business continuity plan2 cover · 2015-09-16 · page 2 of 3 impact on risk assurance framework:...
TRANSCRIPT
Enclosure: NAgenda item: 17
Governing Body
Title of paper: Business Continuity PlanDate of meeting: 23/09/2015Prepared by: Hellen Makamure Title: Interim Governance ConsultantPresented by: Diane Jones Title: Director of Integrated Governance
Summary of 2015-16 Corporate Objectives Supported by this Report (X)
1. To commission high quality, cost effective services to meet the needs of localpeople which improve health outcomes and reduce inequalities.
2. To ensure that the patients’ and public’s voice is heard so that we improve thequality of the services that we commission for the diverse needs of our population.
3. To develop Greenwich CCG as a clinically driven organisation with effective memberengagement, that can attract and retain excellent staff, deliver effective governanceand its full statutory and financial duties.
4. To create and optimise a data rich environment to inform commissioning decisionsat CCG, Transformation Steering Group, Syndicate and practice level.
5. To develop a long term approach to improving healthcare and delivering moreintegrated services for the population of Greenwich delivered by sustainable providersthrough partnership working with RBG, local providers, the community and voluntarysector.
Greenwich Clinical Commissioning Group is committed to meeting statutory requirementsaround emergency planning and Business Continuity as set out in the Civil ContingenciesAct 2004. All NHS Organisations need to have robust business continuity plans in place inorder to maintain their services to the public and patients and as part of their contractualarrangements as commissioners and providers of NHS funded care. This plan forms partof the NHS England EPRR Assurance Review Requirements for 2015/16.
Summary of Impact Assessment and Risk Management Issues (x)
Impact on Risk Assurance Framework (x) Yes x No N/AImpact on Environment (x) Yes x No N/ALegal Implications (x) Yes x No N/AResource implications (x) Yes x No N/AEquality impact assessment (x) Yes x No N/AImpact on current NHS Outcomes Framework areas (x) Yes No N/A xPatient and Public Involvement (x) Yes No N/A xCommunications and Engagement (x) Yes x No N/AImpact on CCG Constitution (x) Yes No N/A x
Page 2 of 3
Impact on Risk Assurance Framework: This plan has been developed as a risk reduction
measure for the CCG’s inability to continue delivering services during a Business Continuity
interruption and is linked to the EPRR risk.
Impact on the environment: Considered in the plan are contingencies relating environmental
hazards which may lead to business continuity incidents impacting on the CCG’s business
functions
Legal implications: The CCG is required to have Business Continuity Plans under the Civil
Contingencies Act 2004
Resource Implications: Business Continuity incidents may require resources to be mobilised from
less critical activities to business crucial activities. Extra resources in terms of staff, space and
equipment may be required as a result of a business continuity incident
Equality Impact Assessment: This has been carried out to ensure that this plan is fair and
equitable to all
Communications and Engagement: Key to this plan is the CCG’s communications arrangements
with staff and key stakeholders during, and after business continuity incidents
Plan objectives
The Business Continuity Plan lays down the processes to be followed in the event of an incident
which impacts upon the delivery of CCG functions by adopting a generic approach to such
incidents thereby meeting the following objectives:
Ensuring the continued delivery of critical functions during a business continuity
incident/interruption.
Identification of individual and organisation wide roles and responsibilities
Identification of communication processes and platforms during incidents
Identification of the escalation and de-escalation procedures for BC incidents
Setting out the procedures and a framework to mitigate the effects of identified risk areas.
Communication
Under the Civil Contingencies Act 2004, the CCG is required to communicate with members of the
public, partners and other stakeholders. Internal and external communication arrangements are
detailed in this plan in the event of Business Continuity interruptions.
Training and Exercising Requirements
The following testing and exercising arrangements will be mandatory to this plan:
6 monthly communications test
Annual table top exercise/ discussion to check arrangements are robust and fit for purpose
3 yearly live exercise which can be replaced by a live incident
Annual reviews for Assurance purposes by NHS England
The CCG Business Continuity work plan sits under the Integrated Governance Directorate.
Page 3 of 3
The Director of Integrated Governance is the Accountable Emergency Officer (AEO) for EPRR and
Business Continuity for the CCG.
Brief Summary of Recommendations
The Governing Body is requested to approve the CCG Business Continuity Plan
Greenwich CCG Business Continuity Plan
Public Sector Equality Duty
Equality and diversity are at the heart of the NHS Strategy. Throughout the productionof this document, due regard has been given to eliminate discrimination, harassmentand victimisation, to advance equality of opportunity, and to foster good relationsbetween people who share a relevant protected characteristic (as cited under theEquality Act 2010) and those who do not share it. This document therefore abides bythe Equality and Diversity Act 2010.
Author(s) Interim Governance Consultant
Version 0.1
Approval Date September 2015
Approving Body Governing Body
Review Date September 2016
Policy Category Operational
Policy Reference Number
Greenwich CCG Business Continuity Plan Page 2 of 42GB September 2015Version 0.1
Version Control
Version Author Date Reason for review
0.1 Hellen Makamure September2015
New Plan, Statutory Requirement
0.2 Hellen Makamure September2015
Updated Draft with comments fromRBG colleagues
0.3 Hellen Makamure September2015
Updated draft with comments fromDatix Project Manager
0.4 Hellen Makamure September2015
Updated Draft with comments fromHead of Analytical Support
Staff or Groups Consulted
Name Job Title
Diane Jones Director of Integrated Governance
Maggie Aiken Associate Director of Integrated Governance
Langley Gifford Associate Director of Integrated Commissioning
Vee Scott Associate Director of Communications and Engagement
Neil Taylor Head of Analytical Support
Judy Durrant Interim Head of Safeguarding Adults and Children
Andrew Coombe Interim Named Nurse for Adult Safeguarding
Carol Berry Compliance Manager
Kerry Cleaver Communications and Engagement Manager
Suleiman Banian Datix Project Manager
Ian Cheshire Emergency Planning & Resilience Officer (RBG)
Lynette Russell Head of Emergency Planning (RBG)
Jacqueline Lo Emergency Planning Officer – Oxleas NHS FT
Greenwich CCG Business Continuity Plan Page 3 of 42GB September 2015Version 0.1
Contents Page
1. Contents2. Glossary of Terms ............................................................................................... 5
3. Related Documents ............................................................................................. 6
4. Summary ............................................................................................................. 6
5. Introduction.......................................................................................................... 6
6. Aim ...................................................................................................................... 6
6.1 Objectives......................................................................................................... 7
7. Scope .................................................................................................................. 7
8. Business Impact Analysis .................................................................................... 7
8.1 Business Critical Functions .............................................................................. 8
9. Risk Analysis ....................................................................................................... 8
10. Generic Roles and Responsibilities.................................................................. 9
10.1 Specific Roles and Responsibilities............................................................... 9
10.2 Greenwich CCG Governing Body ................................................................. 9
10.3 Chief Officer .................................................................................................. 9
10.4 Director of Integrated Governance ................................................................ 9
10.5 Director of Finance...................................................................................... 10
10.6 Director of Delivery and Service Transformation......................................... 10
10.7 Business Continuity Operational Lead (Executive Manager) ...................... 10
10.8 All CCG Directors and Heads of Services................................................... 10
10.9 Associate Director of Communications ....................................................... 11
10.10 Human Resources ...................................................................................... 11
11. Activation Process and Incident Control Team............................................... 11
11.1 Business Continuity Incident Activation Flow Chart .................................... 12
11.2 Initial Actions ............................................................................................... 13
12. Full details of the Incident Control Room........................................................ 13
13. Roles and Responsibilities of the Incident Control Team ............................... 14
13.1 Alerting Process for staff ............................................................................. 14
14. Communication Cascade Tree ....................................................................... 15
15. Communications of Incidents ......................................................................... 15
15.1 Media Handling ........................................................................................... 16
16. Response and Recovery ................................................................................ 16
16.1 Handover .................................................................................................... 17
16.2 Stand down ................................................................................................. 17
16.3 Post Incident Actions................................................................................... 17
Greenwich CCG Business Continuity Plan Page 4 of 42GB September 2015Version 0.1
17. Finance........................................................................................................... 17
18. Incident Logs .................................................................................................. 18
19. Debriefing and Reporting................................................................................ 18
20. Disaster Recovery .......................................................................................... 18
21. Health and safety ........................................................................................... 19
22. Testing, Exercising and Maintenance............................................................. 19
Maintenance Training and Exercising Schedule ...................................................... 19
23. Training .......................................................................................................... 19
24. Review............................................................................................................ 19
25. Sources of Evidence....................................................................................... 20
Appendix 1: Business Critical Functions .................................................................. 21
Priority A- Business Critical Functions: Same day of incident............................... 21
Priority A- Business Critical Functions: Next working Day .................................... 21
Priority A- Business Critical Functions: Up to 3 working days............................... 22
Priority B- Business Critical Functions up to 1 week............................................. 23
Priority C- Business Critical Functions up to 2 weeks........................................... 24
Priority D-Business Critical Functions up to 1 month ............................................... 24
Appendix 2: Staffing Requirements to cover Prioritised/ Critical Activities ............... 26
Appendix 3: Suggested First Meeting Agenda ......................................................... 27
Appendix 4: Business Continuity Incident Control Team Key Tasks ........................ 28
Appendix 5 Action Cards.......................................................................................... 29
Incident Control Manager Action Card ..................................................................... 29
Incident Recovery Manager Action Card.................................................................. 30
BC Recovery Support Manager Action Card............................................................ 31
Communications Action Card................................................................................... 32
Telephone Operator Action Card ............................................................................. 33
Loggist Action Card.................................................................................................. 34
Appendix 6: Initial Response Checklist .................................................................... 35
Appendix 7: Business Continuity Contingency Plan................................................. 36
Business Continuity Risks and Action/ Contingency Plans ...................................... 37
Appendix 8: Key Contacts ........................................................................................ 39
Appendix 9: CCG IT Requirements .......................................................................... 40
Appendix 10: Equality & Equity Impact Assessment & EDS2 Checklist ............... 41
Greenwich CCG Business Continuity Plan Page 5 of 42GB September 2015Version 0.1
2. Glossary of TermsTerm Acrony
m
Definition
Business
Continuity
BC Strategic and tactical capability of an organisation to continue
delivery of services at acceptable predefined levels following a
disruptive event.
