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Business Continuity Plan East and North Hertfordshire Clinical Commissioning Group

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BUSINESS CONTINUITY PLAN

Copies of this plan can be found in the Incident Control Room located in MR1.2 on the first floor and also the on-call pack issued to Directors/ Managers.



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DOCUMENT CONTROL SHEET Document Owner: Director of Operations Document Author(s): Director of Operations Version: 8.1 FINAL Directorate: Operations Approved By: Governing Body Date of Approval: 22 November 2018 Date of Review: November 2019 Change History:

Version Date Reviewer(s) Revision Description

1.0 July 2013 Valerie Penn Updated following JW comments

2.0 August 2013 Valerie Penn General update following Draft Business Impact Assessments

3.0 October 2013 John Webster Whole Document Review – Updates to Plan, Business Impact Assessments and Policy Statement in line with EPRR Core Standards

4.0 November 2013

Valerie Penn Updated following Exec Comments

4.1 Draft

January 2015 Oskan Edwardson

Annual Update – for approval

5.0 Final

January 2015 Jas Dosanjh Formatting

5.1 Final

April 2015 Jas Dosanjh Sharn Elton

Appendix with contacts updated. Critical Functions of the Operations Director added to BIA Appendix

5.2 Final

June 2015 Anne Ephgrave Critical Functions of HR added to BIA Appendix

5.3 Final

July 2015 Phil Turnock Addition of ‘Objectives for the Recover of Services’ and updated Appendix 4 Critical Functions of HBL ICT Shared Service

5.4 Draft

September 2015

Jas Dosanjh Sharn Elton

Update in line with NHSE EPRR Framework and Toolkit requirements

5.5 Draft

February 2016

Jas Dosanjh Formatting and updated Business Impact Assessment included

5.6 Draft

February 2016

R Steadman (No change recorded)



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5.7 Draft

March 2016 R Steadman Minor amendment to text on p.1

5.8 Draft

July 2016 R Steadman Review of Business Impact assessments to ensure consistent methodology used and minor text changes

6.0 Final

July 2016 R Steadman Updates confirmed following approval by Governing Body

6.1 Draft

June 2017 R Steadman, Darren O’Rourke, Jas Dosanjh

Version history tracked and updated, Business Impact Assessments reviewed and updated, contacts reviewed, Real time assessment template added as Appendix

6.2 Draft

July 2017 Jas Dosanjh Minor amendments following feedback from team

7.0 Final

September 2017

Jas Dosanjh Governing Body approval, minor reformatting

7.1 Draft

November 2018

Jas Dosanjh Annual review of plan with minor format/grammar amendments, key contacts updated, Business Impact Assessments reviewed and updated by teams, new Equality and Privacy Impact Assessments undertaken

7.2 Draft

November 2018

Jas Dosanjh Minor amendments following feedback from EPRR group, Equality and Privacy Impact Assessments signed off

8.0 FINAL

December 2018

Jas Dosanjh Formatting and review following Governing Body approval (22 Nov 2018) – some minor updates to BIA’s

8.1 FINAL

January 2019 Jas Dosanjh Review of Business Impact Assessments (critical functions reviewed in light of BREXIT readiness) carried out by Business Continuity Leads



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Implementation Plan:

Development and Consultation

EPRR Consultant Executive Team

Dissemination Staff can access this policy via the intranet and will be notified of new/revised versions via the staff briefing. This policy will be included in CCG Publication Scheme in compliance with the Freedom of Information Act 2000.

Training Staff will be made aware of the emergency and business continuity response arrangements within the plan at their corporate induction training, and will also be made aware of where the overarching and departmental plans can be located. The skills and knowledge of Incident Commanders and staff at an operational level will be achieved and maintained through regular training and exercising as documented in the training and exercising annual programme which covers:

• Awareness training, including roles/responsibilities,

• Incident coordination centre training, • Communications testing and exercising.

If there are any significant changes to the plan, then this will be communicated to departmental leads to cascade to all staff. Business Continuity arrangements w i l l be exercised at least once a year in order to validate the effectiveness and highlight any gaps which can then be corrected.

Monitoring and Review

This document will be reviewed on an annual basis or when there are changes in the working systems of the organisation; or major changes to the contact arrangements of staff or suppliers that affect the content. It is the responsibility of the identified departmental leads to update local departmental plans on an ongoing basis and the Business Continuity Lead to ensure the generic section of this document is kept update. The plan will be used/deployed when the ability of the CCG to carry out its statutory duties are compromised. The plan will be exercised and tested every two years; incident management will account to testing and exercising, in accordance with the processes defined within the Major Incident Plan (including testing with dependent stakeholders).

Equality and Diversity

Equality Impact Assessment Data Protection Impact Assessment



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Associated CCG Documents

Major Incident Plan System Escalation Plan Major Incident Action Cards Incident Control Centre Plan CCG on-call folder CCG Risk Management Strategy and Policy

References The ISO Standard for Business Continuity (ISO 22301) British Standard NHS Business Continuity Management

(BS25999)

Document Status: This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet http://www.enhertsccg.nhs.uk/policies

Sustainable Development - Environmental

Do you really need to print this document?

Please consider the environment before you print this document and where possible copies should be printed double-sided. Please also consider setting the Page Range in the Print properties, when relevant to do so, to avoid printing the policy in its entirety.

http://www.enhertsccg.nhs.uk/policies



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Contents

Section No.

Section Name Page No.

1.0 Introduction 7

2.0 Scope 7

3.0 Definitions 7

4.0 Policy Statement 8

5.0 Role and Responsibilities 10

6.0 Plan Activation 11

6.1 Business Continuity Management Team (Crisis and Recovery Team)

12

6.2 Continuing Services in the Event of a Disruption 12

6.3 Insurance/Incident Costs

17

6.4 Communications and Alerts

18

6.5 Record Keeping

19

Appendix 1 Business Continuity Management – CCG Policy Statement

20

Appendix 2 Business Recovery Template 21

Appendix 3 Real Time Assessment Template 23

Appendix 4 Key Contacts List 24

Appendix 5 Business Impact Assessment - Template and Summary

25

Appendix 6 Equality Impact Assessment 46

Appendix 7 Data Protection Impact Assessment 47



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1.0 Introduction

The Civil Contingencies Act 2004 came into force in November 2005 and focuses on local arrangements for civil protection, establishing a statutory framework of roles and responsibilities for local responders (such as CCGs) as Category 2 Responders. It is a requirement of the Act that the CCGs have Business Continuity Plans in place to support the CCG’s Major Incident Plan.

2.0 Scope

The scope of this plan is to provide overarching organisational guidance of business continuity management and the invocation process within the CCG, and an outline of responsibilities. The following table indicates the links with other CCG and System Resilience Plans:

Document

Community Risk Register The CCG is a Category 2 responder for Emergency Preparedness Resilience and Response which will be led by the NHS England Midlands and East (Central Midlands) Area Team. These plans will be owned by the Local Resilience Forum with input from the Local Health resilience Partnership. However, the CCG will have a role in planning for and responding to the relevant incident.

LRF Flood Plan

LRF Pandemic Influenza Plan

LRF Severe Weather Plan

The purpose of the Business Continuity Plan is to outline the responsibility of the CCG and their staff in the event of a crisis in order to maintain as normal a service as practically possible. The over-riding aim is to ensure a prompt and efficient recovery of critical activities from any incident or physical disaster that may affect the CCG’s ability to operate and deliver their commissioning service in support of the NHS economy. It must be recognised that any event not only impacts on staff, premises, technology and operations, but also on the CCG’s brand, status, relationships and reputation and that all business continuity arrangements should ensure that the CCGs meet their legal, statutory and regulatory obligations to both their staff and dependent stakeholders.

