Greenwich CCG Business Continuity Plan€¦ · Greenwich CCG Business Continuity Plan Page 7 of 42...

Greenwich CCG Business Continuity Plan

Public Sector Equality Duty

Equality and diversity are at the heart of the NHS Strategy. Throughout the production of this document, due regard has been given to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it. This document therefore abides by

the Equality and Diversity Act 2010.

Author(s)

Interim Governance Consultant

Version

1.1

Approval Date

October 2016

Approving Body

Greenwich Executive Group

Review Date

October 2017

Policy Category Operational

Policy Reference Number

019

Greenwich CCG Business Continuity Plan of 42 Version 1.2

Version Control

Version Author Date Reason for review

0.1 Hellen Makamure September 2015

New Plan, Statutory Requirement

0.2 Hellen Makamure September 2015

Updated Draft with comments from RBG colleagues

0.3 Hellen Makamure September

2015

Updated draft with comments from

Datix Project Manager

0.4 Hellen Makamure September

2015

Updated Draft with comments from

Head of Analytical Support

1.1 Anna English October 2016 Updated with new address The

Woolwich Centre

1.2 Anna English March 2017 Updated in light of BIAs and new

staff


Contents Page

1. Contents 2. Glossary of Terms ............................................................................................... 5

3. Related Documents ............................................................................................. 6

4. Summary ............................................................................................................. 6

5. Introduction .......................................................................................................... 6

6. Aim ...................................................................................................................... 7

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 Business 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

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. 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


2. Glossary of Terms

Term 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 RTO The target time for resuming the delivery of a product or service to


Objective an acceptable level following its disruption. This could be a

resumption of full service or a phased return over a period of time.

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. Summary Business Continuity is the capability of an organisation to continue delivery of products or services at acceptable predefined levels following a disruptive incident.

Business Continuity Management (BCM) is the process of achieving business continuity and is about preparing an organisation to deal with disruptive incidents that might otherwise prevent it from achieving its objectives.

BCM involves:

a) being clear on the organisation’s key products and services and the activities that 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; and e) 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 done to protect its resources (e.g. people, premises, technology and information), supply chain, interested parties and reputation, before a disruptive incident occurs.

5. Introduction The continued operation of Greenwich Commissioning Group (Greenwich CCG) depends on a given combination of people, space, processes and technology, in connection with a given set of current business assets. Greenwich CCG seeks to provide its services by following a strategic operational plan, the achievement of

which is dependent on effective business operations.

This plan is to be used to assist in the continuity and recovery of Greenwich CCG in the event of an unplanned disruption. A disruption would be any event that threatens personnel, buildings or operational capacity and requires special measures to be

taken to restore normal service.


6. Aim This plan aims to define the strategic and tactical capability of Greenwich CCG, to plan for and respond to major business interruptions, to enable Greenwich CCG to continue 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 Management (BCM). This system is delivered following the structures outlined and

agreed in Greenwich CCG’s Business Continuity Policy.

6.1 Objectives

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. Scope This plan covers the alerting process, activation mechanism, roles and responsibilities of the Business Continuity Incident Control Team, guidance relating to command, control and recovery. This plan is flexible and meant to be used as generic guidance in the response to a business continuity incident/interruption. It provides suggested actions that might be effective in response. It does not cover all eventualities as is expected in Business Continuity Management.

This plan applies to the functions provided by Greenwich CCG at the following sites: The Woolwich Centre 35 Wellington Street Woolwich SE18 6ND

8. Business Impact Analysis Activities are disrupted by a wide variety of incidents, many of which are difficult to predict or analyse. By focusing on the impact of disruption rather than the cause, business continuity identifies those activities on which the organisation depends for its survival, and enables the organisation to determine what is required to continue to

meet its obligations.

To this effect, all critical and non-critical functions have been assessed and documented using a Business Impact Analysis (BIA). This will be reviewed and updated on an annual basis based on the changes to the services provided by

Greenwich CCG.

