Published: 03/11/2005 Volume 115 No. 5980 Page 14 15

Terrorist bombings, avian flu, killer heatwaves...no wonder the latest emergency planning guidance warns NHS organisations that they need to prepare for events of a 'different type and magnitude'. Mark Gould reports

'Big bang', 'rising tide, 'cloud on the horizon' - they all sound like the titles of straight-to-video disaster movies. In fact they are some of the soundbitestyle buzzwords in the latest NHS emergency planning guidance.

But even they sound dull when you consider that the threats being described include terrorist attacks on nuclear power stations, the rise of 'monkeypox', killer heatwaves and floods of Biblical proportions. And do not even mention the current outbreak of acute and contagious headlinitis around the 'killer' avian flu.

Only last week it was revealed that lecture notes by an eminent nuclear safety consultant outlining the threat of a terrorist attack on UK nuclear power stations were found in a car linked to the people behind the July terror bombings. They included slides showing the precise layout of Sizewell B power station on the Suffolk coast.

But do not panic. NHS chief executive Sir Nigel Crisp has told HSJ that the latest guidance, a pencil slim 47-pager released last month, recognises that it would be pointless to try to plan for every eventuality. It focuses on structures, planning, communication and ensuring as much as practicable that it is business as usual for the NHS.

The new tome builds on 1998 guidance, incorporating knowledge about how the NHS fared during real and desktop exercises, and how organisations coped with events such as London's July bombings.

It also examines the changing nature of the threats the NHS may face. Only two years ago the French heatwave killed over 15,000 elderly people as temperatures topped 40C (104F) and newspapers reported over 400 bodies lying unclaimed in Paris morgues. What was not reported at the time, and only emerged from reports in July this year, was that the death toll in Italy topped 20,000 - more than double the original estimate.

The guidance also recognises the creation of the Health Protection Agency and incorporates new legislation in the form of the Civil Contingencies Act 2004 which comes into effect from 14 November, and sets out clear responsibilities for 'first responder' organisations such as ambulance trusts.

The major change over the 1998 document emphasises the need for the NHS to plan for major incidents of 'a different type and magnitude' than previously considered. It also introduces new command and control structures, and new arrangements for organisation and management of immediate care.

The document also defines the type of incident for which NHS organisations will be required to develop emergency preparedness arrangements for (see box, right below).

Sir Nigel told HSJ that, given the current state of the political, environmental and biological world climate, 'emergency preparedness must be part of the health service's day-to-day business and can no longer be regarded as an optional extra'.

He says trusts should take note of the Civil Contingencies Act, which sets out 'clear expectations and responsibilities for front-line responders' to ensure they are prepared for any emergencies.

'Well planned, practised and robust local response arrangements are vital to the health community's ability to deal with large-scale incidents. The NHS has an excellent track record of responding to a whole range of major incidents, as we saw on the morning of 7 July.

'The response was professional and robust, but we have to ensure we can maintain and improve on our performance if we are going to respond effectively to new challenges, such as a flu pandemic, flooding, heatwaves and terrorist outrages more serious and complex than recent attacks.' Sir Nigel stresses that he does not want to see detailed plans for specific threats. 'Major incidents are by their very nature unpredictable.

We do not expect NHS organisations to anticipate them in detail. But they must be able to draw on relevant expertise and have developed a set of core processes.'

The key principles are speed and flexibility. The guidance recommends the creation of a new public health adviser role to be the main source of public health and health protection advice for responding organisations.

The adviser will be a senior public health practitioner who specialises in incident command.

Dr Jeremy Hawker from the Faculty of Public Health says the guidance irons out some weaknesses in the old system which technically excluded public health experts from some emergencies.

'The new system builds on the old joint health advisory cell which was developed to deal with chemical, biological, radiological and nuclear (CBRN) events, ' he says. 'That meant that, as the July bombings didn't involve CBRN, we technically should not have been there. By the same token, if there was a terrorist incident at a chemical factory that caused a spill, we would be excluded as it was a terrorist event, despite the chemical spill.' He said that the new system would require the creation and training of a cadre of public health advisors drawn from the HPA, public health officials in government agencies and strategic health authorities.

The guidance also recognises the the HPA's role in providing expert health and emergency planning advice to government and the NHS.

Camden primary care trust covers King's Cross station, which was targeted by the 7 July bombers.

Head of communication and corporate development Claire Torkington is happy with the new guidance.

'It has made us think more clearly about joint working - our flu pandemic group which was PCT based now includes members from the local authority and acute trust.' Ms Torkington says that although the PCT and the London emergency plans worked well in response to the July bombs, they have started to address the problems which caused the mobile network to fail.

'We are putting a different communications system in place, so people in different parts of buildings can talk to each other.' As part of the planning in the event of a situation which disabled the transport system, the PCT is also building a database of where staff live in relation to work so that those with easier access are called first.

And it is asking staff to detail other skills and qualifications so they can be redeployed in a pandemic if large numbers of staff are taken ill.

Last month, Westcountry Ambulance Services trust won a special incident award from the Ambulance Services Institute for its work during the flash floods in the Cornish town of Boscastle in August last year.

Peter Allen, the trust's emergency planning officer, on duty during the floods, said the new definitions of how a major incident were particularly relevant in the case of Boscastle: 'They are all soundbites that have been adopted by the emergency community, but quite useful as they sum up what might be happening.

'I was on duty when we had a 'rising tide' situation [see box above, top] as we knew there was a potential flood problem and then bang - it just hit and turned into a 'big bang', so I think these things are useful.' Ambulance trusts will be responsible for the selection, recruitment and training of medical incident commanders who would become members of a pool of specialists. Mr Allen said his trust has been working with doctors from the British Association for Immediate Care who would be able to provide on-site command and control, leaving paramedics and technicians free to do their jobs.

All NHS organisations will be required, as a minimum, to undertake a live exercise every three years, a desktop exercise every year and test communication cascades every six months. To support these arrangements an executive director of each NHS trust board will be designated to take responsibility for emergency preparedness on the trust's behalf.

Last week East Anglian Ambulance trust was in the middle of a week-long table-top exercise drill to evacuate its headquarters in Norwich after a flash flood. The trust covers 5,000 square miles of Norfolk, Suffolk and Cambridgeshire. As well as major flood risks along the coast and on the Norfolk Broads, it must take into account nuclear power stations, gas terminals, container ports and US and British airbases.

Trust resilience and contingency planning manager Roy Wallace said the overall effect encapsulated in the new guidance was to instil a sense of teamwork among the trust's 1,800 staff on 70 sites.

'We cover three counties with their own multi-agency local resilience forums and a regional forum. We provide an emergency planning officer for each, so there has been a massive amount of work in each forum. These exercises have shown everyone here - not just the paramedics and technicians - that we all have an important role to play.' .


Big Bang A serious transport accident, explosion, or series of smaller incidents.

Rising Tide A developing infectious disease epidemic or a capacity/staffing crisis.

Cloud on the Horizon A serious threat such as a major chemical or nuclear release developing elsewhere and needing preparatory action.

Headline News Public or media alarm about a personal threat.

Internal Incidents Fire, breakdown of utilities, major equipment failure, healthcare-acquired infections, violence.

Deliberate Release Chemical, biological or nuclear materials.

Mass Casualties Pre-planned events - demonstrations, sports fixtures etc that require detailed pre-planning.


Major For example, multivehicle motorway crashes usually handled by individual ambulance and acute trusts under long-established major incident planning. Now more patients will be dealt with without affecting the status of the service.

Mass A much larger event affecting potentially hundreds of people, possibly involving the closure or evacuation of a major facility due to fire or contamination, or a disruption over many days. These will require a collective response by several trusts.

Catastrophic Events of catastrophic proportions. These are defined as severely disrupting health and social care and other functions (for example, mass casualties, power and water failures) and those exceeding even the collective local capacity of the health service.