3.0 Definitions 3.1 Business Continuity Management the process that helps manage the

risks to the smooth running of the organisation in the delivery of its services, ensuring that essential business can continue in the event of a disruption and can be sustained in the event of an emergency. It is aimed at reducing or eliminating the risks of business interruption and it is necessary to have contingency plans in place to ensure normal business functions can be resumed as soon as possible.



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For the NHS, Business Continuity Management is defined as the management process that enables an NHS organization to: • Identify those key services which, if interrupted for any reason, would have

the greatest impact upon the community, the health economy and the organisation.

• Identify and reduce the risks and threats to the continuation of these key services.

• Develop plans which enable the organisation to recover and/or maintain core services in the shortest possible time.

There are many and varied possible causes of service disruption; these may range from the loss of infrastructure e.g. offices; buildings; IT systems; managing a power cut or extreme weather to arranging service provision during an emergency or epidemic. These events may not be mutually exclusive i.e. extreme weather can lead to loss of electricity or staff being unable to get to work.

3.2 A Service Interruption can be defined as ‘Any incident which

threatens personnel, buildings or the operational procedures of an organisation and which requires special measures to be taken to restore normal functions’

4.0 Policy statement

It is the policy of East and North Hertfordshire Clinical Commissioning Group (CCG) to develop, implement and maintain a Business Continuity Management System (BCMS) in order to ensure the prompt and efficient recovery of our critical activities from any incident or physical disaster affecting our ability to operate and deliver our services in support of the NHS economy.

It is the policy of the CCG to take all reasonable steps to ensure that in the event of a service interruption, the organisation will be able to respond appropriately and continue to deliver its essential functions and that we are able to respond to the needs of our local population. A service interruption is defined as:

‘Any incident which threatens personnel, buildings or the operational procedures of an organisation and which requires special measures to be taken to restore normal functions.’ (www.cabinetoffice.gov.uk/ukresilience).

The CCGs Policy Statement is provided at Appendix 1.

4.1 Resources

The CCG recognises its obligations with regards to emergency planning, resilience, responding to major incidents and business continuity. Funds, as identified as being necessary, will be made available in the event of a major incident to ensure the CCG meets its obligations with respect to these.

http://www.cabinetoffice.gov.uk/ukresilience)



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4.2 Emergency Planning - Business Continuity

The Cabinet Office’s “Expectations and Indicators of Good Practice Set for Category 1 and 2 Responders” describes seven expectations regarding the Civil Contingencies Act (2004), Regulations (2005) and guidance:

1. Duty to assess risk 2. Duty to maintain plans – Emergency Plan 3. Duty to maintain plans – Business Continuity 4. Duty to communicate with the public 5. Business Continuity Promotion 6. Information sharing 7. Cooperation

Clinical Commissioning Groups are Category 2 Responders and as such will be required to co-operate with Category 1 Responders in the event of an emergency. They are also required to have Business Continuity Plans and Major Incident Plans. These requirements will be achieved in three stages: Stage 1 – A Business Impact Assessment: The impacts of the loss of staff, communications, data systems, transport and buildings. Appendix 5 provides details of the Business Impact Assessments undertaken at Departmental level within the CCG. Some functions are hosted by or delivered through contracts with other organisation’s, and where applicable details have been included within the assessments. The Business Impact Assessments include prioritized activities that have been linked to the Business Continuity Corporate Risks. The Business Impacts Assessments detail: • Responsibilities of key staff and departments, • Responsibilities of the appropriate Accountable Emergency officer or

Executive Director. Stage 2 - A Business Continuity Plan: The measures to be taken internally in the event of such a loss. The Business Continuity Plan will comprise the mitigating actions arising from the Business Impact Assessments, taking into consideration the key risks that could potentially cause service disruption resulting in the plans being evoked. Information of the key contacts that will instigate the relevant mitigating actions and the contact details of all staff that might have to undertake those actions



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are also included - be it communicating with others or changing their way of working. Stage 3 – A Major Incident Plan: The measures to be taken in support of Category 1 responders in the event of an ‘Emergency’. This details the organisation’s response to: • an event or situation which threatens serious damage to human welfare; • an event or situation which threatens serious damage to the environment; • War, or terrorism, which threatens serious damage to the security of the

UK. The CCG is required to equip nominated staff with the Major Incident Plan, the Business Continuity Plan, an incident control centre, an emergency telephone line and a list of all relevant telephone and email contacts. The plans have been built on experience and will be subject to a desktop test, as part of best practice, in order that they are further refined. The result of the desktop testing will be reported to the CCG Governing Body.

5.0 Roles and Responsibilities

Overall accountability for the smooth running of the organisation lies with the CCG’s Accountable Officer. The Director of Operations is the lead director for Business Continuity and will be responsible for providing positive assurance to the Governing Body on the CCG’s plans.

5.1 Executive Directors The Executive Directors are responsible for maintaining their individual

services, and for alerting the need to activate Business Continuity Plans if such an event occurs within their directorate.

5.2 Designated Associate Directors and Assistant Directors

The Designated Associate Directors and Assistant Directors must ensure that any changes of contact details of key staff noted in their plans are updated as required, that their Directorate plans are reviewed at least annually and that any new services that are developed are included in the plans.

5.3 Lead for Emergency Preparedness, Resilience, Response and

Business Continuity

The Director of Operations is the lead for Emergency Preparedness, Resilience, Response and Business Continuity, providing specialist guidance during the invocation of the Business Continuity Plans in line with the Major Incident Plan.



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The Chief Finance Officer takes the lead for the day-to-day Business Continuity arrangements within the CCG, which is a critical function of the organisation.

5.4 Communications Team The Communications Team will be responsible for informing the public of

events where necessary, following agreement of the Accountable Officer or Director of Operations (designated deputy), and will also keep staff informed of developments as appropriate.

5.5 CCG Staff All CCG employed staff are responsible for co-operating with the

implementation of the Business Continuity Plans as part of their normal duties and responsibilities.

6.0 Plan Activation

A nominated post holder from each department will decide in discussion with the Heads of Department and the Director of Operations whether the plan or any part of it should be activated using the process in the following flow chart. Out of hours the decision will be made with the direction of the on call CCG director/manager



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6.1 Business Continuity Management Team (Crisis and Recovery Team)

A team will be convened t o oversee the process of ensuring essential services are maintained and that recovery plans are put into place, Membership may include the following:

• Director of Operations or nominated Deputy • Associate Director where incident has occurred • Assistant Director of Communications • Estates representation (as required) • Any other personnel deemed necessary, i.e. representative of HR,

specialist advice, etc.

The team will meet initially on a daily basis and will keep notes of the meeting, actions taken, resources committed, and progress made using the template a t Appendix 2.

Incident Control Centre location and resources: located in the Office next to the Boardroom, Second Floor, Charter House, WGC. Includes additional paper copies of this Plan.

The Major Incident Plan includes the scalable plan setting out how the command and control arrangements will be managed and by whom.

6.2 Continuing Services in the event of a Disruption

As part of the Business Impact Assessment process, a critical function analysis has been carried out to determine those parts of the service that are a priority to maintain or reinstate. The CCG is responsible for commissioning a wide range of patient services to the local population and the following will be restored and maintained as soon as is practically possible.

• Maintaining an emergency response and support to Category 1

responders; • Incident investigation; • Mobilisation of the workforce, and support for staff safety and welfare; • Provision of IT (through a shared service (called Herts Beds and Luton

ICT Shared Service) with ENHCCG as the host for this service); • Maintaining communications with the general public and CCG staff; • Essential Finance functions; including the making and receiving of

payments; • Essential HR processes; • Safeguarding adults and children; and • Continuity of contract management responsibilities • System leadership role.



