Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams - October 2011

ORGANISATIONAL ARRANGEMENTS

Accountability and reporting arrangements

34. NHS Boards share statutory responsibility for improving and protecting public health with Local Authorities. In addition, representatives from other statutory agencies will be involved in planning for and managing public health incidents, each agency fulfilling a remit on behalf of their own organisation and being responsible to it for actions taken in this regard. Each will have its own statutory duties to fulfil with regard to protecting public health. NHS Boards, as the lead agency for protecting health, are responsible for the overall integrity of the arrangements for planning for public health incidents, and for the effectiveness of the incident response. See Annex A and B for more information on roles and responsibilities.

35. NHS Boards should reach agreement with their partners, especially Local Authorities, on:

• Developing, training and testing joint plans for managing public health incidents. Normally this will be through Joint Health Protection Planning arrangements. Most public health incidents do not require a SCG co-ordinated emergency planning response;
• Reviewing and approving incident plans. Members of the NHS Board and where appropriate, political or appointed representatives of other organisations should be involved in this process;
• Following up the recommendations made in IMT reports; and
• Liaising with SGHD and other national agencies in developing national plans and procedures and reviewing the overall effectiveness of public health incident management in Scotland.

36. NHS Boards should appoint a lead officer to be responsible for putting these arrangements in place and updating them as appropriate. Normally this will be the Director of Public Health. He/she is responsible for ensuring that the NHS Board has sufficient resources to discharge the functions detailed in this guidance.

37. Occasionally there will be indications that the IMT is not working as effectively as required. In such instances, the lead NHS Board officer for assessing IMT performance should take steps with senior management counterparts in the other agencies participating in the IMT, to assess and remedy any shortcomings.

Joint planning for public health incidents

38. NHS Boards should draw up co-ordinated incident plans with Local Authorities and these should be formally endorsed by agencies involved. These plans should be reviewed annually and jointly exercised on a regular basis. The plans should outline a generic approach to managing incidents and be suitable to address the investigation and management of incidents resulting from exposure to scenarios involving microbiological, chemical, radiation and other hazardous agents.

39. It is essential that arrangements for handling incidents are integrated with overall wider multi-agency arrangements for emergency response. This is particularly important if there is any question of any criminal activity being involved in the causation of the incident e.g. the illegal supply of drugs and sale of food unfit for human consumption. However, the control of the incident and prevention of further illness must remain the priority. The IMT Chair should consider an early meeting with the police and other key partners to agree the most effective forensic recovery plan if the police are not members of the IMT.

40. NHS Boards should reach agreement with their emergency planning partners, and in particular the relevant police force about emergency response arrangements in the circumstances when criminal activity is implicated and consideration should be given to developing memorandums of understanding.

41. In certain incidents, e.g. those involving the deliberate release of a chemical or biological agent, the NHS Board, while retaining its own responsibilities, will be required to play a key part in the overall response led by the SCG of the area in which the incident occurs and to have regard to the potential requirement to protect the crime scene in order to avoid prejudicing prosecutions.

42. When incidents involve, or have the potential to involve, legal proceedings, it is important that the local Procurator Fiscal's department is kept informed.

43. NHS Boards and Local Authorities must ensure that adequate resources are made available from the outset to investigate and manage the incident including the provision of suitable accommodation, facilities and sufficient administrative support, particularly in the case of prolonged investigations. An inadequate initial response may have serious consequences for the wider public health. Investigations should never be delayed for financial or contractual reasons. Representatives of agencies on the IMT should have sufficient devolved authority to commit agency resources required to investigate and control an outbreak. These issues should be discussed among agencies as part of the arrangements for formally agreeing joint plans.

The Incident Management Team

Arrangements for Leading the Team

44. It is the responsibility of the NHS Board to call an IMT. In public health incidents, a Consultant in Public Health Medicine (CPHM) or registered Specialist in Public Health will lead the investigation and management of the incident on behalf of the NHS Board, chair the IMT and co-ordinate the multi-agency IMT response. Usually this will be a CPHM with responsibility for Health Protection who will be acting with the delegated authority of the Director of Public Health. The CPHM will be responsible for initial action in response to the incident and convening an IMT. The size and nature of the incident will determine the exact arrangements and the IMT Chair can delegate some of the assigned tasks as necessary.

45. In a healthcare setting the CPHM or the Infection Control Doctor (ICD) will chair the IMT depending on the circumstances and this should be agreed in advance and documented in the local plan. The ICD will usually chair the IMT, lead the investigation and management of incidents limited to the healthcare site, where no external agencies are involved and where there are no implications for the wider community. The CPHM would normally chair the IMT where there are implications for the wider community e.g. TB, measles etc. The Hospital Infection Incident Assessment Tool (HIIAT) (December 2009) can be used to guide decisions about who should chair the IMT (Annex D).

46. For rare events, or where there is doubt about who should lead the investigations, the CPHM and ICD should discuss and agree who should chair the IMT e.g. CJD or Hepatitis B/HIV look back. Where there is an actual or potential conflict of interest with the hospital service it may be preferable for the CPHM to chair the IMT in discussion with DPH and HAI Executive lead (if necessary). Further guidance on HAI incidents can be found in Annex D.

Problem Assessment Group

47. In some circumstances where it is unclear if there is a threat to the public health the CPHM may choose to convene a Problem Assessment Group (PAG) to undertake an initial assessment and determine if an IMT is required.

48. Outcome of the initial assessment may be one of the following:

• No significant risk to the public health or the environment - continue to monitor and PAG stands down
• Potential/actual significant risk to the public health or environment and/or media interest - IMT required.
• Potential for significant public and/or media interest - IMT required
• Not possible to determine if there is significant risk with current information - further investigation required. PAG or delegated member of PAG continues to review but no IMT at this stage.

49. The PAG should not delay definitive action and would normally only meet on one occasion to assess the situation.

Membership of the IMT

50. The membership of the IMT will vary depending on the nature of the incident. The IMT Chair will decide on the composition of the IMT and invite members to attend. The IMT would normally include:

• NHS Board chair (usually a CPHM);
• Health Protection Nurse Specialist
• Local Authority Environmental Health Officer;
• Specialist with expertise in the detection and characterisation of the hazardous agent involved in the incident e.g. a consultant microbiologist, public analyst;
• Infection Control Doctor and Infection Prevention and Control Team representative, if appropriate
• Consultant Epidemiologist, Health Protection Scotland (if required)
• Corporate communications officer
• Administrative support
• SGHD Senior Medical Officer may attend in an observer capacity

51. For healthcare settings the IMT may include senior hospital management, ward managers of affected wards, clinicians, pharmacists, estates and Occupational Health.

52. The IMT may also contain officers from other relevant agencies e.g. Animal Health and Veterinary Laboratories Agency, Scottish Water, SEPA, FSA etc whose input is essential to manage the incident. However, it is important that the IMT does not become too large as it may lose focus.

53. Sometimes a representative of SGHD or other SG Department will attend the IMT to facilitate liaison between the IMT and SG. In such instances, unless otherwise indicated, his/her status on the team will be as an observer.

54. The status of IMT members should be clarified at the first meeting i.e. full members, in attendance or observers. Prospective members of the IMT should declare any potential conflict of interest as individuals or on behalf of their organisations. Where a declaration of potential conflict of interest is made, it should be recorded and a decision made on the individual's status. Individuals who are not full members may continue to attend the IMT by invitation, but should not expect to have equal rights in terms of determining the conduct of the investigation, the advice given to the public, the content of press statements, or the final IMT report.

Role of the IMT

55. The IMT is a multi-disciplinary, multi-agency group with responsibility for investigating and managing the incident. The remit of the IMT is to enable the NHS Board and other statutory agencies to fulfil their remits to:

• reduce to a minimum the number of cases of illness by promptly recognising the incident, defining how cases have been exposed to the implicated hazard, identifying and controlling the source of that exposure, and preventing secondary exposure;
• minimise mortality and illness by ensuring optimum health care for those affected;
• inform the patients, actually or potentially exposed groups, staff, clinical and management colleagues, public, their representatives and the media of the health risks associated with the incident and how to minimise these risks; and
• collect information which will be of use in better understanding the nature and origin of the incident and on how best to prevent and manage future incidents.

56. In carrying out this remit, the IMT should assist the relevant statutory organisations, in a timely manner to:

• ensure that systems are in place to collect and collate all relevant information and verify, review and interpret its significance;
• carry out a risk assessment and decide on courses of action necessary to protect the health of the public;
• co-ordinate the investigation and management of the incident within the protocols and codes of practice of the agencies involved and having regard to extant legislation;
• liaise with HPS, SGHD and other relevant agencies to share information, draw on their expertise and ensure the agencies implement the actions that they are responsible for. See Annex G for more detail on sharing personal/patient information;
• co-ordinate the issuing of advice and information to the public directly and through the media, liaising as necessary with the SGHD communications team;
• ensure arrangements for the care of patients are in hand, and keep all relevant clinical professionals updated;
• agree criteria for standing the IMT down and declaring the end of the incident; and
• produce a full IMT report or SBAR for the NHS Board Clinical Governance Committee and the Health Protection Network normally within 3 months of the debrief to ensure lessons identified are captured and shared (see Table 1).

57. All members of the IMT must have due regard to the confidentiality of information discussed in the IMT meetings. However, the IMT must also bear in mind the need to demonstrate openness and transparency when reporting the facts to the public, and the possibility of records being released under the terms of the Freedom of Information Act. All agencies represented in the IMT must ensure that relevant staff within their own organisations are regularly briefed about the incident.

58. Representatives from the individual agencies involved in an IMT should normally only carry out investigations, assess risk to the public health, take control measures, and make public statements after full discussion and agreement within the IMT, or, if that is not practical, with the IMT Chair. The IMT should bear in mind however some agencies i.e. the FSA and HSE are not bound to seek agreement from the IMT Chair or IMT itself, however good practice would suggest that they be consulted prior to any investigations commencing.

59. Meetings should be kept to a minimum and be as short and efficient as possible without compromising safe working. Careful consideration should be given to the composition of the agenda, the timing, duration and frequency of meetings. Attention should be paid to the context of public concern in which an incident may be taking place, the different information requirements of the print and broadcast media, and the crucial issue of timing, to ensure optimal dissemination of information. Responsibility for this should be clearly assigned. Facilities should be in place to support the IMT i.e. identified room with the appropriate technology which can be commandeered immediately. A draft IMT agenda is included in Annex H.

Administrative support

60. NHS Boards must ensure experienced administrative support is provided to support the IMT and is available in and out of hours. Accurate records must be kept of all IMT meetings. Provision must be in place to support good record keeping throughout the incident from the initial notification to the completion of the report. All discussions held, including phone and email, decisions made, and actions taken should be recorded. The successful management of public health incidents requires fit-for-purpose national information management systems. In large or complex incidents senior administrative support must be available and may need to include loggists and action chasers.

61. The IMT Chair should ensure that the findings of the initial investigation; timing and content of communications; outcome of initial risk assessment; decisions taken and all other relevant matters are carefully documented. This documentation should also include reasons why certain actions were not taken/appropriate as well as why actions were taken/appropriate. A formal Decision Log that records options considered and decision taken could be used to facilitate this process.

Support for the IMT

62. If some situations pressures may be brought to bear on the IMT, which could distract it from its core purpose of managing the incident. An example is when there is a sustained, large volume of enquiries about the incident from the public, media and politicians. Very large incidents can have secondary impacts on a range of services e.g. hospital care, food and water supply and may lead to the need for increased expenditure with money being reallocated from existing budgets. In large and/or lengthy incidents, there will be a need to make appropriate provisions for relieving IMT members who may become fatigued. In such instances, the IMT Chair should discuss with the Director of Public Health the need for a corporate response by the NHS and partners to provide additional support within the locally agreed structures for example an Incident Management Support Team. In some circumstances it may be necessary to consider activating Business Continuity and/or Major Incident Plans.

63. The IMT chair and the DPH should consider whether the incident can continue to be dealt with by the Health Protection Team or whether the incident requires a wider Public Health and/or NHS Board response. It may be necessary to reprioritise the activity of the public health department and this should be done in a planned way. Shift systems should be implemented if it is anticipated that an incident may be large or protracted. These issues should be documented in Business Continuity Plans.

64. The Local Authority and other agencies involved in the IMT should also consider the impact of the incident on their resources and consider the need to activate their own Business Continuity Plans.

65. The support required from other NHS Board staff or partners could include:

• supporting the IMT by providing additional information and resources needed for its effective functioning;
• if necessary, acting as an alternative resource to help deal with certain external factors, including aspects of media enquiries;
• making tactical/strategic decisions on the wider impact of the incident on services not directly implicated in the incident;
• mobilising additional resources to aid the management of the incident; and
• responding to requests from the IMT for additional help required to resolve problems which may compromise the function of the IMT.

Decision making by the IMT

66. The IMT is not simply an advisory group but a group set up specifically to act to investigate and manage the response to a public health incident. The IMT Chair's leadership role is delegated by the DPH on behalf of the NHS Board Chief Executive and the NHS Board, as the lead agency for protecting the public health. The IMT Chair, therefore, has overall responsibility for managing a public health incident. As such the leadership of an IMT is invested in the IMT Chair and he/she will co-ordinate the activities of the other agencies.

67. It is expected that the IMT will reach collective decisions but it may be necessary for the IMT Chair to make difficult decisions if the IMT cannot resolve an issue by consensus or if urgent decisions are required between IMT meetings. The final decision on action rests with the IMT Chair. However, in some circumstances it may be necessary for emergency action to be taken to protect the public health e.g. under the Use of Hygiene Emergency Prohibition procedures. The Local Authority should advice the IMT chair that emergency action has been taken as soon as possible.

68. All members of the IMT must recognise their individual roles as a member of the IMT and that they should be in a position to commit to act on behalf of their organisation.

69. Usually all members of the IMT will commit to collective decisions. In the rare event that a member is not supported by his/her organisation to a collective agreement to act, and this cannot be resolved by the IMT Chair, then the issue must be resolved at a higher executive level in both organisations. The DPH of the NHS Board should work to achieve this in the first instance, and only if this does not achieve resolution should the Chief Executives of both organisations work to resolve the issue. Escalation to Scottish Government would not normally be envisaged, as issues of significant public health risk should be given priority by all organisations involved.

70. In some incidents the IMT Chair may be required to contribute to a Scotland wide IMT led by HPS. In this situation the IMT Chair retains responsibility for the investigation and management of the local public health response to the incident.

71. If the SCG requests that the DPH convenes a STAC this response will be based on the Preparing Scotland STAC guidance. In this situation the NHS Board still retains the responsibility for the investigation and management of the public health aspects of an incident, accountable to the NHS Board, irrespective of an SCG led response. There is still a need for the NHS Board to ensure that the public health tasks associated with an incident are addressed in line with this guidance.

72. Depending on the situation there are various options:

• If an IMT has already been set up, it could simply carry on as an NHS Board led IMT and the IMT Chair could agree with the SCG chair that the IMT would act as the nominal STAC. In this case the focus of an IMT/STAC would remain primarily the investigation and public health management but additional members (e.g. SEPA, Scottish Water etc) could be invited on to ensure that any other scientific or technical issues raised during the incident could be addressed if requested by the SCG.

• The alternative model recognises that, in view of an outbreak being primarily a public health incident, there is an overriding need for the NHS Board resources to be focussed on maintaining the IMT and addressing the incident from the public health perspective. Hence the IMT should remain intact and separate but as a sub-group of a STAC, itself chaired by the DPH or CPHM. In this alternative option, the IMT (as a STAC sub-group) should continue to deal with all issues pertinent to the public health response (as per this guidance) and should maintain contact with the STAC but via a liaison representative; the IMT is then free to leave any other scientific or technical advice issues to the rest of the STAC.

• The first option is likely to be preferable where NHS resources are limited. If NHS resources are particularly stretched there is also the option for the STAC to be chaired by a non-NHS Board agency.

• The structures implemented in any incident should be kept under review and essentially must address the needs of the particular situation and will also be influenced by the resources available.

73. In some hospital based incidents it may be necessary for the CPHM to chair the IMT, because of the wider public health implications or because the hospital based chair may have a perceived conflict of interest. The line of reporting of the IMT in this instance should be agreed with the DPH, the HAI Executive lead, and the NHS Board Chief Executive. The role of the IMT Chair does not change but may have different reporting lines. The IMT can only have one lead and this is the IMT Chair.

74. In Local Authority premises the Local Authorities should recognise the potential for conflict of interest and ensure that measures are in place to manage such conflict.

External Advice

75. There may be circumstances when the IMT needs to seek external expert advice beyond what can be provided by HPS. This should be discussed and agreed at the IMT with HPS present, and the IMT Chair or the HPS representative should seek this advice on behalf of the IMT.

After the incident

76. The IMT must decide when the public health response to an incident is over and make a statement to this effect for release to the general public and other interested parties. This should be based on a formal assessment that there is no longer a significantly increased risk to the public health.

77. The IMT should document the incident to ensure lessons learnt are identified and shared. More detail on debriefs and IMT reports is provided in the section on Audit, evaluation and documentation.