Business
Continuity
Management
BCM A holistic management process that identifies potential threats to
an organisation and the impacts to business operations that those
threats, if realised, might cause, and which provides a framework
for building organisational resilience with the capability for an
effective response that safeguards the interest of its key
stakeholders, reputation, brand and value creating activities.
Business
Continuity
Management
System
BCMS Part of the overall management system that establishes
implements, operates, monitors, reviews, maintains and improves
business continuity. This includes the organisational structure,
policies, planning activities, responsibilities, procedures,
processes and resources.
Business
Continuity Plan
BCP Documented procedures that guide the organisation to respond,
recover, resume and restore to a predefined level of operation
following disruption. Typically, this covers resources, services and
activities, required to ensure the continuity of critical business
functions.
Business Impact
Analysis
BIA The process of analysing activities and the effect that a business
disruption might have upon them.
Civil
Contingencies
Act 2004
CCA Covers the responsibilities for Category 1 and 2 responders who
provide strategic, tactical and operational response in
emergencies.
Business
Continuity
Incident Control
Team
BC ICT Comprises of senior managers/ directors who will manage an
emergency/ disruption/ crisis
Emergency
Planning
Resilience and
Response
EPRR The programme of work in preparation for respond to, a wide
range of incidents and emergencies that could affect health or
patient care while maintaining services as required by the CCA.
International
Organisation for
Standardisation
ISO
22301
The International Standard for Business Continuity management
systems providing guidance based on good international practice
for planning, establishing, implementing, operating, monitoring,
reviewing, maintaining and continually improving a documented
management system that enables organisations to prepare for,
respond to and recover from disruptive incidents when they arise.
Maximum
Tolerable Period
of Disruption
MTPoD 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. This is the duration after which an
organisation’s viability will be irrevocably threatened....”
Recovery Time
Objective
RTO The target time for resuming the delivery of a product or service to
an acceptable level following its disruption. This could be a
resumption of full service or a phased return over a period of time.
Greenwich CCG Business Continuity Plan Page 6 of 42GB September 2015Version 0.1
3. Related Documents Greenwich CCG Business Continuity Policy Greenwich CCG Emergency Planning Policy SE London Director on Call Handbook Human Resources Policy SEL CSU Business Continuity Plan
4. SummaryBusiness Continuity is the capability of an organisation to continue delivery ofproducts or services at acceptable predefined levels following a disruptive incident.Business Continuity Management (BCM) is the process of achieving businesscontinuity and is about preparing an organisation to deal with disruptive incidentsthat might otherwise prevent it from achieving its objectives.
BCM involves:
a) being clear on the organisation’s key products and services and the activitiesthat deliver them;
b) knowing the priorities for resuming activities and the resources they require;c) having a clear understanding of the threats to these activities, including their
dependencies, and knowing the impact of not resuming them;d) having tried and tested arrangements in place to resume these activities
following a disruptive incident; ande) making sure that these arrangements are routinely reviewed and updated so
that they will be effective in all circumstances.
Through business continuity, an organisation can recognise what needs to be doneto protect its resources (e.g. people, premises, technology and information), supplychain, interested parties and reputation, before a disruptive incident occurs.
5. IntroductionThe continued operation of Greenwich Commissioning Group (Greenwich CCG)depends on a given combination of people, space, processes and technology, inconnection with a given set of current business assets. Greenwich CCG seeks toprovide its services by following a strategic operational plan, the achievement ofwhich is dependent on effective business operations.
This plan is to be used to assist in the continuity and recovery of Greenwich CCG inthe event of an unplanned disruption. A disruption would be any event that threatenspersonnel, buildings or operational capacity and requires special measures to betaken to restore normal service.
6. AimThis plan aims to define the strategic and tactical capability of Greenwich CCG, toplan for and respond to major business interruptions, to enable Greenwich CCG tocontinue its business critical functions at an acceptable pre-defined and agreed level.To achieve this aim Greenwich CCG will adopt a system of Business Continuity
Greenwich CCG Business Continuity Plan Page 7 of 42GB September 2015Version 0.1
Management (BCM). This system is delivered following the structures outlined andagreed in Greenwich CCG’s Business Continuity Policy.
6.1Objectives To ensure the delivery of critical functions during a business continuity
incident/interruption. To identify individual and organisation wide roles and responsibilities To identify the communication processes and platforms during incidents To identify the escalation and de-escalation procedures for BC incidents To set out the procedures and a framework to mitigate the effects of identified
risk areas.
7. ScopeThis plan covers the alerting process, activation mechanism, roles andresponsibilities of the Business Continuity Incident Control Team, guidance relatingto command, control and recovery. This plan is flexible and meant to be used asgeneric guidance in the response to a business continuity incident/interruption. Itprovides suggested actions that might be effective in response. It does not cover alleventualities as is expected in Business Continuity Management.
This plan applies to the functions provided by Greenwich CCG at the following sites:31-37 Greenwich Park StreetGreenwichLondonSE10 9LR
8. Business Impact AnalysisActivities are disrupted by a wide variety of incidents, many of which are difficult topredict or analyse. By focusing on the impact of disruption rather than the cause,business continuity identifies those activities on which the organisation depends forits survival, and enables the organisation to determine what is required to continue tomeet its obligations.
To this effect, all critical and non-critical functions have been assessed anddocumented using a Business Impact Analysis (BIA). This will be reviewed andupdated on an annual basis based on the changes to the services provided byGreenwich CCG.
The Business Impact Analysis was developed through use of Greenwich CCG’s RiskManagement Strategy based on impacts caused by loss of services/ activities toGreenwich CCG and its stakeholders. The impacts considered included
Reputational impact Financial loss Breach of statutory duty/ inspections Negative impact on safety of patients, staff, public Negative impact on quality/ complaints/ audit Staffing and culture (poor morale)
Greenwich CCG Business Continuity Plan Page 8 of 42GB September 2015Version 0.1
The table below outlines the process of determining Greenwich CCG’s criticalservices and their order of recovery priority. All departments assessed each of theiractivities using the following criterion which forms part of their local level planning.
Figure 1: Priority Rating
Priority
Rating
Maximum
Tolerable Period
Of Disruption
Impact
A Up to next
working day
CCG services, which if disrupted would have catastrophic
effects on Greenwich CCG’s business objectives almost
immediately
but some services can operate with reduced resources for up
to 3 days
Up to 3 days
B Up to 1 week CCG services, which if disrupted would have major effects on
Greenwich CCG’s business objectives. Activities can be
scaled back for up to a week.
C Up to 2 weeks CCG services, which if disrupted would have moderate
impact on Greenwich CCG’s business objectives and can be
scaled back 2 weeks.