The Business Impact Analysis was developed through use of Greenwich CCG’s Risk Management Strategy based on impacts caused by loss of services/ activities to Greenwich 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)

The table below outlines the process of determining Greenwich CCG’s critical services and their order of recovery priority. All departments assessed each of their

activities 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.

8.1 Business Critical Functions These are processes and activities which, if interrupted, will cause a business or organisation to sustain a severe economic loss, or jeopardise the continued existence of the organisation or whose loss would cause an adverse outcome for

patients.

Greenwich CCG’s Business critical functions derived from the BIA are listed in Appendix 1 in order of Recovery Time Objectives. The minimum staffing

requirements for directorates/ departments are set out in Appendix 2.

Due to the nature of Greenwich CCG’s business cycle, the order of recovery may vary as the criticality of certain activities is time sensitive, depending on the time of

the year.

9. Risk Analysis Possible 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

10. Generic Roles and Responsibilities The broad structure of roles and responsibilities within Greenwich CCG for business continuity management are detailed in Greenwich CCG’s Business Continuity Policy. In both planning and response, a team approach to all aspects of business continuity is preferable. The lead for BCM with the overall responsibility for business continuity within Greenwich CCG will determine representation from all levels of staff to the adopted system.

10.1 Specific Roles and Responsibilities Specific Greenwich CCG staff will have roles and responsibilities to fulfil as below. A series of Action Cards (Appendix 5) have been produced for each of the potential risk areas that set out the specific roles and responsibilities of staff members, actions

to take and in what order.

10.2 Greenwich CCG Governing Body The 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 Officer The Chief Officer has overall accountability of BCM across the organisation and for meeting the requirements of legislation and guidance and is responsible for the

following:

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 Governance The Director of Integrated Governance is Greenwich CCG’s Accountable Emergency Officer (AEO) for Business Continuity and Emergency Planning. Their

responsibilities 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

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 and recovery)

Report on BCM to the Governing Body

Ensure robust strategies for managing any incident/ event

10.5 Director of Finance

The 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 Transformation The 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 Business Manager) Greenwich CCG BC Operational Lead who is the Executive Business Manager is

responsible for:

Supporting and overseeing the production, maintenance, validation of the plan

Participating in the implementation of, and review findings from BCM exercises

Auditing the organisation's level of BCM preparedness

10.8 All CCG Directors and Heads of Services All 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

10.9 Associate Director of Communications The Associate Director of Communications and communications team are

responsible 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 Resources

Identified 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 Team For the purposes of decision making in the event of a business continuity incident Greenwich CCG Chief Officer has the ultimate responsibility for activating the Business Continuity Plan. In the Chief Officer’s absence, the Deputy Chief Officer, the Director of Integrated Governance or any member of the Senior Management

team can activate this and request the Incident Control Team to meet.

Greenwich CCG may be alerted of a Business Continuity Incident via the On Call Director or internally. Below is Greenwich CCG BC incident escalation procedure

as 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.

11.1 Business Continuity Incident Activation Flow Chart

YES NO

Source

Internal/ External

CCG Chief Officer

Assess risk to individual

Greenwich CCG services

Is this a major Business

Continuity Incident

Activate Corporate Business Continuity

Plan

Routine Management Processes. No

further BC response required

Consult Action Plans in Service Level Plans to provide appropriate response following initial

assessment

MEDIUM IMPACT

Alert key officers to put

resources and staff on

standby or activate the

Business Continuity Plan

LOW IMPACT

No actions to be taken.

Normal systems can cope

HIGH IMPACT

Declare Business Continuity

Incident and activate Corporate

Business Continuity Plan


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 other

suitable space.

The composition of this team will vary depending on the type and scale of the business 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 the Business Continuity Plan.

11.2 Initial Actions

On being alerted, the Chief Officer is responsible for:

Directing the agreement of roles and initial tasks for members of the Incident Control Team

Agreeing on the best location(s) for dealing with incident or whether the best

option is a virtual one

12. Full details of the Incident Control Room

1a. Greenwich CCG Offices BG.02

The Woolwich Centre

35 Wellington Street

SE18 6ND

Business Continuity Accountable Officer : Director of Quality and Integrated Governance

Main Incident Control Room number : 02030499091

Communications Number: 07468 716 393


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 multiagency issues arising from Greenwich CCG BC issue

13. Roles and Responsibilities of the Incident Control Team The Business Continuity Incident Control Team is there to ensure the following (Key

tasks detailed in Appendix 4 and initial response checklist in Appendix 6):

Evaluate the extent of the situation and the potential consequences to business continuity

Provide the Executive Members with reports of the scale/impact on normal services 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 expenses should be kept)

Establish the return to normal working; (or new normality) after the incident response phase has concluded using recovery plans already established within each individual Service Level Business Continuity Plan.

Ensure that any backlog created will be the responsibility of local service

managers.

13.1 Alerting Process for staff Managers will verbally or by email or text, communicate information to staff on site or by telephone/mobile to staff away from the office. If it is out of hours, managers will send group text messages to staff (Please refer to Communication Cascade tree).

Each line manager will hold their staff’s telephone numbers for Business Continuity purposes.

mailto:[email protected]


14. Communication Cascade Tree

Director on Call for SE London CCGs will inform other CCGs

15. Communications of Incidents The Communications Team will send accurate and consistent messages and advice to staff and other stakeholders regarding any BC Incident as agreed by the Chief Officer and the BC ICT.

Operational Business

Continuity Lead to email or

telephone

NHS England

Other CCGs and providers/RBG

SEL CSU

Associate Director of

Communications

Will advise the public and other

stakeholders via the CCG internet of the

incident as appropriate

Associate Directors

Head of Services

All Directorate Staff

Key contacts/ partners for directorate

Directorate Leads to email/

telephone

Associate Directors or Heads

and Heads of Service to

telephone/ email

Chief Officer

Deputy Chief Officer

SEL CCGs Director on Call

Associate Director of Communications

All Directors

Executive Manager -Operational BC Lead

Head of Analytics

GP ChairChief Officer emails/

Telephones

On call Director communicates

Business Continuity Incident/

Disruption

Accountable Officer emails or

telephones


Messages sent out during a BC Incident will be clear and advise that the incident is real (this is not a test/ exercise). Below is an example of a message which may be sent 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 the situation as quickly as possible”.

The Chief Officer or nominated deputy with support from Communications will:

Be responsible for activating communications with other agencies including the 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 Handling BC Incidents may attract media attention. The Communications team staff will liaise with 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 will

normally be a member of the BC ICT if the incident requires it.

The media spokesperson will be supported by the Communications Team whose main 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 Recovery Once a Business Continuity Incident has been declared, the Incident Control Team will devise a phased recovery based on the time frames indicated in the Business

Impact Analysis.

Following an incident, Greenwich CCG may need to undertake a number of organisational recovery activities which may include but are not limited to the following:

Identifying appropriate support mechanisms which can be made available to staff, 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


The BC Incident Control Team will refer to the appropriate individual contingency action plans (see Appendix 7) in response to an incident where it relates to a risk or threat identified.

16.1 Handover In a prolonged incident it may be necessary for additional members to be brought in to cover the roles of the Incident Control Team. These will be the identified deputies and if unavailable additional suitable senior management can be called in. They will

be briefed on key issues and actions taken up to that point.

16.2 Stand down The Chief Officer or Accountable Emergency Officer (AEO), in agreement with the other members of the Incident Control Team and appropriate operational managers

and staff will decide when to stand down.

After ensuring that the BC incident has been resolved, the AEO will be responsible for activating the cascade of the stand down message to all staff and agencies

involved using communication cascade call trees.

Prior to the stand down being agreed it is essential that all recovery issues and actions are agreed and activated to assist in the return to normal working

arrangements.

16.3 Post Incident Actions It 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 incident b. Contribute and participate in any debriefs led by NHS England c. 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 plan

d. 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. Finance All decisions relating to Finance will be logged clearly especially where spending is incurred. This responsibility is managed by the Director of Finance as a member of

the Incident Control Team.


18. Incident Logs A log of all Business disruptions/interruptions/incidents e.g. power, telecommunications, water etc. will be maintained. These will be recorded even if a

Business Continuity Incident is not declared.

All Business Continuity Incidents/Disruptions will be reported to Greenwich CCG Business Continuity Operational Lead (Executive Business Manager) by e-mail within 24 hours of a minor incident or immediately if a “Business Continuity Incident”

is declared.

19. Debriefing and Reporting The AEO or Chief Officer is responsible for providing Situation Reports (SitREPs) to NHS England as required and providing a post incident report. Immediately after an incident has been stood down, the AEO or Chief Officer should coordinate ‘Hot Debriefs’.

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 weeks of the incident. Any officer involved in the response to the incident may be called, as may any associated external agencies. A full debrief report will be submitted to the

Chief 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 any necessary changes in management methods/processes as well as identify any possible training needs.

20. Disaster Recovery The South East Commissioning Support Unit (CSU) provides Information Technology (IT) and telephony support to Greenwich CCG. In the event of any IT and telephony downtime, the CSU is contacted immediately. The Head of Analytical

Support leads on this.

Appendix 9 identifies the IT applications that are used within Greenwich CCG and the 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 the triangulation of Lower Marsh and Wimbledon. The CSU Disaster Recovery Plan can be 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

http://nww.southlondoncsu.nhs.uk/Resources/Pages/Policies.aspx?RootFolder=/Resources/Documents/ICT%20Policies&FolderCTID=0x012000DEA48E982618E341B3BBE6AC9CBB3062&View=%7b1B827514-4A0F-452B-8D1B-C8ACB9F611DB%7d




21. Health and safety Care should be taken to manage any additional risks created by staff performing roles they do not normally do during the incident or its aftermath. A risk assessment should be completed for any areas of work which may present additional risks to the welfare of staff.

22. Testing, Exercising and Maintenance This plan must be tested at least annually and the communications cascade should be tested every six months. (See schedule below)

Following any exercise, incident or significant change to the organisation it will be necessary to review and update the plan with any lessons identified, gaps or

changes.

Maintenance Training and Exercising Schedule

Scope of Review Frequency Responsible Lead

Light touch (Call Cascade) – check contact details are up to date and correct

Every 6 months CCG BC Operational Lead/ Executive Business Manager

Implementing a change programme

As required CCG BC Operational Lead/ Executive Business Manager

Table top discussion/ exercise (formal review) – check to ensure that all procedures are current and still applicable

Every 12 months CCG BC Operational Lead/ Executive Business Manager

Live exercise Every 3 years CCG BC Operational Lead/ Executive Business Manager

Post incident/exercise review After every exercise and incident

CCG BC Operational Lead/ Executive Business Manager

23. Training Greenwich CCG Directors and senior managers will be involved in table top exercises annually to test Business Continuity arrangements for Greenwich CCG

through various business continuity scenarios.

This plan will be reviewed annually as required under the Business Continuity

Management Standards ISO22301:2012.


24. Sources of Evidence BC (2013) Business Continuity Best Practice Guidelines, London: Business Continuity Institute BS ISO (2012) Societal Security. Business Continuity Management Systems- Requirements, BS ISO 22301:2012, London: British Standard Institute BSI (2006) Specification for Business Continuity Management, BS 25999, London: British Standard Institute Civil Contingencies Act (2004). c. 36, London: The Stationery Office Health and Social Care Act (2012), c.7, London: The Stationery Office PAS 2015 (2012) Framework for Health Service Resilience NHS Commissioning Board Business Continuity Management Framework (service resilience) (2013) NHS Commissioning Board Command and Control Framework for the NHS during significant incidents and emergencies (2013) NHS Commissioning Board Core standards for Emergency Preparedness, Resilience and Response (EPRR)


Appendix 1: Business Critical Functions

CCG Business Critical Functions within 48hours of incident

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 Acute Commissioning

Management of EPRR issues e.g. surge and capacity issues

Same day of incident

Next working day


Responding to operational issues in providers which impact service delivery to patients


Next working day


Responding to alerts regarding the quality of care (safeguarding) or of the environment for patients in receipt of CHC and fully funded Nursing Care


Next working day

Integrated Governance

Business Continuity (development of CCG arrangements and support during incidents) Immediately

Same day


Emergency Planning (development of policies and resilience requirements) Supporting with guidance Immediately


Finance / IT Maintenance of NDrive Same Day of Incident 2 days

Communications

Supporting the Incident Control Team in the event of an EPRR or BC incident

4 hours

Next working day

Priority A - Business Critical Functions: Next working Day

Directorate /Dept Activity RTO MTPOD

Non Acute Commissioning System resilience planning

Next working day 1 week

Finance Financial Accounting (Statutory Accounts / Payments - invoices & payroll)

Next working day 3 days

Finance/IT Maintenance of YDD36M552- SQL Server Next working day 1 day

Finance/ IT Maintenance of YDD36M551- Reports server Next working day 1 day

Communications Internal communications Next working day 3 days

Communications Maintain CCG website - external communications


Communications Receive and manage Media enquiries



Directorate /Dept Activity RTO MTPOD

Medicines Management

Advice to local health Professionals on Medicines Management

Next working day 1 week

Priority A - Business Critical Functions: Up to 3 working days



Commissioning Delivery Plan and operational implementation 3 days 1 week

Non Acute Commissioning Point of contact for legal reactive work 3 days 1 week

Integrated Governance Complaints, MP Letters and enquiries 3 days

Over 1 month


Corporate services (Admin pool X7) provision of admin support to Directors and directorates 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


Maintain Database for Prescription Support Tool- Script Switch 3 days 1 week


Regular Practice Visits to support in-house work (management and audit) 3 days 1 week


Work with other stakeholders in agreeing guidelines and formulary regarding medicines Management 3 days 1 week


Medicines Safety Officer Responsibility making sure there is a reporting mechanism to MHRA 3 days 1 week

Safeguarding Adults and Children

Providing safeguarding advice and support to GPs, providers and other agencies 3 days 1 week


Responding to serious incidents, serious case reviews and safeguarding adults reviews 3 days 1 week

Clinical Engagement & Membership

Primary Care Transformation (Developing GP provider networks) 3 days 1 week


Priority B - Business Critical Functions up to 1 week Directorate/Dept. Activity RTO MTPOD

Finance Financial Management (Budgeting/Budgetary Control/ Reporting) 1 week 1 week

Finance Financial Strategy (Financial Strategy / Support to business cases) 1 week

1 month

Finance Performance (Activity Reporting / Statutory Returns / Business Case Support / Strategic Planning / QIPP 1 week 1 week

Finance Risk Management 1 week 1 week Integrated Governance Managing Freedom of Information (FOI) requests 1 week

2 weeks

Integrated Governance Management of the Corporate Risk Register 1 week

2 weeks

Integrated Governance Management of Board Assurance Framework 1 week

2 weeks

Finance/ IT Maintenance of 10.161.211.242- DISCRO Server (CSU) 1 week 2 weeks


Timely and accurate payments of Providers of services commissioned by CCG 1 week

1 month


Provision of data to support contract monitoring and management and forecasting of contractual position 1 week

1 month

Non Acute Commissioning Undertaking legal assessments including CHC and reviews 1 week

1 month

Integrated Governance Equalities (EDS implementation) 1 week

Over 1 month

Integrated Governance Quality Services (Management of Quality Alerts) 1 week

Over 1 month

Integrated Governance Reviewing RCA Investigations/ Serious Incidents 1 week

1 month


Management of the Incident Reporting System for CCG employed staff 1 week

1 month

Integrated Governance Managing reported HCAIs with Public Health 1 week

1 month

Finance Financial Strategy (Financial Strategy / Support to business cases) 1 week

1 month

Communications Publications - Annual reports/ Integrated reports 1 week 1 month

Communications Receiving and managing FOIs 1 week 1 month

Communications Media campaigns - winter campaign 1 week 1 month


Performance and Financial Reporting Practice Level and QIPP level 1 week

1 month

Strategy and Performance Quarterly meetings with NHS England 1 week

1 month

Strategy and Performance

Responding to NHS England on Performance Assurance and Delivery 1 week

1 month

Strategy and Performance Monitoring Provider Performance 1 week

1 month

Clinical Engagement & Membership Managing CCG Primary Care Steering group 1 week

1 month

Non Acute Commissioning Deprivation of Liberty Assessments 1` week

1 month


Directorate/Dept. Activity RTO MTPOD Non Acute Commissioning Safeguarding and monitoring of compliance 1 week

1 month

Priority C - Business Critical Functions up to 2 weeks



Programme and Project Management for individual work streams e.g. Better Care Fund 2 weeks 1 month

Clinical Engagement & Membership Organisational Development 2 weeks 1 month


Programme and performance management of QIPP and BCF 2 weeks 1 month

Strategy and Performance Monitoring and Development of QIPP 2 weeks 1 month

Priority D - Business Critical Functions up to 1 month The Business Impact Analysis also identifies those functions that are less critical and could be suspended for a period greater than 1month. These are documented in the

table below:


Non Acute Commissioning Maintenance of robust contracting management 1 month

Over 1 month

Non Acute Commissioning Commissioning of Non-Acute care 1 month 1 month


Project and programme management for service redesign 1 month

Over 1 month

Non Acute Commissioning Quality Assurance Reporting to CCG Governing Body 1 month

Over 1 month


Review of Action Plans in place to review areas of non-compliance with National contracts 1 month

Over 1 month


Responding to NHS England on performance assurance and delivery - TOP 8 1 month

Over 1 month

Non Acute Commissioning Procurement 1 month

Over 1 month


Providing training support to care homes to build operational resilience and prevent LAS conveyance 1 month

Over 1 month

Integrated Governance Contract Monitoring Meetings 1 month

Over 1 month

Communications Facilitating Ministerial visits 1 month 1 month

Communications Facilitating public engagement events 1 month 1 month


Analysing Prescription data on behalf of practices and share quarterly 1 month

Over 1 month




Develop and disseminate monthly newsletter on prescribing including ad hoc news flash for very important messages from Department of Health and NHSE 1 month

Over 1 month

Medicines Management Work with the CSU regarding contract issues 1 month

Over 1 month


Providing assurance to Greenwich CCG on provider safeguarding performance 1 month 1 month


Developing policy, procedures and safeguarding strategies for Greenwich CCG and monitoring adherence to these 1 month

Over 1 month


Attending relevant provider safeguarding meetings - seeking assurance on behalf of Greenwich CCG 1 month

Over 1 month


Supporting multiagency safeguarding boards and partnership working 1 month 1 month


Safeguarding training for CCG staff and providing training support to GP Lead for safeguarding 1 month

Over 1 month


Ad hoc training for providers on safeguarding 1 month

Over 1 month


Providing Information to the Health and Wellbeing Board and Council 1 month 2 months

Strategy and Performance Developing Organisational Direction/ Strategic Plans 1 month 3 months

Strategy and Performance Supporting the Commissioning Cycle 1 month 3 months

Strategy and Performance Monitoring of Constitution Standards 1 month

Over 1 month

Clinical Engagement & Membership Workforce development in Primary Care 1 month

Over 1 month

Clinical Engagement & Membership Facilitating GP Education and Training (PLT) 1 month

Over 1 month


Engagement with GP membership around commissioning matters and getting feedback. 1 month

Over 1 month


Clinical engagement and contracting commissioning project leads 1 month

Over 1 month

Clinical Engagement & Membership Helping GP surgeries with OT solutions requirements 1 week 1 month

Clinical Engagement & Membership Developing Primary Care strategy 1 month

Over 1 month

Clinical Engagement & Membership CCG representation for coordinated care 1 month

Over 1 month


Appendix 2: Staffing Requirements to cover Prioritised/ Critical Activities The following minimum staffing requirements were identified across the different directorates within Greenwich CCG for a short period of time lasting up to 1 week maximum. (These requirements will be dependent on the nature of the incident, the time of the year in relation to commissioning activities and duration; therefore may

need to be scaled up).