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Objectives for the Recovery of Services

The recovery of Services in a Disaster Recovery or Business Continuity scenario is defined by two Objectives:

Recovery Time Objective (RTO): is defined as the time period after a disaster at which business functions need to be restored.

Recovery Point Objective (RPO): is the maximum period of time based data loss (relative to the disaster) which cannot be recovered.

The Business Impact Assessments include details of the activity surge plan to ensure that critical services are maintained in periods of peak activity, including the maximum periods of tolerable disruption for all critical activities, and how the recovery/restoration principles will be managed and by whom. The critical function analysis also identifies those functions that are less critical and could be suspended, in light of the RTO and other timescales that may be identified within the Business Impact Assessments.

Service Function Length of time function can be suspended

Financial management 7 days

Planning services - preparing commissioning plans 28 days

Commissioning services through pathway development and redesign 28 days

Contract management – acute contracts 14 days Contract management – community and third sector 14 days

Performance and data analysis 14 days Governance duties to ensure continuous compliance with statutory duties 14 days

Partnership working to ensure joined up working to improve the health and wellbeing of patients 14 days

Support and guidance to member practices 14 days

Quality and safety 14 days

Administration 14 days

If an incident occurs and this plan is activated, permission will be sought from the Accountable Officer, or in their absence the Director of Operations (or nominated Deputy) to suspend the mainstream service functions detailed above and release the CCG staff who cover these functions to provide support to critical functions provided in other areas of the CCG.



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The plan will be activated in accordance with the processes outlined in the Major Incident Plan and the Incident Control Centre Plan, including the escalation system in place and who assumes responsibility at each stage (as well as action cards and aide memoirs for use by key team members). Through the Business Impact Assessments, each department has identified its own critical functions that are required to maintain its service and have their own local departmental plans which a re accessible in both paper copy and electronically. It is the responsibility of designated Associate/Assistant Directors to communicate the location of these plans to their staff.

In the event of an emergency, or business interruption, the CCG will endeavor to maintain services as usual or as close to the usual standard as possible. However, where it is clear that this is not achievable, the Head of Service in conjunction with the Director of Operations (or on-call Director/Assistant Director if out of hours) will decide which priority functions of the department must continue, depending on the nature of the business interruption.

There are some generic areas that could potentially affect all departments and these are described below:

6.2.1 Failure of IT Systems

The CCG, like many organisations, rely upon IT systems for their day to day business. A disaster that prevents the organisation from accessing these systems whether caused by the failure of the systems themselves, or being due to an incident such as fire or flooding will potentially have a serious impact on the continuation of the CCG’s functions. IT system failures may include:

• Loss of email, • Loss of internet, • Loss of Microsoft Office Applications, • Loss of access to stored documents (shared server), • Loss of individual IT systems/applications, • Major IT network outage.

While it is impossible to consider and document a recovery plan for every disaster that may occur the impact of the loss of IT systems to each department is covered in the individual departmental plans and it is expected that they can be adapted to cater for any specific incident. If there is a failure in the IT system or any stand-alone computer for important data for a prolonged period of time, staff will need to change to a paper back-up system where possible to capture the data so that this can be recorded on the system retrospectively.

The development of telecommunications that are reliant upon the IT network makes it likely that telephone failure will also result from any IT network



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failure. The priority in which restoration is required will depend on the service area and is detailed in individual departmental plans.

If there is a loss of hardware or software through theft or damage then advice should be sought from the IT provider and the incident reported to the CCG’s Governance and Corporate Affairs (via the Company Secretary).

The maintenance of the CCG IT systems is provided by the Herts Beds and Luton ICT Shared Service (HBL ICT) under a Service Level Agreement (SLA). Under the terms of this SLA, HBL ICT will invoke their Emergency Disaster and Recovery Plan to cope with any event causing prolonged interruption of service. The standard RPO and RTO within the agreed partnership service agreements is:

• RPO – 1 day from date of failure • RTO = 24 hours from the time of failure

Restoration of services will be managed through the agreement ICT Major Incident processes which will include full engagement of the CCG executive. Whereby the standard RPO or RTO cannot be achieved, this will be brokered with the CCG Executive during the respective phases of the Major Incident process.

6.2.2 Failure of Telecommunications

The telephone lines are provided under contract with BT, and the system is under a maintenance contract with Vodafone.

Each departmental plan identifies in more detail the actions required should the telephone systems (including mobile telephony) be inactive. The priority in which restoration of phone lines are required will depend on the service area and if crucial will be detailed in individual departmental plans.

CCG contact in the first instance: HBLICT Service Desk on 07799 895274* (Note:- this number is only activated if the Phone System is down at Charter House).

If electricity has failed then prior consideration needs to be given to the ability to recharge mobile phone batteries.

6.2.3 Loss of Records

Where there has been a loss of records (electronic and paper), the processes defined within Records Management Policy will be followed. Each departmental plan identifies in more detail the actions required should there be a loss of electronic/paper records.

6.2.4 Failure of Utilities – Electricity / Gas / Water Supplies



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Resolution is via NHS Property Services, the CCG contact in the first instance is NHS Property Services.

The fault should be reported and a request made as to whether they are able to give an indication of the length of time the supply will be unavailable.

If heating is lost an assessment should be made to the effect of the loss of the heating related to the time of year and the forecast temperature as to whether services can continue from the affected location.

For plumbing emergencies: contact NHS Property Services

In the event that the water supply fails the impact of the following must be assessed:

• Toilets • Hand hygiene • Drinking water

6.2.5 Loss of Building

If premises are unable to be used then services may need to be suspended or relocated. Local departmental plans detail who to contact and measures to be taken where there is a denial of premises (including actions taken in the event of a fire or flood).

Alternative locations for staff will include HCT HQ at Howard Court, HPFT HQ at Waverley Road, St Albans and HVCCG HQ at Hemel Hempstead. Initiation of these arrangements will be agreed by the Director of Operations (or nominated Deputy) or by agreement with the on-call Director/Manager. The Incident Control Centre Plan includes information on alternative locations where the service/activity could be delivered from in case of denial of access to Charter House and Fountain House. The plan also includes details of any provisions for staff to be accommodated overnight if the incident dictates and how this would be activated via pre-agreed arrangements.

6.2.6 Fuel Shortages

In the event of a fuel shortage the ability to maintain services may be affected. If it has been necessary for the invocation of the National Fuel Plan then the Business Continuity Management Team will be convened to oversee the management of the situation within the CCG

It is unlikely there will be provision of fuel for staff to get to their work base and the responsibility for alternative travel arrangements is with the individual members of staff in discussion with their line manager.



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6.2.7 Staff Shortages The absence of staff will have a varying effect depending on their role. In some cases roles can be covered by other staff but others may be highly specialised and necessary arrangements will be detailed in departmental plans as to whether a service can continue particularly if the service depends on that person alone. Potential threats related to staff shortages include;

• Loss of staff (>25%), • Serious injury to, or death of, staff whilst in the office, • Significant absence due to severe weather or transport issues, • Pandemic flu, • Simultaneous resignation or loss of key staff.

There may be a scenario when a number of staff are all incapacitated at the same time such as pandemic influenza. The departmental manager will be responsible for assessing the impact on the ability to continue to provide a service and what contingencies can be put in place, and whether some non-critical services can be cancelled as detailed in the individual departmental plans.