D Up to 1 month
and over 1 month
CCG services, which if disrupted would have negligible
effects on Greenwich CCG’s business objectives. They will
have minimal impact on Greenwich CCG for longer than a
month.
8.1Business Critical FunctionsThese are processes and activities which, if interrupted, will cause a business ororganisation to sustain a severe economic loss, or jeopardise the continuedexistence of the organisation or whose loss would cause an adverse outcome forpatients.
Greenwich CCG’s Business critical functions derived from the BIA are listed inAppendix 1 in order of Recovery Time Objectives. The minimum staffingrequirements for directorates/ departments are set out in Appendix 2.
Due to the nature of Greenwich CCG’s business cycle, the order of recovery mayvary as the criticality of certain activities is time sensitive, depending on the time ofthe year.
9. Risk AnalysisPossible and considered critical risks to Business Continuity for Greenwich CCG are:• Loss of staff• Loss of Information Technology and Telecoms• Loss of Facilities/Utilities and Buildings• Flooding/Severe Weather• Infectious Diseases (e.g. Pandemic Flu)• Fire• Disruption to Transport services (strike/ fuel shortage)• Industrial Action
Greenwich CCG Business Continuity Plan Page 9 of 42GB September 2015Version 0.1
10.Generic Roles and ResponsibilitiesThe broad structure of roles and responsibilities within Greenwich CCG for businesscontinuity management are detailed in Greenwich CCG’s Business Continuity Policy.In both planning and response, a team approach to all aspects of business continuityis preferable. The lead for BCM with the overall responsibility for business continuitywithin Greenwich CCG will determine representation from all levels of staff to theadopted system.
10.1 Specific Roles and ResponsibilitiesSpecific Greenwich CCG staff will have roles and responsibilities to fulfil as below. Aseries of Action Cards (Appendix 5) have been produced for each of the potentialrisk areas that set out the specific roles and responsibilities of staff members, actionsto take and in what order.
10.2 Greenwich CCG Governing BodyThe Governing Body is responsible for the following:
Endorsing/ approving the BCM Plan Ensuring BCM is appropriately resourced and embedded into the culture of
the organisation Scrutiny of the on-going review, maintenance and exercising of Greenwich
CCG Business Continuity arrangements
10.3 Chief OfficerThe Chief Officer has overall accountability of BCM across the organisation and formeeting the requirements of legislation and guidance and is responsible for thefollowing:
Liaising with executive members Activating/ Invoking the Business Continuity Plan Authorising expenditure Receiving updates on service impact Requesting mutual aid Authorising communications strategy and media statements Identifying and briefing internal and external key stakeholders Agreeing future meetings, format and frequency of these
10.4 Director of Integrated GovernanceThe Director of Integrated Governance is Greenwich CCG’s Accountable EmergencyOfficer (AEO) for Business Continuity and Emergency Planning. Theirresponsibilities include:
Chairing the Business Continuity Meeting (Incident Control Team) Confirming resource availability across Greenwich CCG and any
requirements Providing an overview of impact on Greenwich CCG Facilitating any mutual aid requests
Greenwich CCG Business Continuity Plan Page 10 of 42GB September 2015Version 0.1
Offering advice on EPRR matters if directly related to the BC incident Advising on data protection issues with support from the Caldicott Guardian Facilitating debriefing post incidents
At all other times, the Director of Integrated Governance should:
Ensure the organisation has robust BCM plans in place (response andrecovery)
Report on BCM to the Governing Body Ensure robust strategies for managing any incident/ event
10.5 Director of FinanceThe Director of Finance is responsible for:
Highlighting short/ medium and long term financial impact or requirements Authorising expenditures with Chief Officer’s agreement Leading and managing emergency spending cost centres and prioritising
urgent payment requests e.g. for equipment, staffing etc. Advising on Information security as the Senior Information Risk Owner (SIRO) Liaising with Head of Analytical Support to provide advice on impact on IT
infrastructure, downtime, recovery time/point objectives
10.6 Director of Delivery and Service TransformationThe Director of Delivery and Service Transformation is responsible for:
Advising on impact or breaches on contractual agreements Advising on short/medium and long term risks with contracts
10.7 Business Continuity Operational Lead (Executive Manager)Greenwich CCG BC Operational Lead who is the Executive Manager is responsiblefor:
Supporting and overseeing the production, maintenance, validation of theplan
Participating in the implementation of, and review findings from BCMexercises
Auditing the organisation's level of BCM preparedness
10.8 All CCG Directors and Heads of ServicesAll Greenwich CCG Directors and Heads of services are responsible for:
Having input into the Business Continuity Planning for their Directorates Ensuring all the staff are aware of their responsibilities / priorities regarding
BCM Facilitating communication cascades to their teams during an incident Report on overall resource issues
Greenwich CCG Business Continuity Plan Page 11 of 42GB September 2015Version 0.1
10.9 Associate Director of CommunicationsThe Associate Director of Communications and communications team areresponsible for:
Providing information to staff and external stakeholders Informing and advising members of the ICT of any potential reputational
issues Dealing with external media enquires Highlighting any issues around communication and platforms Supporting Greenwich CCG media spokes person Multi-agency liaison to ensure a common and consistent message across
partners Updating and liaising with other key stakeholders communications team such
as NHS England, Department of Health and Local Authority
10.10 Human ResourcesIdentified Human Resources representative is responsible for:
Updating on staff absenteeism and overall resource issues Ensuring HR policies in relation to absence/ special leave are followed Advising and assist with urgent recruitment matters for short term staff and
long term staff
11.Activation Process and Incident Control TeamFor the purposes of decision making in the event of a business continuity incidentGreenwich CCG Chief Officer has the ultimate responsibility for activating theBusiness Continuity Plan. In the Chief Officer’s absence, the Deputy Chief Officer,the Director of Integrated Governance or any member of the Senior Managementteam can activate this and request the Incident Control Team to meet.
Greenwich CCG may be alerted of a Business Continuity Incident via the On CallDirector or internally. Below is Greenwich CCG BC incident escalation procedureas detailed in the BC Policy.
Figure 2: BC Incident Escalation Procedure
Level Description Escalation
1 All services are operating normally None required
2 Disruption for a short period of
time
Utilise Action Cards- Escalate if situation
does not resolve.
Communicate the issue within Greenwich
CCG and relevant partners in case there is a
wider problem (small isolated problems when
aggregated may show a bigger incident on
the horizon)
3 Disruption to most CCG services
affecting the ability to provide
critical services
Inform Chief Officer and On call director-
CCG Internal incident declared. CCG BC
Plan invoked.
Greenwich CCG Business Continuity Plan Page 12 of 42GB September 2015Version 0.1
11.1 Business Continuity Incident Activation Flow Chart
Following activation of the Business Continuity Plan, the Incident Control Team (ICT)will convene in the Loft or available space.
Other choices will be:
Meet virtually using teleconference arrangements Use an alternative control room not previously identified but necessary due to
the nature of the incident. This could be the Chief Officer’s office or othersuitable space.
Greenwich CCG Business Continuity Plan Page 13 of 42GB September 2015Version 0.1
The composition of this team will vary depending on the type and scale of thebusiness continuity incident and its actual/potential impact on the organisation.
These Officers will include: The Chief Officer Deputy Chief Officer/ Director of Strategy and Performance Chief Finance Officer Director of Integrated Governance Director of Delivery and Service Transformation Business Continuity Operational Lead- (Executive Manger) The Head of Analytical Support may be included in the team where incident is
IT related. A representative from Human Resources may be included where incident
relates largely to staffing issues
In the absence of these Officers, their deputies will have the authority to invoke theBusiness Continuity Plan.
11.2 Initial ActionsOn being alerted, the Chief Officer is responsible for:
Directing the agreement of roles and initial tasks for members of the IncidentControl Team
Agreeing on the best location(s) for dealing with incident or whether the bestoption is a virtual meeting
12.Full details of the Incident Control Room1a. Greenwich CCG Offices The Loft
31-37 Greenwich Park Street
SE10 9LR
Business Continuity Accountable Officer : Director of Integrated Governance
Main Incident Control Room number : 02030499091
Communications Number: 07799072242
Communications Email: [email protected]
Contingency Plan: In the event of CCG Corporate Office being affected by the incident or
because the control room needs to be nearer the incident a virtual meeting will suffice.