Directorate/

Dept.

Minimum Staffing Requirements

Integrated

Governance

Director of Integrated Governance

Executive Business 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


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


Appendix 4: Business Continuity Incident Control Team Key Tasks

1 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 the disruption. Immediate focus on Priority A (Critical Functions with an RTO of up to 3 days) then Priority B onwards.

6 Agree if necessary which non prioritised activities can be suspended and when ensure that MTPoD’s and RTOs are adhered to as per Service Level BIA information.

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 directly involved 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 arrange appropriate relief

Recovery Focused Tasks

17 Declare the incident over and stand down staff

18 Conduct debriefs

19 Produce a detailed report of the incident.


Appendix 5 Action Cards Incident Control Manager Action Card

Nominated 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


Incident Recovery Manager Action Card


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


BC Recovery Support Manager Action Card


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


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


Communications Action Card


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


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


Telephone Operator Action Card


To be agreed by the

ICT

1. To establish and maintain liaison with internal and external

services


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


Loggist Action Card

Your role Loggist

Your Base The Woolwich Centre, 35 Wellington Street, Woolwich, SE18 6ND

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.


Appendix 6: Initial Response Checklist

Task 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 Yvonne Leese: Director of Integrated Governance

Location The Woolwich Centre, 35 Wellington Street, Woolwich, SE18 6ND

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 patient safety 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 public need and bring care closer to home. Risk to reputation and morale of staff. • Loss of reputation

BC Action Plan Owner CCG Chief Officer: Jo Murfitt

Deputy BC Champion Director of Integrated Governance - AEO

Business Continuity Lead: Operational Executive Business Manager

Business Continuity Risks and Action/ Contingency Plans

Risk 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


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


Contact South East CSU helpdesk on 020 38163 163 for solution and

estimated downtime

Refer to North 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.


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 RBG 020 8921 6085

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 RBG 020 8921 6085

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


Appendix 8: Key Contacts

Key Contact/

supplier

Service Provided Telephone Email

NHS

England

EPRR 020 7932 3943

08448 222 888

NHS01- for

incidents

[email protected]

North East

London CSU

Information

Technology

020 38163 163 [email protected]

[email protected]

South East

CSU

Communications 02030493333

07876 448602

[email protected]

SEL Surge

hub

Surge & Capacity

management

02030049666 [email protected]

LGT

Emergency

Planning

Team

Lewisham Acute

Trust

02083333000 [email protected]

Royal

Borough

Greenwich

Local Authority 020 8921 6085 [email protected]

Royal

Borough

Greenwich

Security 020 8854 8888

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










Appendix 9: CCG IT Requirements

IT

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


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 do you assess there may be?

1. Does the proposal affect one group more or less favourably 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, gay bisexual and transgender people)

No

Age No

Disability (including learning disabilities, physical disability, sensory impairment and mental 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 and learning)

No

3. Will the proposal have an impact on social environment?

(e.g. social status, employment (whether paid or not), social/family support, stress, income)

No

4. Will the proposal have an impact on physical environment?

(e.g. living conditions, working conditions, pollution or climate 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 of services?

(e.g. Health Care, Transport, Social Services, Housing Services, Education)

yes Improved services through continuity of services

By using evidence and insight to assess and grade our equality performance, NHS Greenwich can generate much of the information we will require to demonstrate compliance with the PSED. The checklist is to enable the policy lead and the relevant committee to see if a particular policy or project


will provide the relevant evidence to assist NHS Greenwich CCG meet the set out EDS goals to achieve better outcomes for patients and staff. Please assess your policy, project or service against the 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: A English Date : 13.05.17.

Equalities Lead

Signature: Date: 13.05.17

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