6.2.8 Other

Other areas that could potentially affect departments may include the following, this list is not exhaustive:

• Terrorist attack or threat affecting the transport network or office locations

• Theft or criminal damage • Chemical Contamination • Infectious disease outbreak • Industrial action • Fraud, sabotage or other malicious acts

The Severe Weather Response Plan includes details regarding the impact of severe weather (including snow, heat wave, prolonged periods of cold weather and flooding), and should be referred to in such circumstances.

6.3 Insurance/Incident Costs The insurance arrangements in place which may apply to incidents are:

• Corporate Liability Insurance • NHS Litigation Authority

The incident costs will be tracked by use of unique cost centres to assist and supplies/replacement equipment will be managed/maintained throughout the disruptive incident via a specific EP cost centre.



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6.4 Communications and Alerts

The CCG will respond to a significant incident in line with the formal organisation Communications Strategy and processes defined within the Major Incident Plan.

The Major Incident Plan sets out the alerting mechanism for external and self-declared incidents, including trigger points and escalation procedures. If an event occurs that is so severe that alternative arrangements for the provision of care commissioned by the CCGs need to be communicated to internal and external stakeholders, as well as the local population, this will be carried out via the Assistant Director of Communications after discussion with the Director of Operations.

The internal (Appendix 4) and external stakeholders that could be affected by the disruptive incident, especially around service delivery, could include the following and specific details have been included within the Business Impact Assessments:

• Providers including Primary Care, • Neighboring CCG’s, • Social Care, County and Borough Council.

The process for receiving and cascading warnings, and other communications before, during and after a disruption or significant event, and any resilient communication systems used is as follows:

• Alerts (i.e. Met Office) received into the CCG’s EPRR mailbox ([email protected]) are cascaded by the Operations Team to all Senior Managers, AD’s and Directors on-call,

• For incident management, the CCG has a secure nhs.net email account,

• The Incident Control Centre Plan documents how Senior Managers, AD’s and Directors can remotely access the account.

Mechanisms for informing the relevant partners including, but not limited to, other CCG’s, NHS care providers, and NHSE detailed in the Major Incident Plan. There is also a Hertfordshire Communications Group in place to support the management of consistent messaging to the public.

6.4.1 CCG On-Call Arrangements

The 24-hour arrangements for alerting managers and other key staff are in place as per the CCG on-call system arrangements in/out of hours, which are as follows:

• All calls centrally received to the CCG on-call phone to be answered by the allocated Senior Manager/AD/Director on-call as per the centrally agreed rota

mailto:[email protected]



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• 09:00 – 17:00 Monday to Friday (in hours) – Day Manager on-call acts as first point of contact. Although the Director On-call maintains overall responsibility.

• 17:00 – 09:00 Monday to Friday, and weekends/BH (out of hours) – AD/Director on-call acts as first point of contact.

The contact details (including relevant key stakeholders) are updated on a 6-monthly basis as part of the review of the CCG on-call folder, and HR hold a list of all staff contacts which can be accessed remotely via the intranet.

6.4.2 Local Cooperation

The Major Incident Plan documents how the independent healthcare sector may be used in a disruptive incident to assist in service delivery. It also outlines how mutual aid from other NHS providers can be requested if a disruptive incident occurs.

6.5 Record Keeping

The processes for the listed actions below will be managed in accordance with the guidance as outlined in the Major Incident Plan, including details on how the;

• organisation will maintain their incident logs, and minutes of meetings during and after the meeting,

• post incident report will be produced including how a debrief will be held to identify lessons,

• lessons identified from the incident will affect future plans.



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Appendix 1 Business Continuity Management Policy Statement “Business Continuity Management (BCM) is an important part of NHS East and North Hertfordshire CCG’s risk management arrangements. The Civil Contingencies Act (CCA) 20041 identifies all CCGs as ‘Category 2 Responders’, and imposes a statutory requirement on each CCG to have robust BCM arrangements in place to manage disruptions to the delivery of services.

It is the policy of NHS East and North Hertfordshire CCG to develop implement and maintain a Business Continuity Management System (BCMS) in order to ensure the prompt and efficient recovery of our critical activities from any incident or physical disaster affecting our ability to operate and deliver our services in support of the NHS economy.

The aim of Business Continuity Management is to prepare for any disruption to the continuity of the business, whether directly - i.e. within the responsibility control or influence of the business, or indirectly - i.e. due to a major incident occurring to a partner, supplier, dependent or third party, or from a natural disaster.

It is recognised that plans to recover from any disruption must consider the impacts not only to our staff, premises, technology and operations, but that NHS East and North Hertfordshire CCG must also plan to maintain its brand, status, relationships and reputation.

Business Continuity arrangements should ensure that the CCG continues to meet i t s legal, statutory and regulatory obligations to its staff and to its dependent stakeholders. All NHS East and North Hertfordshire CCG departments are to continue to develop and implement BCM for their areas of business.

In order for this to be achieved, members of each department have been nominated as Business Continuity Leads to represent their part of the business for Business Continuity Management. These individuals are responsible for reviewing and maintaining the departmental Business Continuity arrangements within the CCG. To ensure that the BCMS fully meets the changing needs of the business all Business Continuity Plans will be exercised, reviewed and audited annually.

In accordance with the NHS England Guidance2, NHS East and North Hertfordshire CCG BCMS will be in accordance with and aligned to the ISO 223013.” …………………………………… …………………………… Beverley Flowers Date Accountable Officer

1 NM Government (2004) Civil Contingencies Act 2 NHS England (2013) Board Business Continuity Framework 3 ISO 22301 Societal Security - Business Continuity Management Systems – Requirements



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Appendix 2 Business Recovery Template Reason for Invoking Plan: Date: Time: Brief Summary of Situation: Department/s Affected: Other Organisations Involved / Alerted: Date:



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Actions Required (including Resources)

By Whom Communication requirements

Status Update

Immediate:

Within 8 Working Hours:

Within 1 Working Day:

Within 3 Days:

Within 1 Week:

Situation to be reviewed every ……….. hrs / ……. days



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Appendix 3 Real Time Assessment Template: This form should be completed, during a Major Incident that has affected your working environment, based on the information within the Business Impact Assessments (Appendix 5) and sent to your Executive Director.

Functional Area (Directorate/Team): Prioritisation category

Essential/ Priority Area (Linked to BIA categories)

Current Impact

Actions Required (workaround including resources, who is to carry out the activity and communications)

Status Update

Serious impact within the next 24 hours with no work around

Serious impact within the next 24 -48 hours with no work around

Work around that will cover for next 3 days

Work around that is sufficient for >3days

No impact within next 7 days or longer

Situation to be reviewed every ……….. hrs / ……. days



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Appendix 4 Key CCG Contacts

On Call Member Role

1 SUNDAY ADENIYI Deputy Chief Finance Officer

2 DENISE BOARDMAN Director of Primary Care

3 HARPER BROWN Director of Commissioning (currently STP secondment)

4 JO BURLINGHAM Assistant Director Operations

5 SHARN ELTON Director of Operations

6 SARAH FEAL Company Secretary

7 BEVERLEY FLOWERS Accountable Officer

8 JAMES GLEED Associate Director Commissioning Primary Care

9 EDWARD JAMES AD Financial Services

10 RACHEL JOYCE Medical Director

11 NUALA MILBOURN Assistant Director of Communications

12 GERRY MOIR Associate Director of Performance

13 ALAN POND Chief Finance Officer

14 SHEILAGH REAVEY Director of Nursing and Quality

15 CATH SLATER Assistant Director of Quality and Patient Safety

16 HEIN SCHEFFER Director of Workforce, HR & OLD Shared Services

18 TRUDI SOUTHAM Assistant Director of Locality and CCG Commissioning,

19 PAULINE WALTON Assistant Director - Head of Pharmacy and Medicines Optimisation

20 PHIL TURNOCK ICT Shared Service Director, HBL ICT

21 SAM WILLIAMSON Public Health Consultant



Page 25 of 48

Appendix 5 Business Impact Assessments - Summary The full Business Impact Assessments can be accessed via the local network drive and CCG intranet. CRITICAL FUNCTIONS*:

Operations Directorate: • Operations and Resilience Team p.26 • Continuing Healthcare p.27 • Locality Team p.28

Nursing and Quality Directorate: • Quality Team p.29 • Pharmacy and Medicines Optimisation p.32

Finance Directorate: • Finance (Financial Services, Contracting, Information Team) p.34 • Governance and Corporate Affairs Team p.36 Primary Care Development p.37 Medical Directorate and Programme Office p.38

Chief Executives Office - Communications and Engagement p.39 Hertfordshire, Bedfordshire and Luton CCGs HR and ODL p.43 Shared Service Hertfordshire, Bedfordshire and Luton ICT Shared Services p.44 Integrated Health and Care Commissioning Team p.45

Contingency - Priority for the Restoration of Services [Recovery Time Objective (RTO)]: 1. Critical: Immediate Response - Danger to staff and/or patients. Prevents

provision of an essential service/function 2. Urgent: Within 8 hours – Will degrade to ‘Critical’ if not addressed within this

time band 3. Essential: Within 24 hours – Major disruption – no danger to staff and/or

patients. Does not prevent provision of an essential service/function 4. Important: Within 3 days – Will affect services without causing danger to

patients 5. Necessary: Within 7 days – Minor disruption to services 6. Routine: Within 14 days – Will not directly disrupt services but will cause

inconvenience 7. Non-Urgent: Within 28 days – Will involve non-urgent repair



Page 26 of 48

Directorate/Team: OPERATIONS: Operations and Resilience Team Key Contacts: Sharn Elton – Director of Operations

Jo Burlingham – Associate Director of Operations and Resilience Phil Lumbard – Assistant Director Urgent Care Jo Field – Head of Performance Solomon Brown (CCG EPPR Lead and BC Lead for team)

Essential/Priority activities undertaken: Risk to activities: A – Activities which must be continued

A1 Provide System Leadership Quality of services and experiences of our patients System oversight

A2 Maintain emergency and day to day operational management

A3 Maintain on call response in and out of hours

A4 Maintain category 2 responder role

B – Activities which could be scaled down if necessary

B1 Performance oversight and delivery

Quality of services and experiences of our patients System oversight

C – Activities which could be suspended if necessary

C1 Attendance at external meetings where the CCG is a partner

Partnership working Service developments/ Decision Making



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Directorate/Team: OPERATIONS DIRECTORATE – Continuing Healthcare Team Key Contacts: Sharn Elton – Director of Operations

Alison Sansom – Assistant Director CHC Chris Colgan – Retrospective Team Manager Alison Rees – Business Process Manager Gill Borg – Commissioning Manager


A1 Responding to new fast track referrals (case management of care packages) to ensure safety and wellbeing of patients

If not responded to on the same day there could be a risk to patient care and a delay in discharge effecting patient flow in and out of the acute sector.

A2 Ensuring CHC functions are performed in relation to procurement of placements

Those individuals won’t be in receipt of appropriate package of care or would be delayed within a hospital setting.


B1 Responding to new non-fast track referrals (adults case management of care packages)

Delays in transfers of care or risk of patients having an inadequate package of care at home.

B2 Ensuring eligibility and maintenance of Funded Nursing Care process

Care homes will not be reimbursed in a timely manner.


C1 Case management or reviews Delay in review process resulting in patients possibly having inadequate package of care at home.



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Directorate/Team: COMMISSIONING: Localities and Commissioning Team Key Contacts: Sharn Elton - Director of Operations

Gerry Moir – Interim Associate Director Commissioning and Locality Development (from 1 December 2018)


A1 Coordination of Primary Care Capacity and Liaison with Area Team (NHSE)

Managing access to primary care and impact on secondary care, A&E etc.

A2 Responsiveness to commissioned services for urgent patient specific queries/clinical management

Impact on timeliness in providing advice

A3 Urgent communications to Primary Care

Public Health Communications / Significant Service Provision Failure / Serious Incidents

A4 Primary Care Quality Assurance

Delay in investigating / resolving patient safety concern.


B1 Approval mechanism to authorize payments by finance directorate

Impact on ability to meet financial obligations re payments and risk of Primary Care service disruption

B2 Management of Locality Meetings and Target Events

Impact on ability to maintain clinical engagement and locality focused commissioning/decision making

B3 Service Redesign/Development Programmes

Delay in delivery of quality and performance improvements

B4 Performance monitoring for CF /Enhanced Services

Risk that local targets will not be monitored against agreed timescales.

B5 Research management and development

Failure to discharge statutory duties with resultant loss of income/ delay to clinical studies.


C1 Non urgent meetings Disruption to CCG/Directorate programme of work

C2 Strategic healthcare estates planning

Failure to meet DH Target dates and missed opportunities to secure national funding.



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Directorate/Team: NURSING AND QUALITY Key Contacts: Sheilagh Reavey – Director of Quality and Nursing

Cath Slater – Associate Director, Nursing and Quality Rosie Connolly – Quality Manager Claire Jackson – Quality Manager Geraldine Woods – Clinical Funding Manager Kelly Young – Quality Manager Mary Emson - Designated Nurse Safeguarding Shiobhan Appleton - Deputy Designated Safeguarding

Childrens Nurse Chantelle Stockwell – Deputy Designated Safeguarding

Childrens Nurse Sally Orr - Children’s Commissioner


A1 Responding to urgent safeguarding/LAC alerts, issues & requests for consultation at Designated Nurse level

If alerts, issues not actioned potential safety risk to patients

A2 Complaints and PALS; responding to and actioning urgent concerns raised

If urgent issues not addressed, potential harm to patients could occur

A3 Hotline enquiries relating to patient safety or urgent issues


A4 Serious Incidents; any new SIs identified to be shared with providers for immediate action and investigation


A5 Infection Control – Outbreak management; including PIR’s (for MRSA)


A6 Responding to CQC inadequate judgements of primary care facilities, for patient safety reasons


A7 Participating in Risk Summits If urgent issues not addressed, potential harm to patients could occur

A8 Escalating issues raised as a result of safeguarding or homicide reviews that are likely to attract press interest.

If Exec team and comms are unaware potential for reputational damage to the CCG.

A9 Agree any urgent requests for funding for children with additional needs

If urgent issues not addressed, potential harm to patients could occur – providers would be expected to go ahead with care at risk if necessary.



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B1 Full range of statutory functions for safeguarding adults and children, eg SARS, DHRS, SCRS etc. Notifications to Designated counterparts for LAC placed out of area

Statutory requirements may not be met Delay in learning from incidents, deaths etc. Other providers’ work held up. Risk that Looked After child could have difficulties accessing health services in local placement

B2 Complaints and PALS; routine processing of enquires received

Local and national targets may not be met, patients dissatisfied with service provided and concerns remain unresolved.

B3 Serious Incidents; co-ordination and review of provider Sis, Datix inputting

National timescales may not be met. Risk that quality issues in provider RCAs may not be identified, affecting learning from SIs

B4 Hotline; processing of routine enquiries

Risk that local targets will not be met. GPs dissatisfied with service and key themes not identified.

