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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
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BUSINESS
CONTINUITY
MANAGEMENT
POLICY
Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
DOCUMENT CONTROL
Type of Document Policy
Document Title Business Continuity Management Policy
Description:
This policy and the supporting Business Continuity Management Plan are required to provide the Governing Body with reasonable assurance that the
LCCG is meeting its obligations with regard to business continuity.
Location: File Location: S:/Lambeth Share/Lam/CCG/Governance and
Development/Governance/Policy/
Published version
no. 1.0
Publication date December 2013
Review date December 2016
Author name, job
title and contact
details
Marion Shipman
Assistant Director Governance and Quality
Marion.shipman@nhs.net
020 3049 4467
Consultation Body /
Persons Andrew Parker / Geraldine Hennighan
Consultation date November – December 2013
Approval Body Integrated Governance Committee
Approval date December 2013
Ratification date
(IGC) 18 December 2013
Readership /
Audience: All staff working for, and on behalf of the CCG
Information
Governance Class
(Restricted or
unrestricted)
Unrestricted
Governance and NHS Lambeth CCG
This document supersedes all pre-existing Business Continuity Management policies and protocols.
This Policy applies to all staff of NHS Lambeth Clinical Commissioning Group.
Details of the Equality & Equity Impact Assessment Checklist can be found in Appendix 3.
Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
Version / Change History
Version Date Author Approving Committee / Group
Reason
0.1 3/12/13 Marion Shipman Initial draft version for consultation
1.0 6/12/2013 Marion Shipman Integrated Governance Committee
New policy
Consultation History
Consultation Body /
Persons Area of expertise Date sent Date returned Comments / Changes made
Andrew Parker, Director of
Governance and
Development
EPRR lead for LCCG 3/12/13 6/12/2013 Minor amendments – policy is in line with NHSE requirements and
similar CCG Business Continuity Management policies.
Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
CONTENTS
1. Introduction ................................................................................................................................................... 6
1.1 Introduction................................................................................................................................................ 6
1.2 Policy Statement....................................................................................................................................... 6
2. Scope of Document ..................................................................................................................................... 6
3. Equality and Human Rights Statement ..................................................................................................... 7
4. Roles and Responsibilities ......................................................................................................................... 7
4.1 CCG Governing Body .............................................................................................................................. 8
4.2 Chief Officer .............................................................................................................................................. 8
4.3 Directors and Assistant Directors .......................................................................................................... 8
4.4 Commissioning / Contracting Managers ............................................................................................... 8
4.5 All staff ....................................................................................................................................................... 8
4.6 Governance Team ................................................................................................................................... 8
5. Governance Arrangements ........................................................................................................................ 8
5.1 Business Continuity Management ......................................................................................................... 8
5.2 Updating .................................................................................................................................................... 9
6. The Business Continuity Management Plan ............................................................................................ 9
7. Definitions ..................................................................................................................................................... 9
7.1 Business Continuity ................................................................................................................................. 9
7.2 Business Continuity Management System ........................................................................................... 9
7.3 Business Impact Analysis (BIA) ............................................................................................................. 9
7.4 Prioritised Activities ................................................................................................................................ 10
7.5 Products and Services ........................................................................................................................... 10
7.6 Maximum Tolerable Period of Disruption (MTPOD) ......................................................................... 10
7.7 Minimum Business Continuity Objective (MBCO) ............................................................................. 10
7.8 Recovery Time Objective (RTO) .......................................................................................................... 10
7.9 Incident Identification ............................................................................................................................. 10
7.10 All other terms and definitions ............................................................................................................ 11
Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
8. Policy Audit and Monitoring Compliance ................................................................................................ 11
8.1 Policy Review .......................................................................................................................................... 11
8.2 Policy Monitoring and Audit .................................................................................................................. 12
9. Statement of evidence / references ........................................................................................................ 13
10. Implementation and dissemination of document .............................................................................. 13
11. Associated Documents ........................................................................................................................ 14
12. Appendices ............................................................................................................................................ 14
Appendix 1 NHS Core Standards .................................................................................................................... 15
Appendix 2 The Plan-Do-Check-Act (PDCA) Model .................................................................................... 17
Appendix 3 Equality & Equity Impact Assessment Checklist ...................................................................... 18
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
1. INTRODUCTION
1.1 INTRODUCTION
As Category 2 responders under the Civil Contingencies Act 2004, Clinical Commissioning
Groups (CCGs) are required to have a business continuity plan in place to manage the effects
of any incident that might disrupt its normal business.
Following the reorganisation of the NHS under the Health and Social Care Act 2012, all current
BCPs will need to be reviewed to take into account the changes and a re-evaluation of the
criticality of functions and dependencies undertaken. An interim BCP was agreed for the CCG
from 1 April 2013 and the following policy drafted after completion of a Business Impact
Analysis.
For CCGs duties as a Category 2 responder please refer to:
http://www.england.nhs.uk/ourwork/gov/eprr/
1.2 POLICY STATEMENT
The purpose of Lambeth Clinical Commissioning Group (LCCG) is to commission health
services to improve the health of the citizens of Lambeth. It is the Policy of the LCCG to ensure,
so far as is reasonably practicable, that the activities and assets of the LCCG which contribute
to the achievement of that purpose are protected against potential threats, by the
implementation of an effective programme of Business Continuity Management (BCM).
This policy and the supporting Business Continuity Management Plan are required to provide
the Governing Body with reasonable assurance that the LCCG is meeting its obligations with
regard to business continuity.
2. SCOPE OF DOCUMENT
This Policy applies to all LCCG directorates and staff and covers the activities and functions
carried out by NHS Lambeth Clinical Commissioning Group (CCG) including:
Strategic Finance
Corporate Functions including Governance and provider quality monitoring
Medicines Management
Membership Services
Engagement and support services
Strategic commissioning, service redesign work and procurement
Community and Mental Health Commissioning and contract monitoring
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
Primary Care Local Enhanced Service Commissioning and contract monitoring
All CCG activities undertaken at 1 Lower Marsh, Lambeth, London SE1 7NT.
This plan does not include the services commissioned or contracted by NHS Lambeth CCG
including but not limited to:
South London Commissioning Support Unit: HR functions; Information and
Communications Technology; Information Governance; Patient PALS and Complaints;
Acute contract monitoring; Out of Hours emergency communications function.
Provider services: Contracted and commissioned services which provide services to
NHS patients on behalf of the LCCG must have their own business continuity
arrangements, which will be set out in contracts
If the Lambeth Business Continuity Plan (BCP) is activated as part of a declared major incident
NHS England London regional team will be strategically and tactically responsible for the
management of the incident and the Lambeth BCP will be activated (as necessary) as part of
the recovery process.
3. EQUALITY AND HUMAN RIGHTS STATEMENT
Promoting equality, eliminating unfairness and unlawful discrimination, and treating colleagues,
partners and the public with dignity and respect, are fundamental to successful performance by
all staff in the CCG, including the Governing Body, who are all expected to actively promote
equality and human rights and challenge racism, homophobia and other forms of discrimination
through their activities, and support others to do the same.
All staff are expected to work with others on effective approaches to ensure strategies, policies
and activities promote and demonstrate equality and human rights.
Equality Impact Assessment and Equality Analysis are to be used as part of developing and
monitoring proposals and projects for their impact on equality and equity.
All staff of Lambeth CCG, including the Governing Body are required to abide by all equality and
human rights legislation and good practice, and will receive appropriate training and support to
do so.
4. ROLES AND RESPONSIBILITIES
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
The authority and responsibility for the establishment, maintenance, support and evaluation of
the BCM policy and strategy is vested in the LCCG Governing Body.
4.1 CCG GOVERNING BODY
The LCCG Governing Body delegates the responsibility for the approval of the BCM policy and
plan and overall implementation to the Integrated Governance Committee.
4.2 CHIEF OFFICER
The Chief Officer is responsible under the Civil Contingencies Act 2004 for ensuring that a BCM
system is in place and working satisfactorily.
4.3 DIRECTORS AND ASSISTANT DIRECTORS
Directors (and Assistant Directors) of operational directorates are responsible for ensuring that
the BCM programme is fully implemented within their areas of responsibility.
4.4 COMMISSIONING / CONTRACTING MANAGERS
Commissioning / Contracting Managers are responsible for ensuring that contracts and or
service level agreements with providers of goods and/or services include the requirement for
BCM.
4.5 ALL STAFF
All CCG employees will be responsible and accountable to their Line Manager for
implementation of the BCM programme including having read this policy and the Business
Continuity Management Plan.
4.6 GOVERNANCE TEAM
The Governance Team is responsible to the Director of Governance and Development for
developing and delivering the LCCG BCM programme. This includes ensuring there is a central
register of Business Continuity Plans.
5. GOVERNANCE ARRANGEMENTS
5.1 BUSINESS CONTINUITY MANAGEMENT
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
BCM arrangements will be monitored through the Lambeth Integrated Governance Committee.
Reports on BCM will be submitted to the LCCG Governing Body at least annually.
5.2 UPDATING
This Policy will be deemed to have expired 3 years from its approval date, and will be subject to
regular review and updating to reflect legislative, organisational or other significant change
6. THE BUSINESS CONTINUITY MANAGEMENT PLAN
The BCMP will be based on the plan-do-check-act (PDCA) model and will:
Establish the organisational context for BCM
Set clear BC strategy and objectives
Outline potential resource requirements
Set out arrangements for communication to and with interested parties
Contain business impact analysis
Be based on risk assessment
Describe the organisation’s incident response structure
Set out arrangements for recovery from an incident
Set out arrangements for exercising and testing
7. DEFINITIONS
7.1 BUSINESS CONTINUITY
ISO 22301 defines Business Continuity as the capability of the organization to continue delivery
of products or services at acceptable predefined levels following [a] disruptive incident.
7.2 BUSINESS CONTINUITY MANAGEMENT SYSTEM
ISO 22301 defines Business Continuity Management System as a holistic management process
that identifies potential threats to an organization and the impacts to business operations that
those threats, if realized, might cause, and which provides a framework for building
organizational resilience with the capability for an effective response that safeguards the
interests of its key stakeholders reputation, brand and value-creating activities.
7.3 BUSINESS IMPACT ANALYSIS (BIA)
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
Business Impact Analysis (BIA) is defined as the process of analysing activities and the effect
that a business disruption may have upon them.
7.4 PRIORITISED ACTIVITIES
Prioritised Activities is defined as those activities to which priority must be given following an
incident in order to mitigate impacts.
7.5 PRODUCTS AND SERVICES
Products and Services is defined as ‘the beneficial outcomes provided by an organization to its
customers, recipients and interested parties.’
7.6 MAXIMUM TOLERABLE PERIOD OF DISRUPTION (MTPOD)
Maximum Tolerable Period of Disruption (MTPOD) is defined as ‘the time it would take for
adverse impacts, which might arise as a result of not providing a product / service or performing
an activity, to become unacceptable.’
7.7 MINIMUM BUSINESS CONTINUITY OBJECTIVE (MBCO)
Minimum Business Continuity Objective (MBCO) is defined as ‘the minimum level of services
and /or products that is acceptable to the organisation to achieve its business objectives during
a disruption.’
7.8 RECOVERY TIME OBJECTIVE (RTO)
Recovery Time Objective (RTO) is defined as ‘the period of time following an incident within
which:
Product or service must be resumed; or
Activity must be resumed; or
Resources must be recovered
The RTO must be less than the MTPOD.
7.9 INCIDENT IDENTIFICATION
Incident Identification is defined as an incident or set of circumstances which might present a
risk to the continuity of a service might be identified by any member of staff.
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
7.10 ALL OTHER TERMS AND DEFINITIONS
All other terms and definitions used in this document are as found in ISO 22301.
8. POLICY AUDIT AND MONITORING COMPLIANCE
8.1 POLICY REVIEW
The Assistant Director Governance and Quality will collate a central register of Business
Continuity Plans and will ensure that compliance is audited.
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
8.2 POLICY MONITORING AND AUDIT
MONITORING / AUDIT REQUIREMENT Area in document for monitoring – e.g. processes Note specifically any monitoring needed to assure equality and equity of delivery
MONITORING / AUDIT METHOD (e.g. statistics, report)
MONITORING REPORT / AUDIT PREPARED BY (job titles)
MONITORING REPORT / AUDIT PRESENTED TO (name of Committee / group)
FREQUENCY OF MONITORING REPORT / AUDIT (e.g. annually, six-monthly)
Implementation of BCM requirements for CCGs
Report Assistant Director Governance and Quality
Integrated Governance Committee
At least annually
Audit compliance against the CCG Business Continuity Plans
Reports Assistant Director Governance and Quality
CCG Operations Group As required
Ensure robust monitoring and management of EPRR risks
Risk Register Assistant Director Governance and Quality
Integrated Governance Committee
Monthly
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
9. STATEMENT OF EVIDENCE / REFERENCES
This Policy and the supporting Business Continuity Management Plan are required to provide
the Governing Body with reasonable assurance that the LCCG is meeting its obligations with
regard to business continuity.
This policy has been written with reference to:
ISO 22301 Societal Security1
The Civil Contingencies Act 2004 (as amended)
The Health and Social Care Act 20122
NHS England (and former NHS Commissioning Board) EPRR documents and
supporting materials including:
NHS CB Emergency Preparedness Framework (2013)3;
NHS England Command and Control Framework for the NHS during significant
incidents and emergencies (2013); and
NHS England Core Standards for Emergency Preparedness, Resilience and
Response (EPRR).
BSI PAS 2015 - Framework for Health Services Resilience
10. IMPLEMENTATION AND DISSEMINATION OF DOCUMENT
Following ratification, the Business Continuity Management Policy will be
uploaded onto the CCG intranet and the document location confirmed to all CCG staff
launched at a Lower Marsh staff briefing
included in all new staff induction sessions
shared with SLCSU contracting leads
In addition, all CCG staff will be required to confirm that they had seen and read the policy
Staff with a role in BCM will be trained according to their level of need following a Training
Needs Analysis (TNA).
The Assistant Director Governance and Quality will ensure that BCM is incorporated into risk
management, health and safety and emergency planning training.
1 This International Standard for business continuity management specifies requirements to
plan, establish, implement, operate, monitor, review, maintain and continually improve a
documented management system to protect against, reduce the likelihood of occurrence,
prepare for, respond to, and recover from disruptive incidents when they arise.
2 http://www.legislation.gov.uk/ukpga/2012/7/enacted
3 www.commissioningboard.nhs.uk/eprr/
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
Significant changes and updates to BCM requirements or processes will be notified through the
Senior Management Team Meeting and usual corporate routes.
11. ASSOCIATED DOCUMENTS
This document should be read in conjunction with the LCCG Business Continuity Management
Plan.
12. APPENDICES
Appendix 1
NHS Core Standards
Appendix 2
The Plan-Do-Check-Act (PDCA) Model
Appendix 3
Equality & Equity Impact Assessment Checklist
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
APPENDIX 1 NHS CORE STANDARDS
NHS Core Standards for Emergency Preparedness, Resilience and Response (EPRR)
1
All NHS organisations and providers of NHS funded care must develop, maintain and
continually improve their business continuity management systems. This means having
suitable plans which set out how each organisation will maintain continuity in its services
during a disruption from identified local risks and how they will recover delivery of key
services in line with ISO22301. Organisations must:
Make sure that there are suitable financial resources for their BCMS and that those
delivering the BCMS understand and are competent in their roles.
Set out how finances and unexpected spending will be covered, and how unique cost
centres and budget codes can be made available to track costs.
Develop business continuity strategies for continuing and recovering critical activities
within agreed timescales, including the resources required such as people, premises,
ICT, information, utilities, equipment, suppliers and stakeholders.
Develop, use and maintain business continuity plans to manage disruptions and
significant incidents based on recovery time objectives and timescales identified in the
business impact analysis.
2
Business continuity plans must include governance and management arrangements linked to
relevant risks and in line with international standards.
Each organisation’s BCMS should be based on its legal responsibilities, internal and
external issues that could affect service delivery and the needs and expectations of
interested parties.
Organisations should establish a business continuity policy which is agreed by top
management, built into business processes and shared with internal and external
interested parties.
Organisations must make clear how their plan will be published, for example on a
website.
The BCMS policy and business continuity plan must be approved by the relevant
board and signed off by the Chief Executive.
There must be an audit trail to record changes and updates such as changes to policy
and staffing.
The planning process must take into account nationally available toolkits that are seen
as good practice.
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
NHS Core Standards for Emergency Preparedness, Resilience and Response (EPRR)
3
Business continuity plans must take into account the organisation’s critical activities, the
analysis of the effects of disruption and the actual risks of disruption.
Organisations must identify and manage internal and external risks and opportunities
relating to the continuity of their operations.
Plans must be maintained based on risk-assessed worst-case scenarios.
Risk assessments should take into account community risk registers and at very least
include worst-case scenarios for:
severe weather (including snow, heat wave, prolonged periods of cold weather
and flooding);
staff absence (including industrial action);
the working environment, buildings and equipment;
fuel shortages;
surges in activity;
IT and communications;
supply chain failure; and
associated risks in the surrounding area (e.g. COMAH and iconic sites).
Organisations must develop, use and maintain a formal and documented process for
business impact analysis and risk assessment.
They must identify all critical activities using a business impact analysis. This should
set out the effect business disruption may have on the organisation and how this will
be overcome, including the maximum period of tolerable disruption.
Organisations must highlight which of their critical activities have been put on the
corporate risk register and how these risks are being addressed.
4
Business continuity plans should set out how the plans will be called into use, escalated and
operated.
Organisations must develop, use, maintain and test procedures for receiving and
cascading warnings and other communications before, during and after a disruption or
significant incident. If appropriate, business continuity plans should be published on
external websites and through other information-sharing media.
Plans should set out:
the alerting arrangements for external and self-declared incidents, including
trigger points and escalation procedures;
the procedures for escalating emergencies to CCGs and the NHS CB area,
regional and national teams;
24-hour arrangements for alerting managers and other key staff, including how
up-to-date contact lists will be maintained;
the responsibilities of key staff and departments;
the responsibilities of the Chief Executive or Executive Director;
how mutual aid arrangements will be called into use and maintained;
where the incident or emergency will be managed from (the ICC);
how the independent healthcare sector may help if required; and
the insurance arrangement that are in place and how they may apply.
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
APPENDIX 2 THE PLAN-DO-CHECK-ACT (PDCA) MODEL
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Document Title: Business Continuity Management Policy Issue date: Dec 2013 Document Status: Ratified Review date: Dec 2016 File Location: S:/Lambeth Share/Lam/CCG/Governance and Development/Governance/Policy/ Version No: 1.0
APPENDIX 3 EQUALITY & EQUITY IMPACT ASSESSMENT CHECKLIST
The CCGs Equality and Human Rights Statement is included as Section 3 of this document. This
information is also included in CCG job descriptions.
This is a checklist to ensure relevant equality and equity aspects of proposals, policy or guidance have
been addressed either in the main body of the document or in a separate equality & equity impact
assessment (EEIA)/ equality analysis. It is not a substitute for EEIA/ equality analysis which is normally
required unless it can be shown that a proposal has no capacity to influence equality. The checklist is to
enable the policy lead and the relevant committee to see whether the EEIA has covered the ground and
to give assurance that the proposals will not only be legal but also fair and equitable and lead to reduced
health inequality.
Challenge questions
Yes /
No / DK
/ N/A
Comments
1
Does the document set out the health care needs of the groups
intended to benefit from the proposal, including any differences in
need in terms of the legally protected or other characteristics (such
as socioeconomic position)
N/A
2
Does the document set out any known existing inequality in
access, quality, experience and outcome of care for populations
relevant to the proposal (i.e. as defined in 1. and in relation to the
existing health or care service)?
N/A
3 Are there any particular public concerns about equality about the
policy area than need to be addressed? No
4 Has the policy described any gaps in knowledge about 1 -3, and
any action taken to fill gaps (or recommendations for action) N/A
5
Does the document set out risks to equity of access, quality,
experience and outcomes including risk of direct or indirect
discrimination, and risk to good relations between people of
different groups?
N/A
6
Does the document describe any specific opportunities to
promote equality and human rights, good relations between
people of different groups, to enhance participation, etc?
N/A
7 Does the document describe how the proposal, policy etc will
address the identified inequalities, and N/A
8 Does the document make recommendations to mitigate risks and
enhance the opportunities to promote equality and equity? N/A
9
Does the document describe how monitoring and reporting will
take place to assure equality and equity in the future including to
stakeholders? [audit and monitoring table may be used]
N/A
* Race/ ethnicity, gender (including gender reassignment) age, religion or belief, disability, sexual orientation,
marriage or civil partnership, pregnancy and maternity. This will include groups such as refugees and asylum
seekers, new migrants, Gypsy and Traveller communities; and people with long term conditions, hearing or visual
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