Civil Contingencies Act Compliance

Meeting: Trust Public Board

Date: 08.11.2023

Report Title: Civil Contingencies Act Compliance - 2023/24 Emergency Preparedness, Resilience and Response Core Standards and Interoperable Capabilities Annual Self-Assessment Outcome

Agenda Item: 2.2

Link to strategic risk(s):

• SR1a: If we do not ensure our people are safe and their wellbeing prioritised, there is a risk that we will be unable to attract, retain and keep all our people safe and well SR1b: If we do not ensure our leaders are developed and equipped, there is a risk that we will not be able to change our culture, and value, support, develop and grow our people
• SR2: If we do not deliver operational and clinical standards then there is a risk of poor patient outcomes and experience
• SR3: If we do not ensure we have the ability to plan, influence and deliver across our systems to secure change, we will not be able to meet the needs of our public and communities
• SR4: If we do not resolve long standing organisational inefficiencies we will be unable to deliver an effective, sustainable, value for money service to our public
• SR5: If we do not clearly define our strategic plans we will not have the agility to deliver the suite of improvements needed
• SR6: If we do not deliver sustainable regulatory compliance and develop positive relationships, we will have limited ability to deliver our strategy

Equality impact assessment: No negative impact identified

Recommendation: The Trust Public Board are requested to note the self-assessed Substantial Compliance rating for both the EPRR Core Standards and the Interoperable Capabilities. The Board is also asked to note the key issues identified. A full action plan has been developed and progress is being managed via the Performance and Finance Committee. Further resources will need to be determined through detailed review of the plans and Manchester Arena Inquiry recommendations and presented as separate business case requirements when these are determined. These will need subsequent consideration to achieve all required actions, likely to also require external commissioner support for funding.

Previously considered by

• Chief of Clinical Operations
• Deputy Chief of Clinical Operations
• Head of Emergency Preparedness and Specialist Operations
• General Manager - Resilience and Specialist Operations
• Executive Leadership Team
• Self-assessment return approved

Purpose: NHS England is responsible for gaining assurance on the preparedness of the NHS to respond to incidents and emergencies, while maintaining the ability to remain resilient and continue to deliver critical services. This is achieved through the Emergency Preparedness Resilience and Response (EPRR) annual assurance process. This process is directly aligned to the Civil Contingencies Act 2004 and therefore The Trust, as a category one responder, has a legal responsibility to meet the standards and is subject to the full set of civil protection duties.

Executive summary

The East of England Ambulance Service is required, as a Category 1 responder, to complete an annual self-assessment assurance process against the NHS Emergency Preparedness, Resilience and Response (EPRR) Core Standards and Interoperable Capabilities.

This year the standards comprised of 73 Core Standards, of which 58 are applicable to Ambulance Services and 164 Interoperable Capabilities, of which 136 are applicable to Ambulance Services. There was a requirement for EEAST to complete a deep dive element this year which focuses on training and training needs, of which there are 10 standards. The Trust self-assessment achieved Substantial compliance with the Core Standards and Substantial compliance with the Interoperable Capabilities. The deep dive element is not counted towards the overall rating, but we achieved 5 compliant and 5 partially compliant.

The Executive Leadership approved the self-assessment return on Tuesday 22 August 2023. The self-assessment and associated documents were submitted to our Lead ICB - Suffolk and North Essex, on the 24 August 2023. The Deputy COO, Head of EPRR and Specialist Operations and the Regional Business Continuity Manager completed a check and challenge session with EEAST on the 15 September 2023, where it was agreed that the self-assessment rating was correct and appropriate. A summary of the rating will be presented to NHSE Regional EPRR Team for onward processing and presentation to NHSE National EPRR and the National NHSE Board.

This report describes the outcome of the self-assessment, key issues identified and risks this relates to.

Introduction/ Background

NHS England EPRR Core Standards

The NHS core standards for EPRR are the basis of the assurance process. This year Domain 10 – Chemical, Biological, Radiological and Nuclear (CBRN) of the core standards has been reviewed and will also incorporate updated interoperable capabilities standards. The refreshed core standards can be found in the NHS core standards for EPRR self-assessment tool (separate document in support of this paper).

The Trust is required to undertake a self-assessment against the individual core standards and rate compliance for each.

The compliance level for each standard is defined as:

Fully compliant: Fully compliant with the core standard.

Partially compliant: Not compliant with the core standard. The organisation's EPRR work programme demonstrates evidence of progress and an action plan is in place to achieve full compliance within the next 12 months.

Non-compliant: Not complaint with the core standard. In line with the organisation's EPRR work programme, compliance will not be reached within the next 12 months.

Deep dive

Following key themes and common health risks raised as part of last year’s annual assurance process, the 2023/24 EPRR annual deep dive will focus on EPRR responder training. Training is a fundamental element of embedding resilience within organisations as part of the cycle of emergency planning.