B5 Infection Prevention & Control: HCAI case reviews & surveillance, C-Difficile appeals

Statutory requirements may not be met, delay in identifying lower level risks, providers have delay in appeal outcome decisions

B6 Quality Assurance; undertaking Quality Review Meetings, Quality Visits, analysing and monitoring providers in relation to wide range of quality standards such as LAC IHA’s, Quality Schedule requirements etc.

Lack of assurance to CCG, may be delay in identifying quality issues. Direct impact on patients if processes such as LAC IHA or acute trust target performance deteriorates.

B7 Individual Funding Requests, Prior Approval and Choice;; processing of funding requests and providing patient choice service (NB Urgent CFT requests not graded in section A above due to protocol enabling retrospective agreement in cases where delay will lead to significant harm)

Risk that procedures will be undertaken that would not have been approved for funding. Risk that patients will not be offered choice. Risk that protocol not followed, leading to patient harm.



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B8 Attendance at multi agency panel for funding childrens packages of care could be virtual if required

Reliant on remote IT working such as RAS tokens and IT connectivity.


C1 CQUIN/ Quality Schedules; on-going monitoring and contract negotiation cycle

Lack of development of schemes could affect future provider contracts. Performance issues may not be identified in a timely way, however key issues would be identified via alternative functions.

C2 Regular reporting to Quality Committee, Governing Body, localities etc

Low risk, key issues and headlines would be shared with committees and GB as required.

C3 External & internal meetings on wide range of quality & clinical topics

Lack of assurance to CCG, may be delay in identifying quality issues. Lack of progress on areas of quality improvement Staff effectiveness may be reduced due to lack of coordination.

C4 C4a – Staff training C4b – Training delivery

Lack of development of staff, Lack of updating, if mandatory training risk that local targets/national requirements may not be met; loss of money if training place already booked. Lack of development of provider trust etc. staff, loss of money if venue etc. already booked



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Directorate/Team: NURSING AND QUALITY: Pharmacy and Medicines Optimisation Team

Key Contacts: Sheilagh Reavey – Director of Quality and Nursing Pauline Walton - AD Pharmacy & Medicines Optimisation Sue Russell - Lead Pharmacist (CCG Localities) Stacey Golding - Lead Pharmaceutical Adviser (Governance) Maxine Davis - Lead Pharmaceutical Adviser Colin Sach - Lead Pharmaceutical Adviser


A1 The provision of clinical support and personnel for ‘front line’ patient facing services at times of pandemic and/or other public health emergencies

Inappropriate/delayed clinical advice and treatment Financial risk

A2 Management of patient safety alerts and serious incidents

Risk to patient safety


B1 To ensure the provision of expert prescribing advice in a timely manner to GP practices, non-medical prescribers, pharmacists, Trusts and other commissioned services etc

Clinical risk, financial risk, reputational risk

B2 To ensure the strategic oversight of medicines optimisation and patient safety

B3 The provision of expert advice for example concerning clinical pathways

B4 Local/national initiatives such as raising antibiotic awareness

B5 Signing off invoices

B6 The provision of weekly clinical support to intermediate care beds in Woodlands and Knebworth Nursing Homes and Westgate Care Centre

No medicines reconciliation, patients in intermediate care not receiving the correct medicine.

B7 Individual treatment requests, high cost drugs and invoice validation

Financial risk if drugs are funded that would not normally be approved. In breach of NICE guidance



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B8 The provision of expert advice to CCG commissioners on the managed entry of new medicines and medical devices

Risk of judicial review Reputational risk

B9 Clinical medication reviews of care home patients

Limit to responding to urgent queries


C1 The oversight of financial management in respect of prescribing and medicines usage

C2 Locality prescribing meetings, Hertfordshire Medicines Management Committee, Primary Care Medicines Management Group

C3 Monitoring of prescribing, key performance indicators

C4 Non-medical prescribing approval of applications and support for prescribers



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Directorate/Team: FINANCE: Financial Management Contracting Information Team Financial Services

Key Contacts: Alan Pond - Chief Finance Officer Sunday Adeniyi - Financial Management [BC Lead] Holly Fairhurst - Contracting Edward James - Financial Services David Hodson – Information


A1 Management of the DoS DoS unable to be re-profiled A2 Authorisation for patient

transport Delays to authorising transport requests

A3 Payments to key suppliers / NHS Trust and other healthcare providers.

Payments to staff, key supplies to services & service disruption


B1 Access to invoicing and payments system within 3 days

CCG unable to meet the BPPC target. Cash flow issues to small suppliers.

B2 Monitoring financial position within 3 days (within 1 day if within first week of month)

Unable to provide support to provider organisations

B3 Monthly reports to NHSE and Annual Accounts (if the latter in March or April)

Loss of reputation, failure to achieve CCG statutory duty

B4 Finance support to commissioning

Loss of financial control/ delays in agreeing contracts if January/ February/ March

B5 Financial planning Delays in meeting National timetable for agreeing contracts/investments/savings

B6 Response to FOIs Delay in responding to FOIs resulting in breaches

B7 Sending monthly validations to Providers

Financial loss to CCG if providers are not in agreement to revise deadlines for validations to be submitted

B8 Contract sign off No contract in place between CCG and Providers

B9 Enacting Contract Levers (Information Breach Notices and Contract Performance Notices)

Delays to implementing contract levers

B10 Scale down payments frequency and move to

Loss of Reputation. Cash flow issues to small suppliers. Possible impact on delivery



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urgent payments only goods and services. B11 Extend the time between

reviewing and reconciling ledger to key control accounts

In the short term ledger may not be a true reflection of spend. Cash forecast targets may not be achieved

B12 Decisions for primary medical care applications, for example, list closures

Unable to meet contractual timescales to decide on outcome to list closures


C1 Monthly reports to Governing Body and localities

Loss of financial control if long period

C2 Finance support to business cases and localities

Delays in proceeding with investments or wrong decisions taken

C3 Production of monthly budget statements re running costs

Loss of financial control if long period

C4 Attendance at Contract Review Meetings with Providers

Unable to hold Providers to account and implement contractual levers where required

C5 Credit control Short term cash issues



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Directorate/Team: FINANCE DIRECTORATE – Governance & Corporate Affairs Team Key Contacts: Alan Pond – Chief Finance Officer

Sarah Feal – Company Secretary Jas Dosanjh – Corporate Governance Manager (Mat Leave Jan’20) Nakiya Jafferji – Corporate Governance Manager Leon Adeleye – Interim Corporate Governance Manager


A1 Day to day management of On-call rota

Risk that in/out of hours response will not be available

A2 Letter of claim related to C2 needs to be sent to NHS Resolution within 24 hours

Risk is that CCG will not be adequately protected from litigation claims


B1 Coordination of FOI responses within specified timescale

If target not met, action could be taken by Information Commissioners Office

B2 Reporting of IG breeches within specified timescale

If target not met, action could be taken by Information Commissioners Office

B3 Administration of meetings – minutes/ papers for the Governing Body, Governance and Audit Committee, Quality Committee, Primary Care Commissioning Committee, IG Forum

Loss of record of accountability / decision making/ record keeping / public record

B4 Managing Conflicts of Interest Requirement to declare in accordance with Health and Social Care Act. CCG Constitution requirement to keep register up to date.


