are cared for and affect immediate treatment.

7.2.6 Children’s sector

Any incident that has an impact on schools, nurseries and other childcare settings is likely to require an expanded response from mental health services due to the emotive nature of these events. Care should be taken when responding to events involving the children’s sector to ensure staff have adequate training and are aware of child protection legislation.

7.3 Previous mass casualty events

Examples of complex incidents which could produce numbers on a scale that could be described as mass casualty events include the following:

8. Equality, diversity and inclusion

As public sector bodies, NHS England, ICBs, NHS trusts and foundation trusts are subject to a range of equalities’ legal duties. These include the Public Sector Equality Duty and duties to reduce inequalities in respect of access to NHS services and the outcomes achieved from providing NHS services.

Mass casualty incidents have the potential to exacerbate existing health inequalities or result in inequitable access to care for different communities. This includes disparities in access to specific treatment, routine services, and support for patients, the public and staff. The outcomes of a mass casualty incident could be life-changing, particularly for victims. These additional needs must be considered and planned for when helping the public access healthcare both during and after a mass casualty incident.

Patients, casualties and staff will be impacted in different ways throughout the response to a mass casualty incident. While some will require physical health treatment, there will also be a large impact on the mental health of those involved in the incident. Ensuring people have access to the appropriate care at the right time will help to minimise the impact on existing health inequalities.

Health equity is the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically (WHO, Social determinants of health). Multiple factors can impact this. This could be trust, health literacy, availability and accessibility of interventions and messaging. There could be differential access to healthcare or impact on the uptake of preventative, diagnostic or treatment interventions, such as follow up appointments and screening. Health equity means these differences are, to an extent, unfair and avoidable. Organisations should be mindful to work in ways, and make decisions in response, which reduce these differences that people and communities experience in the exposure to, and impact of, health hazards and protection measures. 

Consideration should be given to how response activities might reduce existing inequalities, exacerbate them, create new ones, or disproportionately impact those with a protected characteristic. These considerations should then guide recommendations to mitigate any negative impacts and maximise opportunities to improve health inequalities

Incident management teams must assess and review equity from the perspective of all populations within their local areas. Early engagement with the voluntary and community sector and others is essential. Monitoring and feedback arrangements will be implemented through co-ordination meetings initially, with additional bespoke arrangements established if necessary. 

Depending on the initial and dynamic assessment of the scenario, it may be appropriate to convene a specific health inequalities group to provide advice and guidance on the response and agree whether an ongoing health inequalities group needs to be established with scheduled review points. 

Considering how to identify and mitigate health inequalities should happen throughout any response. Organisations should undertake their own Equalities and Health Inequalities Impact Assessment as the basis for health inequalities consideration relevant to their incident response. Reducing the actual or unintentional impact on health inequalities during an incident is vital.

Under the Equality Act 2010, organisations need to ensure information is inclusive and accessible, including providing it in formats that are suitable for people’s needs.

Annex 1: Section 252A of the NHS Act 2006

Section 252A of the NHS Act 2006, as amended by the Health and Care Act 2022, allows NHS England to take the steps it considers appropriate for facilitating a co-ordinated response to an emergency. This would be invoked by the Chief Executive and notified to the Secretary of State for Health and Social Care. The instruction will also be issued to NHS organisations to ensure compliance with any incident instructions.

Annex 4a: Invocation

Upon invocation of 252A, the following notification will be issued by NHS England’s Chief Executive to all NHS organisations, copied to the Secretary of State of Health and Social Care, Care Quality Commission and NHS Blood and Transplant.

“Following the incident at [insert name], we are required to establish national command and control to direct and co-ordinate the response of the NHS in England. To facilitate this requirement, NHS England is invoking section 252A of the NHS Act 2006, as amended by the Health and Care Act 2022, and has appointed a national incident director to lead the response. Our national incident response team will co-ordinate the strategic response, in collaboration with local health commissioners at the tactical level. All providers of NHS funded care are required to co-operate with the response as directed by NHS England during this time. I would like to thank you for your ongoing support during this challenging time and would be grateful if you would share this with your own incident management team.”

Annex 4b: Stand down

Once the decision has been made to stand down the response to the incident, NHS England’s Chief Executive will write to all NHS organisations. This letter will be copied to the Secretary of State for Health and Social Care, Care Quality Commission and NHS Blood and Transplant, confirming the return to normal business and suspension of any action taken by NHS England under its powers. The following wording will be used:

“Further to my letter of [date and any publication reference] confirming the NHS response to the [incident name] incident, I can confirm this has now been stood down to a level which no longer requires NHS England to direct and co-ordinate the response of the NHS in England. Following this decision, NHS England has now agreed to suspend its use of section 252A of the NHS Act 2006 (as amended by the Health and Care Act 2022). Local co-ordination and response arrangements may continue to be in effect, and we request providers of NHS funded care continue to co-operate with these. I would like to take this opportunity to thank you and your staff for your co-operation during this time and the dedication and commitment shown while responding to this incident.”

Publication reference: PRN01798