The outcome of the deep dive will be used to identify areas of good practice and further development whist seeking additional assurance in this area of core standards and guide organisations in the development of local arrangements. The outcome of the deep dive is not included in the Trust overall rating.

Interoperable Capabilities

In addition to the EPRR Core Standards, all Ambulance Trusts are required to undertake a self-assessment against the Interoperable Capabilities. These are a set of specialist capabilities which are nationally specified under the NHS England EPRR Framework. These capabilities are interoperable between services. They must be maintained according to strict national standards to ensure they can be combined safely to provide an effective national response to certain types of incidents.

The interoperable capabilities include:

• Hazardous area response teams (HART)
• Special operations response teams (SORT)
• Mass casualty vehicles (MCV)
• Command and Control (C2)
• Joint emergency services interoperability principals (JESIP)

The criteria for each organisational rating are defined as: Fully: The organisation is fully compliant against 100% of the relevant NHS EPRR core standards Substantial: The organisation is fully compliant against 89-99% of the relevant NHS EPRR core standards Partially: The organisation is fully compliant against 77-88% of the relevant NHS EPRR core standards Non-compliant: The organisation is fully compliant up to 76% of the relevant NHS EPRR core standards

Overall assessment

Overall assessment: Substantially compliant - 89.6%

Interoperable capabilities: Substantially compliant - 95.5%

The number of core standards applicable to EEAST is 58 (out of 73), an increase from previous years of 50 due to the inclusion of Domain 10 – CBRN. The overall EPRR assurance rating is based on the percentage of core standards that organisations assess itself as being “fully compliant” with.

The number of interoperable capabilities applicable to EEAST is 136, a decrease from previous years due to the reconfiguration of the CBRN and MTA interoperable capabilities standards in line with the introduction of SORT.

The number of deep dive standards applicable to EEAST is 10. There is no comparison to previous years as the deep dive section is different each time. The Trust has assessed the 10 standards and has rated 5 as fully compliant and 5 as partially compliant.

This section is not rated and doesn’t count towards the outcome of this assessment. It should be noted that in previous years this section has been used to amend or create standards for full inclusion in future years so will likely have impact on our future compliance and requirements.

Key Issues/ Risks

• The capacity required of the Resilience and Specialist Operations Department to deliver all that is required of the EPRR Core Standards and Interoperable Capabilities, the compliance requirements of the legislative Protect Duty (which is passing through the legislative process at the moment), the Civil Contingencies Act, the requirements to implement the recommendations from the Manchester Arena Inquiry, the Ten Second Triage and Major Incident Triage Tool training and the extensive Business Continuity work required to bring the organisation in line with the ISO 22301 standards and EPRR core Business Continuity standards.
• The commitment and capacity of required members of staff and the senior leadership to undertake the required training and exercising as laid out in the Manchester Arena Inquiry recommendations, the EPRR Core Standards, the NARU Duty of Care Guidance and Interoperable Capabilities along with the Business Continuity ISO 22301 Standards.
• The Trust's ability and capacity to develop and embed a suitable incident command centre which meets the requirements of the EPRR Core Standards and the national guidance.

EPR0001 – If the Trust fails to comply with the Civil Contingencies Act 2004, the NHS Act 2006 and the Health and Social Care Act 2022 then the Trust will be in breach of its statutory obligations as a Category 1 responder. CRO0013 – If the Trust fails to embed appropriate and effective business continuity plans within the Emergency Operations Centres it will in in breach of the Civil Contingencies Act 2004 and may potentially cause patient harm. EPR0003 – If the Trust fails to effectively plan for Pandemic and High Consequence Infectious Disease events there is a risk that the Trust will not have the ability to provide a safe and effective Ambulance Service to the population of the East of England region. EPR0006 – If the Trust fails to comply with the Command-and-Control Requirements of the EPRR Core Standards and the Civil Contingencies Act then the Trust will be in breach of legislation and its statutory obligations as a Category 1 responder. CRO0012 – If the Trust does not have an incident coordination center, then the Trust will be in breach of the Civil Contingencies Act 2004 resulting in potential litigation and associated financial cost and penalties.

Options

N/A

Summary

As stated above.

Executive Leadership

The above information was presented to the Executive Leadership on Tuesday 22nd August 2023 and approved for submission to the Lead ICB and NHSE Regional EPRR.

Appendix A

The breakdown of the EPRR Core Standards compliance is as follows:

Please note, there are 19 standards in Domain 10 in total but only 8 required for Ambulance Services as the remainder CBRN standards for Ambulance Services sit within the Interoperable Capabilities.

A breakdown of the Interoperable Capabilities compliance is as follows:

*Please note, the SORT standards this year are new and are made up of the combined MTA and CBRN standards from last year.

**Please note, the bracketed numbers in the No of 2023/24 Standards column are the number of standards in each domain in the 2022/23 set of standards.

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