C1 Managing Gifts and Hospitality Register

Reporting requirement to Governance and Audit Committee

C2 Coordination of Clinical Negligence Cases from Solicitors to enable reporting to NHS Resolution

14 day turnaround with NHS Resolution

C3 Updating of policies/procedures

Staff wellbeing - access to current guidance

C4 Coordination of the Assurance Framework and Corporate Risk Register updates

Information may not be current, however updated three times/year, low risk

C5 Coordination of Internal Audit reports/recommendations

Head of Internal Audit opinion, if the CCG can’t provide assurance for implementation of recommendations

C6 Administration of the Data Security Protection toolkit

Around annual reporting time (end of Mar)



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Directorate/Team: PRIMARY CARE DEVELOPMENT Key Contacts: Dee Boardman – Director for Primary Care Development

James Gleed - Associate Director Commissioning Primary Care Andrew Tarry – Head of Primary Care Development Sarah Walker – Primary Care Workforce and Education

Programme Manager Essential/Priority activities undertaken: Risk to activities: A – Activities which must be continued

A1 Payments to extended access primary care service providers.

Healthcare providers cannot pay staff resulting in clinical services are cancelled.

A2 Urgent communications to /from primary care.

Primary care providers fail to receive urgent information potentially affecting patient care and service provision.


B1 Seasonal influenza vaccination monitoring and reporting.

Practices unaware of vaccination coverage of their eligible patients leaving patients vulnerable to flu and flu related illnesses.

B2 Payments to federations against other funding streams e.g. £1.50 transformation money.

Delays to the implementation of new services & care models, projects and initiatives.

B3 Staff line management, personal development and appraisal.

Staff inadequately supported to competently fulfil role. Negative impact on staff wellbeing and welfare.

B4 Primary Care Resilience and Transformation panel /fund.

Practices that are in need of urgent assistance experience delays in receiving the required help resulting in service destabilisation and failure.


C1 Primary care workforce planning and education. Including training events and administrative tasks e.g. invoice payments and official reporting (HEE/NHSE)

Delay in the upskilling of workforce and the development of staff succession planning. Delays in assurances regarding progress GPFV and GPN 10PP programmes.

C2 Reporting to NHS England and NHS Digital on GPFV.

NHSE unable to obtain assurances of CCG performance /progress on key GPFV programmes.

C3 STP primary care work programmes.

Reduced progress in transformation of primary care across STP.

C4 Non-urgent meetings. Disruption to CCG /Directorate business.



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Directorate/Team: MEDICAL DIRECTORATE AND PROGRAMME OFFICE Key Contacts: Rachel Joyce – Medical Director

Sam Williamson – Locum Associate Director Stephen Madden – Head of Programme Office Trudi Southam – Associate Director


None identified


B1 Administration of meetings – minutes/ papers for OPD, Long Term Conditions Committee, Stroke Programme Board

Loss of record of accountability / decision making/ record keeping / public record/ access to important documents on the network drive

B2 Attendance at meetings Loss of face to face to contact as part of normal business processes

B3 Telephone access Reliance on email or face to face contact with relevant colleagues


C1 Reporting of projects and work streams

Lack of information to commission and plan services.

C2 Usual place of work Not all staff have remote access working



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Directorate/Team: CHIEF EXECUTIVES OFFICE: Communications and Engagement Team

Key Contacts: Beverley Flowers – Chief Executive Dr Prag Moodley – GB Chair Nuala Milbourn – Assistant Director for Communications Susan Haigh – Communications Manager Gemma McKelvey – Communications Manager Ewan Maddock - Web development and digital communications

officer Mark Edwards – Patient Engagement Manager Lauren Hague - Communications & Engagement Officer Fiona Winspear - STP Communications Manager Elma Maxim-Shortt - STP Communications Manager Lorna Hamblin - STP Communications Manager

The communications team fulfils the following functions: • strategic advice • media management • reputational management • stakeholder management • public affairs – e.g. providing parliamentary briefings • campaigns • brand and corporate identity • event management • online communications – to staff, patients and practices • publications • locality communications • internal communications

The team maintains clear, up-to-date and accurate information for patients, member practices and staff through a variety of appropriate channels. This is particularly important during critical incidents, pandemics and other business critical situations. Protect the reputation of East and North Hertfordshire CCG and the local health system during critical incidents, pandemics and other business critical situations. For example: Communications to GP practices about service disruption, service suspensions or other issues affecting business continuity


A1 acute in-hours home visiting service

This would mean that GPs continue to refer very poorly patients to the acute in-hours visiting service when there is no capacity for them to be visited at home.

A2 problems with capacity at the hospital trust

GPs would be unaware that hospital systems are struggling and patients referred to A&E could experience a long wait for



Page 40 of 48

treatment. As a result they might not seek alternative treatment pathways for their patients.

A3 appeals for doctors to assist with additional shift with Herts Urgent Care

GP practices would not be able to encourage GPs to make themselves available for additional shifts to help Herts Urgent Care to deliver services at pressurised periods.

A4 information about industrial action

CCG guidance on the implications of industrial action for primary care would not be issued directly to practices.

A5 severe weather advice and guidance

Severe weather information and advice for patients and practices – such as heatwave information for vulnerable patients or changes to pathology sample collection times due to bad weather, could not be issued

A6 loss of referral routes or services due to factors outside of the CCG’s control plus out breaks of norovirus, etc.

Urgent changes to referral information, such as a loss of a particular fax or phone number due to technical problems, could not be communicated to practices, which would mean that patients would not be able to access the services they need.

A7 disruption to GP services Patients and carers would not be aware that their planned or emergency GP services are not available

A8 disruption to hospital services Patients and carers would not be aware that their planned or emergency hospital visits would not be possible

A9 disruption to pharmacy services

Patients and carers would not be aware that they could not visit the pharmacy to collect essential medication.

A10 Proactive and reactive communications to the media about issues which could have a negative impact on the CCG’s reputation as a commissioner of NHS services

The CCG’s stakeholders and the public would lose confidence in the organisation and the services we commission.



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A11 Communications to GPs and health professionals on policy and protocol updates, including updating the clinical pathways which is accessed through the CCG’s GP website

Clinicians across Herts would not have the up-to-date referral information that they need for patients.

A12 Supply urgent briefing material in response to requests from NHS England’s Parliamentary hub.

ENHGCC would not be able to account for its actions to Ministers and MPs in the House of Commons.

A13 Communications to the public and the media via the CCG’s website, STP website, the New QEII Hospital website, media releases and social media about service disruption, service suspensions or other issues affecting services the public rely on


B1 The GP bulletin could be shifted across to the GP website

Some of the functionality of the GP bulletin, such as the open rate information and information on which articles have been read, would be lost

B2 The staff magazine could be replaced by all-staff emails covering urgent issues specifically.

Staff morale could be negatively affected and the open rate of all-staff emails could decrease.

B3 Proactive campaign and event work could be scaled down.

The impact and reach of the CCG’s own campaigns and our support for national campaigns would be diminished. This would mean that fewer people receive important health and wellbeing information.

B4 The extent of partnership communications work could be scaled back.

This could lead to confusion and duplication of messages or important messages being missed.

B5 Scheduling of planned social media campaigns could cease. Only reactive responses to social media requests

Any consultations or engagement activity would have to be extended.

C – Activities which could be

C1 The weekly staff round-up email could be suspended

Staff would not be as aware of policy updates, health stories in the media or



Page 42 of 48

suspended if necessary

training sessions. C2 The Friday learning hours Staff would not be as aware

of ‘bigger picture’ health and social care information which could have a positive impact on their day-to-day work or personal circumstances.

C3 The design and printing of leaflets could a) be contracted out to an agency or b) information could be provided on simple word documents instead.

A: This would be more costly and would probably take up more officer time than producing leaflets in-house. B: Information that is produced to a lower quality might not be as valued or trusted by patients.