1b. Virtual
meeting
arrangements
Teleconferencing
arrangements
08447620762
Chair and Participant code :
41872#
Alternative partner premises may be used with agreement where there is room available and
also in case of multi- agency issues arising from Greenwich CCG BC issue
Greenwich CCG Business Continuity Plan Page 14 of 42GB September 2015Version 0.1
13. Roles and Responsibilities of the Incident Control TeamThe Business Continuity Incident Control Team is there to ensure the following (Keytasks detailed in Appendix 4 and initial response checklist in Appendix 6):
Evaluate the extent of the situation and the potential consequences tobusiness continuity
Provide the Executive Members with reports of the scale/impact on normalservices posed by the incident
Maintain a decision log based on the response to the incident. Authorise the recovery procedures in order to maintain the strategic critical
functions of Greenwich CCG Liaise with users and stakeholders who may be involved with the incident. Communicate with relevant partners and stakeholders Arrange for the order of new or replacement equipment to deliver critical
services if required consulting with Finance regarding this (a log of expensesshould be kept)
Establish the return to normal working; (or new normality) after the incidentresponse phase has concluded using recovery plans already establishedwithin each individual Service Level Business Continuity Plan.
Ensure that any backlog created will be the responsibility of local servicemanagers.
13.1 Alerting Process for staffManagers will verbally or by email or text, communicate information to staff on site orby telephone/mobile to staff away from the office. If it is out of hours, managers willsend group text messages to staff (Please refer to Communication Cascade tree).Each line manager will hold their staff’s telephone numbers for Business Continuitypurposes.
Greenwich CCG Business Continuity Plan Page 15 of 42GB September 2015Version 0.1
14.Communication Cascade Tree
Director on Call for SE London CCGs will inform other CCGs
15.Communications of IncidentsThe Communications Team will send accurate and consistent messages and adviceto staff and other stakeholders regarding any BC Incident as agreed by the ChiefOfficer and the BC ICT.
Greenwich CCG Business Continuity Plan Page 16 of 42GB September 2015Version 0.1
Messages sent out during a BC Incident will be clear and advise that the incident isreal (this is not a test/ exercise). Below is an example of a message which may besent out during a Business Continuity Interruption.
“An incident has occurred at Greenwich CCG, which is affecting our service delivery.Greenwich CCG, in partnership with other organisations, is working to resolve thesituation as quickly as possible”.
The Chief Officer or nominated deputy with support from Communications will:
Be responsible for activating communications with other agencies includingthe emergency services (if necessary)
Act as media spokesperson if this is required Agree the frequency of sending out messages and statements; press releases
and platforms of communication internally and externally
15.1 Media HandlingBC Incidents may attract media attention. The Communications team staff will liaisewith the Incident Manager and prepare press releases as necessary. Out of Hours,Greenwich CCG communications function is provided by SE CSU.
The Incident Manager (may nominate an alternative media spokesperson who willnormally be a member of the BC ICT if the incident requires it.
The media spokesperson will be supported by the Communications Team whosemain duties will include:
Advising and supporting the media spokesperson Fielding and dealing with initial media enquiries Organising media releases and other public statements Organising media briefings where appropriate Monitoring information reported in the public domain
16.Response and RecoveryOnce a Business Continuity Incident has been declared, the Incident Control Teamwill devise a phased recovery based on the time frames indicated in the BusinessImpact Analysis.
Following an incident, Greenwich CCG may need to undertake a number oforganisational recovery activities which may include but are not limited to thefollowing:
Identifying appropriate support mechanisms which can be made available tostaff, recognising that staff may be affected directly by the incident
Staffing and resources to address the new environment Reviewing key priorities for service provision and restoration Financial implications, remunerations and commissioning agreements Routine annual performance targets Equipment or restocking of supplies
Greenwich CCG Business Continuity Plan Page 17 of 42GB September 2015Version 0.1
The BC Incident Control Team will refer to the appropriate individual contingencyaction plans (see Appendix 7) in response to an incident where it relates to a risk orthreat identified.
16.1 HandoverIn a prolonged incident it may be necessary for additional members to be brought into cover the roles of the Incident Control Team. These will be the identified deputiesand if unavailable additional suitable senior management can be called in. They willbe briefed on key issues and actions taken up to that point.
16.2 Stand downThe Chief Officer or Accountable Emergency Officer (AEO), in agreement with theother members of the Incident Control Team and appropriate operational managersand staff will decide when to stand down.
After ensuring that the BC incident has been resolved, the AEO will be responsiblefor activating the cascade of the stand down message to all staff and agenciesinvolved using communication cascade call trees.
Prior to the stand down being agreed it is essential that all recovery issues andactions are agreed and activated to assist in the return to normal workingarrangements.
16.3 Post Incident ActionsIt is advised that the AEO or Chief Officer arranges for the following post an incident:
a. Ensure internal debriefs are conducted as soon as possible after the incidentb. Contribute and participate in any debriefs led by NHS Englandc. Prepare reports such as:
Incident logs from loggist staff Compile a short incident report to include learning points and
recommendations Circulate lessons learned to Incident Control Team and BC Manager
for assimilation into the revised corporate BC pland. Ensure Directors implement Recovery Plans for areas where non-critical work
was suspended to redeploy staff into critical services where necessary.e. Ensure there is a system in place to deliver the backlog of work along with
current workload issues to assist in the return to normal working
17.FinanceAll decisions relating to Finance will be logged clearly especially where spending isincurred. This responsibility is managed by the Director of Finance as a member ofthe Incident Control Team.
Greenwich CCG Business Continuity Plan Page 18 of 42GB September 2015Version 0.1
18. Incident LogsA log of all Business disruptions/interruptions/incidents e.g. power,telecommunications, water etc. will be maintained. These will be recorded even if aBusiness Continuity Incident is not declared.
All Business Continuity Incidents/Disruptions will be reported to Greenwich CCGBusiness Continuity Operational Lead (Executive Manager) by e-mail within 24 hoursof a minor incident or immediately if a “Business Continuity Incident” is declared.
19. Debriefing and ReportingThe AEO or Chief Officer is responsible for providing Situation Reports (SitREPs) toNHS England as required and providing a post incident report. Immediately after anincident has been stood down, the AEO or Chief Officer should coordinate ‘HotDebriefs’.
Hot Debriefs will allow:
Staff to express any concerns they may have following the incident The identification of staff who may be in need of support or counselling The organisation to thank staff for their efforts Organisational learning in an honest and open way
In addition to the Hot Debrief, a Full Incident Debrief should be called within 3 weeksof the incident. Any officer involved in the response to the incident may be called, asmay any associated external agencies. A full debrief report will be submitted to theChief Officer and to Greenwich CCG Governing Body. The debrief report should
Summarise any findings and recommendations Identify lessons to be learnt, and Identify any amendments to the BC Plan
Following the incident it will be necessary to review the BC Plan and implement anynecessary changes in management methods/processes as well as identify anypossible training needs.
20.Disaster RecoveryThe South East Commissioning Support Unit (CSU) provides InformationTechnology (IT) and telephony support to Greenwich CCG. In the event of any ITand telephony downtime, the CSU is contacted immediately. The Head of AnalyticalSupport leads on this.
Appendix 9 identifies the IT applications that are used within Greenwich CCG andthe Recovery Time Objectives as set out by directorates through the BIA process.These have been categorised into Priority Levels, 1, 2 and 3 depending on the RTO.
The main servers are located in Bermondsey and back up files are in thetriangulation of Lower Marsh and Wimbledon. The CSU Disaster Recovery Plan canbe located here:http://nww.southlondoncsu.nhs.uk/Resources/Pages/Policies.aspx?RootFolder=/Resources/Documents/ICT%20Policies&FolderCTID=0x012000DEA48E982618E341B3BBE6AC9CBB3062&View=%7b1B827514-4A0F-452B-8D1B-C8ACB9F611DB%7d
Greenwich CCG Business Continuity Plan Page 19 of 42GB September 2015Version 0.1
21.Health and safetyCare should be taken to manage any additional risks created by staff performingroles they do not normally do during the incident or its aftermath. A risk assessmentshould be completed for any areas of work which may present additional risks to thewelfare of staff.
22.Testing, Exercising and MaintenanceThis plan must be tested at least annually and the communications cascade shouldbe tested every six months. (See schedule below)
Following any exercise, incident or significant change to the organisation it will benecessary to review and update the plan with any lessons identified, gaps orchanges.
Maintenance Training and Exercising ScheduleScope of Review Frequency Responsible Lead
Light touch (Call Cascade) –check contact details are up todate and correct
Every 6 months CCG BC Operational Lead/Executive Manager
Implementing a changeprogramme
As required CCG BC Operational Lead/Executive Manager
Table top discussion/ exercise(formal review) – check to ensurethat all procedures are currentand still applicable
Every 12 months CCG BC Operational Lead/Executive Manager
Live exercise Every 3 years CCG BC Operational Lead/Executive Manager
Post incident/exercise review After everyexercise andincident
CCG BC Operational Lead/Executive Manager
23.TrainingGreenwich CCG Directors and senior managers will be involved in table topexercises annually to test Business Continuity arrangements for Greenwich CCGthrough various business continuity scenarios. All other staff will have access to aBusiness Continuity awareness guide available on Greenwich CCG intranet. This willalso be available to new staff as part of induction.
24.ReviewThis plan will be reviewed annually as required under the Business ContinuityManagement Standards ISO22301:2012.
Greenwich CCG Business Continuity Plan Page 20 of 42GB September 2015Version 0.1
25.Sources of EvidenceBC (2013) Business Continuity Best Practice Guidelines, London: BusinessContinuity InstituteBS ISO (2012) Societal Security. Business Continuity Management Systems-Requirements, BS ISO 22301:2012, London: British Standard InstituteBSI (2006) Specification for Business Continuity Management, BS 25999, London:British Standard InstituteCivil Contingencies Act (2004). c. 36, London: The Stationery OfficeHealth and Social Care Act (2012), c.7, London: The Stationery OfficePAS 2015 (2012) Framework for Health Service ResilienceNHS Commissioning Board Business Continuity Management Framework (serviceresilience) (2013)NHS Commissioning Board Command and Control Framework for the NHS duringsignificant incidents and emergencies (2013)NHS Commissioning Board Core standards for Emergency Preparedness,Resilience and Response (EPRR)
Greenwich CCG Business Continuity Plan Page 21 of 42GB September 2015Version 0.1
Appendix 1: Business Critical FunctionsDue to the nature of Greenwich CCG’s business cycle, the order of recovery mayvary as the criticality of certain activities is time sensitive, depending on the time ofthe year
RTO= Recovery Time Objective / MTPOD= Maximum Tolerable Period of Disruption
Priority A- Business Critical Functions: Same day of incident
Directorate/Dept. Activity RTO MTPOD
Non AcuteCommissioning
Management of EPRR issues e.g. surge andcapacity issues
Same day ofincident
Nextworking day
Non AcuteCommissioning
Responding to operational issues in providerswhich impact service delivery to patients
Same day ofincident
Nextworking day
Non AcuteCommissioning
Responding to alerts regarding the quality of care(safeguarding) or of the environment for patientsin receipt of CHC and fully funded Nursing Care
Same day ofincident
Nextworking day
IntegratedGovernance
Business Continuity (development of CCGarrangements and support during incidents) Immediately Same day
IntegratedGovernance
Emergency Planning (development of policiesand resilience requirements) Supporting withguidance Immediately
Same day ofincident
Finance / IT Maintenance of NDriveSame Day ofIncident 2 days
Communications
Supporting the Incident Control Team in theevent of an EPRR or BC incident 4 hours
Nextworking day
Priority A- Business Critical Functions: Next working Day
Directorate/Dept Activity RTO MTPOD
Non AcuteCommissioning System resilience planning
Nextworking day 1 week
FinanceFinancial Accounting (Statutory Accounts /Payments - invoices & payroll)
Nextworking day 3 days
Finance/IT Maintenance of YDD36M552- SQL ServerNextworking day 1 day
Finance/ IT Maintenance of YDD36M551- Reports serverNextworking day 1 day
Communications Internal communicationsNextworking day 3 days
CommunicationsMaintain CCG website - external communications
Nextworking day 3 days
CommunicationsReceive and manage Media enquiries
Nextworking day 3 days
MedicinesManagement
Advice to local health Professionals on MedicinesManagement
Nextworking day 1 week
Greenwich CCG Business Continuity Plan Page 22 of 42GB September 2015Version 0.1
Priority A- Business Critical Functions: Up to 3 working days
Directorate/Dept. Activity RTO MTPOD
Non AcuteCommissioning
Commissioning Delivery Plan and operationalimplementation 3 days 1 week
Non AcuteCommissioning Point of contact for legal reactive work 3 days 1 week
IntegratedGovernance Complaints, MP Letters and enquiries 3 days
Over 1month
IntegratedGovernance
Corporate services (Admin pool X7) provision of adminsupport to Directors and directorates 3 days 1 week
IntegratedGovernance Reception (Front of house) 3 days 1 week
Communications Annual General Meeting 3 days 1 week
Communications Annual engagement report to NHS England 3 days 1 week
Communications Maintenance of CCG intranet 3 days 1 week
MedicinesManagement
Maintain Database for Prescription Support Tool- ScriptSwitch 3 days 1 week
MedicinesManagement
Regular Practice Visits to support in-house work(management and audit) 3 days 1 week
MedicinesManagement
Work with other stakeholders in agreeing guidelinesand formulary regarding medicines Management 3 days 1 week
MedicinesManagement
Medicines Safety Officer Responsibility making surethere is a reporting mechanism to MHRA 3 days 1 week
SafeguardingAdults and Children
Providing safeguarding advice and support to GPs,providers and other agencies 3 days 1 week
SafeguardingAdults and Children
Responding to serious incidents, serious case reviewsand safeguarding adults reviews 3 days 1 week
ClinicalEngagement &Membership
Primary Care Transformation (Developing GP providernetworks) 3 days 1 week
Greenwich CCG Business Continuity Plan Page 23 of 42GB September 2015Version 0.1
Priority B- Business Critical Functions up to 1 weekDirectorate/Dept. Activity RTO MTPOD
FinanceFinancial Management (Budgeting/Budgetary Control/Reporting) 1 week 1 week
FinanceFinancial Strategy (Financial Strategy / Support to businesscases) 1 week
1month
FinancePerformance (Activity Reporting / Statutory Returns /Business Case Support / Strategic Planning / QIPP 1 week 1 week
Finance Risk Management 1 week 1 weekIntegratedGovernance Managing Freedom of Information (FOI) requests 1 week
2weeks
IntegratedGovernance Management of the Corporate Risk Register 1 week
2weeks
IntegratedGovernance Management of Board Assurance Framework 1 week
2weeks
Finance/ IT Maintenance of 10.161.211.242- DISCRO Server (CSU) 1 week2weeks
Non AcuteCommissioning
Timely and accurate payments of Providers of servicescommissioned by CCG 1 week
1month
Non AcuteCommissioning
Provision of data to support contract monitoring andmanagement and forecasting of contractual position
1 week1month
Non AcuteCommissioning Undertaking legal assessments including CHC and reviews 1 week
1month
IntegratedGovernance Equalities (EDS implementation) 1 week
Over 1month
IntegratedGovernance Quality Services (Management of Quality Alerts) 1 week
Over 1month
IntegratedGovernance Reviewing RCA Investigations/ Serious Incidents 1 week
1month
IntegratedGovernance
Management of the Incident Reporting System for CCGemployed staff 1 week
1month
IntegratedGovernance Managing reported HCAIs with Public Health 1 week
1month
FinanceFinancial Strategy (Financial Strategy / Support to businesscases) 1 week
1month
Communications Publications - Annual reports/ Integrated reports 1 week1month
Communications Receiving and managing FOIs 1 week1month
Communications Media campaigns - winter campaign 1 week1month
MedicinesManagement
Performance and Financial Reporting Practice Level andQIPP level 1 week
1month
Strategy andPerformance Quarterly meetings with NHS England 1 week
1month
Strategy andPerformance
Responding to NHS England on Performance Assuranceand Delivery 1 week
1month
Strategy andPerformance Monitoring Provider Performance 1 week
1month
Clinical Engagement& Membership Managing CCG Primary Care Steering group 1 week
1month
Non AcuteCommissioning Deprivation of Liberty Assessments 1` week
1month
Non AcuteCommissioning Safeguarding and monitoring of compliance 1 week
1month
Greenwich CCG Business Continuity Plan Page 24 of 42GB September 2015Version 0.1
Priority C- Business Critical Functions up to 2 weeks
Directorate/Dept. Activity RTO MTPOD
Strategy andPerformance
Programme and Project Management for individual workstreams e.g. Better Care Fund 2 weeks 1 month
ClinicalEngagement &Membership Organisational Development 2 weeks 1 month
Non AcuteCommissioning
Programme and performance management of QIPP andBCF 2 weeks 1 month
Strategy andPerformance Monitoring and Development of QIPP 2 weeks 1 month
Priority D-Business Critical Functions up to 1 monthThe Business Impact Analysis also identifies those functions that are less critical andcould be suspended for a period greater than 1month. These are documented in thetable below:
Directorate/ Dept. Activity RTO MTPOD
Non AcuteCommissioning Maintenance of robust contracting management 1 month
Over 1month
Non AcuteCommissioning Commissioning of Non-Acute care 1 month 1 month
Non AcuteCommissioning
Project and programme management for serviceredesign 1 month
Over 1month
Non AcuteCommissioning Quality Assurance Reporting to CCG Governing Body 1 month
Over 1month
Non AcuteCommissioning
Review of Action Plans in place to review areas of non-compliance with National contracts 1 month
Over 1month
Non AcuteCommissioning
Responding to NHS England on performanceassurance and delivery - TOP 8 1 month
Over 1month
Non AcuteCommissioning Procurement 1 month
Over 1month
Non AcuteCommissioning
Providing training support to care homes to buildoperational resilience and prevent LAS conveyance 1 month
Over 1month
IntegratedGovernance Contract Monitoring Meetings 1 month
Over 1month
Communications Facilitating Ministerial visits 1 month 1 month
Communications Facilitating public engagement events 1 month 1 month
MedicinesManagement
Analysing Prescription data on behalf of practices andshare quarterly 1 month
Over 1month
MedicinesManagement
Develop and disseminate monthly newsletter onprescribing including ad hoc news flash for veryimportant messages from Department of Health andNHSE 1 month
Over 1month
MedicinesManagement Work with the CSU regarding contract issues 1 month
Over 1month
Greenwich CCG Business Continuity Plan Page 25 of 42GB September 2015Version 0.1
Directorate/ Dept. Activity RTO MTPOD
Safeguarding Adultsand Children
Providing assurance to Greenwich CCG on providersafeguarding performance 1 month 1 month
Safeguarding Adultsand Children
Developing policy, procedures and safeguardingstrategies for Greenwich CCG and monitoringadherence to these 1 month
Over 1month
Safeguarding Adultsand Children
Attending relevant provider safeguarding meetings -seeking assurance on behalf of Greenwich CCG 1 month
Over 1month
Safeguarding Adultsand Children
Supporting multiagency safeguarding boards andpartnership working 1 month 1 month
Safeguarding Adultsand Children
Safeguarding training for CCG staff and providingtraining support to GP Lead for safeguarding 1 month
Over 1month
Safeguarding Adultsand Children
Ad hoc training for providers on safeguarding1 month
Over 1month
Strategy andPerformance
Providing Information to the Health and WellbeingBoard and Council 1 month 2 months
Strategy andPerformance Developing Organisational Direction/ Strategic Plans 1 month 3 months
Strategy andPerformance Supporting the Commissioning Cycle 1 month 3 months
Strategy andPerformance Monitoring of Constitution Standards 1 month
Over 1month
Clinical Engagement& Membership Workforce development in Primary Care 1 month
Over 1month
Clinical Engagement& Membership Facilitating GP Education and Training (PLT) 1 month
Over 1month
ClinicalEngagement &Membership
Engagement with GP membership aroundcommissioning matters and getting feedback. 1 month
Over 1month
Clinical Engagement& Membership
Clinical engagement and contracting commissioningproject leads 1 month
Over 1month
Clinical Engagement& Membership Helping GP surgeries with OT solutions requirements 1 week 1 month
Clinical Engagement& Membership Developing Primary Care strategy 1 month
Over 1month
Clinical Engagement& Membership CCG representation for coordinated care 1 month
Over 1month
Greenwich CCG Business Continuity Plan Page 26 of 42GB September 2015Version 0.1
Appendix 2: Staffing Requirements to cover Prioritised/ Critical ActivitiesThe following minimum staffing requirements were identified across the differentdirectorates within Greenwich CCG for a short period of time lasting up to 1 weekmaximum. (These requirements will be dependent on the nature of the incident, thetime of the year in relation to commissioning activities and duration; therefore mayneed to be scaled up).
Directorate/
Dept.
Minimum Staffing Requirements
Integrated
Governance
Director of Integrated Governance
Executive Manager
Compliance Manager
3 Admin staff
Safeguarding 1 Designated nurse for safeguarding Adults and Children
Communications Associate Director of Communications
Medicines
Management
1 Associate Director of Medicines Management
2 Prescribing Advisors
1 Pharmacy Advisor
1 Nurse
Finance Chief Finance Officer
2 Accounting managers
Information Manager- Head of Analytical Support
Strategy and
Performance
Associate Director of Strategy and Performance
Performance Manager
Staff should be able to communicate virtually where they are
working in different locations due to denial of access
Minimum staff of 4 over 2 weeks maximum
GP engagement
and membership
Head of Clinical Engagement and Membership Development
Primary Care Development Manager
Non Acute
Commissioning
Director of Service Delivery and Transformation
Associate Director of Service Delivery and Transformation
1 Commissioning Manager
Care Home
Support Team
Head of Integrated Commissioning
3 staff (will focus on key areas of the programme identified at the
particular time)
Continuing
Health Care
4 nurses (Mental Health; Learning Disability and 2 Adult Nurses)
GARRI Project 1 Nurse
Information
Management
Head of Analytical Support
1 Analyst
Greenwich CCG Business Continuity Plan Page 27 of 42GB September 2015Version 0.1
Appendix 3: Suggested First Meeting Agenda
Incident
Venue
Date & Time
1. Confirm the chair (AEO) if not available Deputy AEO
2. Set aims and objectives
3. Create a common understanding of the emergency and impact on Greenwich CCG
4. Agree the matters for urgent attention
5. Agree tasks and who is to lead on them
6. Establish communication and information links with other stakeholders
7. Consider the media strategy and messages to staff and other stakeholders
8. Identify and prioritise the strategic/ tactical risks
9. Consider long term operational issues – e.g. Team rota if incident likely to be over 8
hours
10. Agree frequency of meetings if future meetings are likely
11. Agree authorisation of expenditure
12. Any other Business
13. Date and Time of next meeting
Greenwich CCG Business Continuity Plan Page 28 of 42GB September 2015Version 0.1
Appendix 4: Business Continuity Incident Control Team Key Tasks1 Activate the Incident Control Room – plus agenda for first meeting
2 Risk assess the nature of the incident and its effects
3 Determine the size of the problem and establish the resources needed to deal with it
4 Ensure that arrangements are in place to ensure the safety of staff and clients;
5 Ensure all identified prioritised activities are able to continue throughout thedisruption. Immediate focus on Priority A (Critical Functions with an RTO of upto 3 days) then Priority B onwards.
6 Agree if necessary which non prioritised activities can be suspended and whenensure that MTPoD’s and RTOs are adhered to as per Service Level BIAinformation.
7 Take expert advice as appropriate;
8 Liaise with internal and external dependencies and stakeholders
9 Liaise with other organisation services and recovery teams if set up.
10 Agree communication arrangements between agencies
11 Consider who else needs to be notified / involved
12 Establish the second shift of members (post 8 hours) and notify as soon as possible.
13 Keep the Chief Officer informed on the management of the incident if not directlyinvolved with the response
14 Maintain accurate records
15 Consider the need for special recovery measures e.g. document recovery in floods
16 Consider the welfare of all staff engaged in managing the incident and arrangeappropriate relief
Recovery Focused Tasks
17 Declare the incident over and stand down staff
18 Conduct debriefs
19 Produce a detailed report of the incident.
Greenwich CCG Business Continuity Plan Page 29 of 42GB September 2015Version 0.1
Appendix 5 Action CardsIncident Control Manager Action CardNominated Person Role
Chief Officer/
Deputy
1. To liaise with Chief Officer or others regarding incident
2. To implement an initial risk assessment
3. To activate the Incident Control Team
4. To act as a spokesperson for Greenwich CCG at strategic
meetings and any possible media interviews
Having been alerted of a Business Continuity Incident, you need to consider what actions to
take. Use this action card as a checklist, but keep an accurate record of messages and
decisions given on your personal log
1 On being alerted of BC incident, confirm detail with On call Director (if this
is out of hours)
2 Obtain further information
3 Confirm steps being taken to mitigate effects/ impact
4 Implement risk assessment for scoping purposes
5 Alert others
6 Activate Incident Control Team
7 Act as a spokesperson for Greenwich CCG
8 Activate stand down following a response and inform Director On call
9 Initiate Debrief post incident
Greenwich CCG Business Continuity Plan Page 30 of 42GB September 2015Version 0.1
Incident Recovery Manager Action CardNominated Person Role
Director of
Integrated
Governance
To lead and manage the recovery response to a business
Continuity incident, establishing return to normal working
Having been alerted you now need to consider what actions are needed. Use this action
card as a checklist, but keep an accurate record of messages received or given on your
personal log sheet.
1 Agree responsibility and immediate actions with the Incident Control Team
Manager
2 Agree on operating base for the Incident Control Team
3 Alert incident team members - ask them to report to incident control room via
Communications Cascade.
4 Ask the BC Manager to set up the Incident Control Room
5 Convene a meeting of Incident Control Team – Agree Greenwich CCG
Priorities (Prioritised activities continuity as per service level recovery plans)
6 Maintain Liaison with all relevant departments during the response
7 Second meeting - establish second shift of ICT members post 8hrs
8 Staffing considerations ( with Recovery Support Manager)
9 At the end of the incident - Ensure Post Incident Report is prepared
Greenwich CCG Business Continuity Plan Page 31 of 42GB September 2015Version 0.1
BC Recovery Support Manager Action CardNominated Person Role
Business Continuity
Operational Lead-
(CCG Executive
Manager)
1. To set up the Incident Control room
2. To ensure there is adequate administrative support
3. Collect, Collate and display information
4. Arrange for loggist support
Having been alerted you now need to consider what actions are needed. Use this action
card as a checklist.
1 Agree roles and immediate action with Recovery Incident Manager
2 Alert essential administrative staff - ask them to report to incident control room.
3 Set up the incident control room
4 Maintain supervision of support team functions
5 Staffing considerations (with Recovery Incident Manager)
6 Ensure Loggists commence their role as soon as Incident Control Room is set
up
7 At the end of the incident - ensure closure of BC ICT meeting facilities
8 Attend debrief post incident
9 Prepare post incident report
10 Update Greenwich CCG Business Continuity Plan
Greenwich CCG Business Continuity Plan Page 32 of 42GB September 2015Version 0.1
Communications Action CardNominated Person Role
Associate Director
of Communications
/ Communications
Specialist
1. Manage incoming and outgoing communications
2. Ensure staff and stakeholders are regularly updated
3. Liaise with media platforms if required
4. Advise Business Continuity Incident Control Team
Having been alerted you now need to consider what actions are needed. Use this action
card as a checklist, but keep an accurate record of messages received or given on your
personal log sheet
1 Inform Log Keeper of your actions
2 Agree information to be shared out to staff and other stakeholders
3 Liaise with other media partners if required
4 Offer support and advise to the spokesperson for Greenwich CCG
5 Inform staff and stakeholders of stand down when declared
6 Attend debrief post incident
Greenwich CCG Business Continuity Plan Page 33 of 42GB September 2015Version 0.1
Telephone Operator Action CardNominated Person Role
To be agreed by the
ICT
1. To establish and maintain liaison with internal and external
services
Having been alerted you now need to consider what actions are needed. Use this action
card as a checklist.
1 Set up communications point
2 Take incoming calls
3 Process all incoming calls or requests with the Incident Control Team
4 Refer any media queries to the Communications Team
Greenwich CCG Business Continuity Plan Page 34 of 42GB September 2015Version 0.1
Loggist Action CardYour role Loggist
Your Base 31-37 Greenwich Park Street, SE10 9LR
Your
responsibility
You support the Incident Control Team and ensure a record or log of
the incident is maintained
Your immediate
actions
1. Proceed to the Incident Control Room as directed
2. Report to the Incident Manager for briefing
3. Arrange for all internal rooms to be made available as needed
4. Maintain a log of decisions taken, communications and actions
taken by the Incident Control Team
NB: The record must be in permanent black ink, clearly written, dated
and initialled by the loggist at the start of the shift.
All persons in attendance to be recorded in the log.
The log must be a complete and continuous (chronological record of all
issues/ options considered/ decisions along with the reasoning behind
those decisions/ actions.
Timings have to be accurate and recorded each time information is
received or transmitted.
If individuals are tasked with a function or role, this must be
documented and when the task is completed this must also be
documented.
On-going
management
Provide support services as directed
All documentation is to be kept safe and retained for evidence for any
future proceedings.
Stand down Participate in a “hot” debrief immediately after the incident and any
subsequent structured debrief.
Following stand down evaluate admin effectiveness and any lessons
learned and report these to the Incident Emergency Planning
Coordinator for inclusion in the report to the Chief Officer.
Greenwich CCG Business Continuity Plan Page 35 of 42GB September 2015Version 0.1
Appendix 6: Initial Response ChecklistTask Completed Date/ Time/
Owner
Start a log of actions and expenses incurred
Identify which prioritised activities have been disrupted
Consult with the Chief Officer or nominated deputy (if on
unavailable) about activating BCM plan.
Advise the EPRR Area Team & SEL Director On-Call That
Greenwich CCG has activated it’s BCM plan
Agree suspension of non-prioritised activities as per CCG BIA.
Convene Greenwich CCG Incident Control Team Evaluate impact
of situation
Identify any particularly urgent issues e.g. legal/
contractual timescales etc.
Decide on contingency actions to be taken (see Appendix
4)
Identify staff, resources, equipment etc. required Assign
responsibility and timescales
Assess if any implications impact further than Greenwich
CCG area
Inform staff
Inform relevant stakeholders (both internal & external)
Daily Tasks During the Recovery Process
Convene IC Team as necessary to monitor progress made,
obstacles encountered and decide on continuing recovery
process.
Provide updated information to staff & stakeholders
Maintain a log of action and expenses.
Appendix 7: Business Continuity Contingency Plan
Accountable Emergency Officer Diane Jones: Director of Integrated Governance
Location 31-37 Greenwich Park Street, London, SE10 9LR
Impact of general loss of service to
patients, staff and Greenwich CCG
Short term• Loss of day to day communications with member practices, partners, stakeholders• No progression of more strategic risk management issues with possible impact on patientsafety including Safeguarding Adults & Children• Inability to manage complaints and incident investigations as effectively• Inability to provide a robust response to emergencies and deliver Category 2 responsibilities• Reputational impact• Inability to provide critical functions• Financial services – at year end and critical payments
Medium term• Inability to ensure decisions are clinically driven• Potential to miss compliance with national targets• Inability to meet time-specific tasks such as FOI requests• Lack of new or redesigned services to meet public need• Financial payment targets may not be met and an impact on QIPP targets• Inability to performance manage contracts with service providers• Reputational damage
Long term• As above with higher risk to meeting financial balance, provision of services to meet the publicneed and bring care closer to home. Risk to reputation and morale of staff.• Loss of reputation
BC Action Plan Owner CCG Chief Officer: Annabel Burn
Deputy BC Champion Director of Integrated Governance - AEO
Business Continuity Lead: Operational Executive Manager
Business Continuity Risks and Action/ Contingency PlansRisk Contingencies and Actions
Reduced
staffing
Cause: This could be due to disruption to transport network, pandemic,
severe weather such a flooding/ snow/ heat wave
Consequences: Inability to fulfil normal day to day business and affecting
core functions
Contingencies/ Actions:
Emergency and home contact details held for staff and arrangements to
ensure core staffing
Provision for staff to work from home
Provision for staff to work from other CCG locations
Allow staff extra time to travel to work safely as per Policy
Use of agency staff where possible (is staff off for period of time)
If staff off sick due to severe weather, to follow Greenwich CCG
Sickness Absence Policy
Disruption to
Transport
system
Cause: This could be due to strike action, severe weather, fuel supply
disruption
Consequences: Some staff will not be able to travel into work or for
business purposes thereby impacting CCG business objectives
Contingencies/ Actions:
Provision for staff to work from home
Annual Leave as per special Leave Policy (July 2015) for staff who
cannot come into work or work from home or another site
Use of teleconferencing for meetings
Staff to reschedule non-urgent meetings
Identify staff who may be eligible for priority fuel supply
Disruption to
Information
technology
and
telephone
systems
Cause: this could be due to network failure which means IT cannot be
used, loss of electricity, flooding etc.
Consequences: Inability to use IT for specific IT reliant tasks which may
affect deadlines. Interruption to the communication systems in terms of
emails and telephone. Inability to communicate via the intranet
Contingencies/ Actions:
Contact South East CSU helpdesk on 0203049600 for solution and
estimated downtime
Refer to South East CSU ICT Business Continuity Plan and Data
Recovery Protocol.
Ascertain which network services are available and unavailable.
Communicate via telephone is phone lines are not affected
Staff to access emails via NHS Net mail web
If manual workarounds possible, staff to utilise these
Use mobile phones where possible if phone lines are affected
Communications can upload information on CCG website for staff and
general public.
Greenwich CCG Business Continuity Plan Page 38 of 42GB September 2015Version 0.1
Risk Contingencies and Actions
Utilities
failure i.e.
electricity;
water;
heating; air
conditioning
Cause: Disruption to electrical supplies may be due to severe weather or
technical faults. Water supply interruptions may result from technical faults
or system blockages.
Consequences: Where there is a prolonged period of loss of water or
heating, staff may be required to evacuate from the building due to Health
and Safety at work regulations. Loss of electricity will affect IT and
therefore CCG business objectives.
Contingency Actions:
CCG generator backup which is tested
Contact Oxleas on 01322 621019
In case of electricity supply problem, call UK Power Networks on 0800
028 0247 to report the problem or receive an update. Refer to UK
Power Networks guide for business.
In case of a loss of water supply, contact Thames Water on 0845 9200
800.
To report a water leak, contact Thames Water on 0800 714 614.
If air conditioning system is not working, in the event of high
temperatures, staff are advised to use the portable fans provided in the
building. Note that there is no maximum safe working temperature
in an office environment
Report air Conditioning faults to Oxleas on 01322 621019
If necessary, alternative working arrangements will be considered with
authorisation from Senior Management
Denial of
access to
building
Cause: This may be due to fire, flooding or police cordon
Consequences: Staff will be unable to access the building or forced to
evacuate in the event of a fire. Possible injuries in the event of a fire. This
will impact on normal day to day CCG business objectives and possibly
meetings being cancelled
Contingency Actions:
Staff to follow Fire Evacuation Policy
Fire alarms tested weekly
Mandatory training for staff
In the event of a flood, staff to work from other CCG location
Staff to work from home if able to
Patient Records are also available electronically (scanned versions)
Physical contracts are also available electronically
In the event of a fire, Fire Brigade will attend. Staff to call 999
Greenwich CCG Business Continuity Plan Page 39 of 42GB September 2015Version 0.1
Appendix 8: Key ContactsKey Contact/
supplier
Service Provided Telephone Email
NHS
England
EPRR 020 7932 3943
08448 222 888
NHS01- for
incidents
South East
London CSU
Information
Technology
02030496000 [email protected]
South East
CSU
Communications 02030493333
07876 448602
SEL Surge
hub
Surge & Capacity
management
02030049666 [email protected]
LGT
Emergency
Planning
Team
Lewisham Acute
Trust02083333000 [email protected]
Oxleas NHS Foundation
Trust
01322625700 [email protected]
NHS
Property
Services
Site maintenance 020 3049 4229 [email protected]
Oxleas
Estates &
Facilities
Cleaning and
Estates
01322 621019 [email protected]
Allsec Security 0870 033 3391 [email protected]
Royal
Borough
Greenwich
Local Authority 020 8921
6258/ 020
8921 5868/
020 8921 6339
Out of hours:
020 8921 4449
Fax:
020 8921 6267
emergencyplanningunit@royalborough
greenwich.co.uk
Greenwich CCG Business Continuity Plan Page 40 of 42GB September 2015Version 0.1
Appendix 9: CCG IT RequirementsIT
Application
Directorate Recovery Time
Objective
Alternative
Priority Level 1
NHS Net All 1 hour in the absence
of Outlook
Internet
Explorer
All 1 hour Immediate for
Communications
Citrix All 4 hours
MS Office All 4 hours
One Note Strategy and
Performance
1 day
Workforce Strategy and
Performance
1 day Can use Excel
N Drive All 1 day
SQL Server Finance 1 day
Reporting
Server
All 1 day
Telephone
Lines
All 1 day Mobile phones
SBS Finance / Strategy and
Performance
1 day
Priority Level 2
Datix Integrated Governance 3 days
StEIS Integrated Governance 3 days
Script Switch Medicines
Management
3 days
EPACT Medicines
Management
3 days
Nuance PDF
Professional
Strategy and
Performance
3 days
Access DB Strategy and
Performance
3 days
Microsoft
Visio
Strategy and
Performance
3 days
WinZip Strategy and
Performance
3 days
Microsoft
Publisher
Strategy and
Performance
3 days Can use Excel/word
Microsoft
Project
Strategy and
Performance
3 days
Priority Level 3
PAMS Integrated Governance 1 week
QAMS Integrated Governance 1 week
Priority Level 4
Microsoft
SharePoint
workspace
Strategy and
Performance
1 month
Greenwich CCG Business Continuity Plan Page 41 of 42GB September 2015Version 0.1
Appendix 10: Equality & Equity Impact Assessment & EDS2 Checklist
This is a checklist to ensure relevant equality and equity aspects of proposals 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 an EEIA which is 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 an EEIA is required and to give assurance that the proposals will
be legal, fair and equitable.
The word proposal is a generic term for any policy, procedure or strategy that requires assessment.
Challenge questions Yes/No What positive or negative impact doyou assess there may be?
1. Does the proposal affect one group more or lessfavourably than another on the basis of:
Race No
Pregnancy and Maternity No
Sex No
Gender and Gender Re-Assignment No
Marriage or Civil Partnership No
Religion or belief No
Sexual orientation (including lesbian, gaybisexual and transgender people)
No
Age No
Disability (including learning disabilities,physical disability, sensory impairment andmental health problems)
No
2. Will the proposal have an impact on lifestyle?
(e.g. diet and nutrition, exercise, physical activity,substance use, risk taking behaviour, education andlearning)
No
3. Will the proposal have an impact on socialenvironment?
(e.g. social status, employment (whether paid or not),social/family support, stress, income)
No
4. Will the proposal have an impact on physicalenvironment?
(e.g. living conditions, working conditions, pollution orclimate change, accidental injury, public safety,transmission of infectious disease)
yes Improved safety for patients and staff
5. Will the proposal affect access to or experience ofservices?
(e.g. Health Care, Transport, Social Services,Housing Services, Education)
yes Improved services through continuity ofservices
By using evidence and insight to assess and grade our equality performance, NHS Greenwich cangenerate much of the information we will require to demonstrate compliance with the PSED. Thechecklist is to enable the policy lead and the relevant committee to see if a particular policy or project
Greenwich CCG Business Continuity Plan Page 42 of 42GB September 2015Version 0.1
will provide the relevant evidence to assist NHS Greenwich CCG meet the set out EDS goals toachieve better outcomes for patients and staff. Please assess your policy, project or service againstthe following:
The goals and outcomes of EDS2
Description of outcome Yes/
No
Better health outcomes 1.1 Services are commissioned, procured, designed and delivered to meet the health
needs of local communities
Yes
1.2 Individual people’s health needs are assessed and met in appropriate and
effective ways
No
1.3 Transitions from one service to another, for people on care pathways, are made
smoothly with everyone well-informed
No
1.4 When people use NHS services their safety is prioritised and they are free from
mistakes, mistreatment and abuse
Yes
1.5 Screening, vaccination and other health promotion services reach and benefit all
local communities
No
Improved patient
access and experience
2.1 People, carers and communities can readily access hospital, community health or
primary care services and should not be denied access on unreasonable grounds
Yes
2.2 People are informed and supported to be as involved as they wish to be in
decisions about their care
No
2.3 People report positive experiences of the NHS Yes
2.4 People’s complaints about services are handled respectfully and efficiently No
A representative and
supported workforce
3.1 Fair NHS recruitment and selection processes lead to a more representative
workforce at all levels
No
3.2 The NHS is committed to equal pay for work of equal value and expects
employers to use equal pay audits to help fulfil their legal obligations
No
3.3 Training and development opportunities are taken up and positively evaluated by
all staff
No
3.4 When at work, staff are free from abuse, harassment, bullying and violence from
any source
No
3.5 Flexible working options are available to all staff consistent with the needs of the
service and the way people lead their lives
No
3.6 Staff report positive experiences of their membership of the workforce No
Inclusive leadership 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting
equality within and beyond their organisations
No
4.2 Papers that come before the Board and other major Committees identify equality-
related impacts including risks, and say how these risks are to be managed
Yes
4.3 Middle managers and other line managers support their staff to work in culturally
competent ways within a work environment free from discrimination
No
Policy Author Signature: H Makamure Date:26/08/2015
Equalities Lead
Signature: Date: 28.08.15