C4 Suspension of patient and carer member meetings

Patient and carer members would not be aware of the issues facing local health services and communicate that to their communities



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Directorate/Team: HERTFORDSHIRE, BEDFORDSHIRE AND LUTON CCG’s HUMAN RESOURCES AND ORGANISATIONAL DEVELOPMENT AND LEARNING SHARED SERVICE

Key Contacts: Sharn Elton – Director of Operations (Executive Director for HBL HR & ODL)

Hein Scheffer, Director of Workforce Louise Thomas, AD HR and ODL Mandy Wilson, HR Business Partner Delphine Garr, Head of Organisational Development and

Learning Essential/Priority activities undertaken: Risk to activities: A – Activities which must be continued

A1 Delivering statutory functions, including staff pay

If staff are not paid on time, it may result in difficulties regarding their personal situation and/or non-/limited working

A2 Performing HR functions ensuring ability to respond to basic HR issues and concerns, including staff wellbeing

Risk of employment tribunal if could not perform HR functions.

A3 Maintenance of HR compliance for safety of the organisation and staff

Risk of litigation and fines from violation of regulations and lack of compliance.

A4 Recruitment of staff to core functions

Potentially a gap if critical core functions not recruited to (clinical safety, staff wellbeing)


B1 Management of ER cases/issues

Legal challenge where management is not within set timescales.

B2 Reporting to the Executive regarding adherence to statutory governance arrangements

Risk of being unable to roll out a statutory change within required timeframe.


C1 Corporate Induction training programme

Risk new starters wouldn’t receive some of their mandatory and not gain the understanding of how the CCG operates.

C2 Policy reviews Risk that they would not be conducted within required time frame.

C3 Mandatory Training such as IG training & Learning and Development.

Risk of IG breach due to lack of training and non-compliance with regulations.

C4 Joint partnership forum Risk of industrial action.



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Directorate/Team: HERTFORDSHIRE, BEDFORDSHIRE AND LUTON ICT SHARED SERVICES

Key Contacts: Alan Pond – Chief Finance Officer (Executive Director for HBL ICT)

Phil Turnock – ICT Director Simon Carey – Associate Director – ICT Operations Keith Fairbrother – Head of Technical Services Alex McLaren – Head of Governance, Risk and Compliance


A1 Core Infrastructure Services and Connectivity Services

Loss of IT systems

A2 Service Desk Unable to receive and process ICT incidents

A3 Messaging / Unified Comms (inc email)

Loss of IT systems

A4 Clinical Applications (Externally hosted)

Loss of IT systems

A5 B – Activities which could be scaled down if necessary

B1 Procurement, Finance Loss of IT systems B2 Asset Management Loss of IT systems B3 File and Print / Other

Applications


C1 None identified



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Directorate/Team: INTEGRATED HEALTH AND CARE COMMISSIONING TEAM

Key Contacts: Sheilagh Reavey - Director of Quality and Nursing Simon Pattison - Head of Service, Integrated Health and Care

Commissioning Team

Key

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s Fu

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r? (Y

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Description of Impact

What if the key

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Crit

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Pro

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Tim

e (1

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Justification/Comm

ents (inc.

critical times or

year, regulatory or other

deadlines)

Mitigation and Contingency Plans / Arrangements in

Place Suggested Actions and

Strategies to reduce Likelihood / Impact

Minimum Resources (including staffing),

Equipment & Information

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Key

con

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, res

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1 1 1 1 2 2 3 4 5

2 w

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Initial work can continue due to abilities to work from other areas and meetings can be rescheduled. However, the longer the impact the more difficult it becomes to carry out key business functions effectively

Alte

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Head of department on call to make decisions and co-ordinate response - supported by Senior Commissioning Managers (SCMs). The SCMs will then involve staff within their teams where appropriate. 1 laptop and mobile phone for Head of Department - minimum requireme for first 48hrs. Access to emails an shared drive and BCP required for Head of Departmen

Sim

on P

attis

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Yve

tte R

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ts


Page 46 of 48

Appendix 6 Equality Analysis - Equality Impact Assessment Screening Form

Name of policy/service

Business Continuity Plan

What is it that is being proposed?

Annual update to the Business Continuity Plan, in line with legislative and/or administrative changes

What are the intended outcome(s) of the proposal

Plan to be ratified and adopted by the CCG

Explain why you think a full Equality Impact Assessment is not needed

This policy is a high-level business continuity plan. It does not directly impact on people who have, or share, a protected characteristic. The actions it identifies as essential and/or priority include actions that ensure that there is no or minimal impact on people who have a protected characteristic should the plan need to be implemented.

On what evidence/information have you based your decision?

There is no scope within the plan for differential impact based on a person’s protected characteristic status

How will you monitor the impact of policy or service?

The plan will be monitored via exercise and testing every two years; incident management will account to testing and exercising, in accordance with the processes defined within the Major Incident Plan (including testing with dependent stakeholders).

How will you report your findings?

Reporting to Governing Body via the annual EPRR Core Standards Assessment, when this plan is submitted for approval,

Having considered the proposal and sufficient evidence to reach a reasonable decision on actual and/or likely current and/or future impact I have decided that a full Equality Impact Assessment is not required. Assessors Name and Job title Date

Jas Dosanjh – Corporate Governance Manager, Solomon Brown – EPRR Lead October 2018

Assessment reviewed: Name/Title: Paul Curry – Equality and Diversity Lead Date: 09 November 2018 Comments: Agreed sign-off of screening tool


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Appendix 7 Data Protection Impact Assessment – Initial Screening tool Project/Service Name of the Project or Service Business Continuity Plan

Project Reference: Proposed Existing Date of Completion:

November 2018 Date of Review: November 2019

Who is likely to be affected by this project?

Staff Patients Public

Description of Service or Project:

The aim is to ensure prompt and efficient recovery of critical activities from any incident or physical disaster that may affect the CCG’s ability to operate and deliver their commissioning service in support of the NHS economy.

Identified benefits, quality expectations and intended outcomes:

The purpose is to outline the responsibility of the CCG and their staff in the event of a crisis in order to maintain as normal a service as practically possible.

Project/Service Lead Name: Job Title: Corporate Governance Manager /

EPRR Lead Department/Directorate: Governance / Operations Telephone Number: Email address: Information Asset Owner Name: Job Title: Director of Operations / Chief Finance Officer Department/Directorate: Operations / Finance Telephone Number: Email address: Screening Questions Yes No Explanation if yes Q1: Does the proposal involve the use of new technologies or the novel application of existing technologies?

Q2: Does the proposal involve the use of new personal data or the reuse of existing personal data for a new purpose?

Q3: Does the proposal involve data matching, combining, comparing or linking of personal data from multiple sources?


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Q4: Does the proposal involve the sharing of personal data with multiple organisations?

Q5: Does the proposal involve the use of profiling, automated decision making or special category data to make decisions about an individual’s access to a service?

Q6: Does the proposal undertake profiling on a large scale (Estimate numbers if in excess of 100 individuals)?

Q7: Does the proposal involve the processing of genetic, biometric or other special category data?

Q8: Does the proposal involve the processing of children’s personal data for marketing purposes, profiling, automated decision-making, or if you intend to offer online services directly to children?

Q9: Will the proposal involve the systematic monitoring of a publicly accessible area?

Q10: Will the proposal involve the processing of personal data which could result in a risk of physical harm in the event of a data breach?

If Yes to any of the above have the risks been assessed, can they be evidenced, has the policy content and its implications been understood and approved by the Information Asset Owner?

N/A

Assessment to be reviewed by the Information Governance Lead: Name: David Hodson Date: 20-11-2018 Comments:

Assessment to be reviewed by the DPO or Caldicott Guardian: Name: Sarah Feal Role: Company Secretary and DPO Date: Comments: