RESEARCH ARTICLE Open Access Emergency management in health: key issues and challenges in the UK

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RESEARCH ARTICLE Open Access Emergency management in health: key issues and challenges in the UK
  RESEARCH ARTICLE Open Access Emergency management in health: key issuesand challenges in the UK  Andrew CK Lee * , Wendy Phillips, Kirsty Challen and Steve Goodacre Abstract Background:  Emergency planning in the UK has grown considerably in recent years, galvanised by the threat of terrorism. However, deficiencies in NHS emergency planning were identified and the evidence-base that underpinsit is questionable. Inconsistencies in terminologies and concepts also exist. Different models of emergencymanagement exist internationally but the optimal system is unknown. This study examines the evidence-base andevidence requirements for emergency planning in the UK health context. Methods:  The study involved semi-structured interviews with key stakeholders and opinion leaders. Purposivesampling was used to obtain a breadth of views from various agencies involved in emergency planning andresponse. Interviews were then analysed using a grounded approach using standard framework analysis techniques. Results:  We conducted 17 key informant interviews. Interviewees identified greater gaps in operational thantechnical aspects of emergency planning. Social and behavioural knowledge gaps were highlighted with regards tohow individuals and organisations deal with risk and behave in emergencies. Evidence-based approaches to publicengagement and for developing community resilience to disasters are lacking. Other gaps included howknowledge was developed and used. Conflicting views with regards to the optimal configuration and operation of the emergency management system were voiced. Conclusions:  Four thematic categories for future research emerged:(i) Knowledge-base for emergency management: Further exploration is needed of how knowledge is acquired,valued, disseminated, adopted and retained.(ii) Social and behavioural issues: Greater understanding of how individuals approach risk and behave inemergencies is required.(iii) Organisational issues in emergencies: Several conflicting organisational issues were identified; value of planningversus plans, flexible versus standardized procedures, top-down versus bottom-up engagement, generic versusspecific planning, and reactive versus proactive approaches to emergencies.(iv) Emergency management system: More study is required of system-wide issues relating to system configurationand operation, public engagement, and how emergency planning is assessed. Keywords:  Emergency management, Emergency planning, Emergency preparedness, Disaster planning, Disastermanagement * Correspondence: School of Health and Related Research, The University of Sheffield, Sheffield,UK  © 2012 Lee et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (, which permits unrestricted use, distribution, andreproduction in any medium, provided the srcinal work is properly cited. Lee  et al. BMC Public Health  2012,  12 :884  Background The UK experiences around 11 major incidents per year [1]. These often require coordinated multi-agency responses including from the National Health Service(NHS). Previously, this work was conducted in thebackground but the horrifying terrorist attacks of 11 September 2001 and 7 July 2005 have catapulted theemergency management field up the political agenda [2].Since then, research and publications in this field haveaccelerated, as demonstrated by the US experience fol-lowing 11 September 2011 where in the past decadenearly seven hundred articles were published pertainingto this single event alone [3].Emergency management is often erroneously under-stood as only those activities pertaining to the responseto an emergency situation. In its broadest sense however,it is synonymous with emergency planning and encom-passes a spectrum of activities from business continuity management and planning, training and preparedness,as well as the response to, and recovery from emergen-cies. (Figure 1) [4,5] This was further codified in the Civil Contingencies Act, 2004 that set out for the varioushealth agencies key responsibilities to prepare for majorincidents that included the assessment of local hazardsand risks, planning, training and testing activities [6,7]. However, deficiencies in NHS emergency planninghave been previously noted [3 – 6], and questions havebeen raised as to the evidence-base that underpins muchof the activity of emergency planning for major incidents[8]. Also lacking is an evidence-base to support planningaround longer-term  “ rising tide ”  incidents such asinfectious disease outbreaks, covert chemical, biological,radiological, and nuclear events, and threats to infra-structure, and business continuity, such as floods andtransport strikes. There are also inconsistencies in ter-minologies and concepts used [9,10]. Different models of  emergency management exist worldwide that reflect thesituational contexts of the countries in which the systemshave evolved [6,11,12]. What is less clear is what systems and processes work best.We present the results from a study commissionedby the National Institute for Health Research ServiceDevelopment Organisation to determine the evidence-base for emergency planning, specifically for the UKhealth context [13]. This project was a collaborativepartnership between academics, clinicians, public healthand health protection specialists. It consisted of 4 sub-projects: a scoping study of the published literature, aqualitative grey literature scoping review, key informantinterviews, and an e-Delphi study. Mixed methods wereemployed in order to approach the topic holistically. Wereport here the key issues and challenges for emergency planning in health in the UK that were identified. Methods We sought to gather more detailed insight into the stateof emergency planning in health in the UK and any research gaps. In order to do so, we chose a qualitativeapproach, using semi-structured interviews with key  HAZARD ANALYSISCAPABILITY ASSESSMENTEMERGENCY PLANNINGCAPABILITY MAINTENANCEEMERGENCY RESPONSERECOVERY EFFORTSMITIGATION EFFORTSDEVELOPMENT PLANS Recovery Mitigation Preparation Response  Figure 1  The emergency management cycle.  This figure illustrates the key stages of emergency management from mitigation, through topreparedness (covering emergency planning, capability assessment and maintenance), emergency response and eventually recovery. This isderived from the work of McLoughlin (1985) who detailed the various stages and how they are related in an  ‘ integrated emergencymanagement system ’ . Lee  et al. BMC Public Health  2012,  12 :884 Page 2 of 11  stakeholders and opinion leaders acting as our key informants.Ethics approval for this study was sought and receivedfrom the NHS Sheffield Research Ethics Committee (REC Ref 10/H1308/67). The sampling strategy adopted was purposive in orderto obtain a breadth of views from multi-agency stake-holders. Initially, we identified a list of potential key informants to interview. These individuals were selectedon the basis of their known expertise, recognized experi-ence, or research in the field. They were identifiedthrough the World Association for Disaster & Emergency Medicine, the Department of Health Emergency PlanningClinical Leaders Advisory Group, faculty of the Masterscourse in Health Incident Command at ManchesterMetropolitan University, senior faculty of the Emergency Planning College and the Health Protection Agency (HPA). Public representation was also sought through theSheffield Emergency Care Forum, a group of interestedmembers of the public who are involved in providing apublic voice, interest or lay representation in research inSheffield.Potential participants were initially contacted by tele-phone, e-mail, and/or letter, with summary informationon the project. Those participants who agreed to takepart in the project were provided with participant in-formation leaflets and returned a signed consent formor correspondence agreeing to participate. A mutually agreed date, time and venue were then set for theinterviews. The interviews were carried out either face-to-face or by telephone depending on the wishes of the respondents.Of 50 potential key informants identified, twenty-seven were approached and invited to interview. Of thisnumber, 17 key informants agreed to be interviewed.The reason for non-participation by key informantsinvited who decline interview is not known as this infor-mation was not collected. The participants included arange of individuals who in their professional capacitiesincluded emergency planners, health managers, policy-makers, technical experts and scientific advisors.(Table 1) There was representation from the public, pri- vate sector, the military, primary and secondary care,ambulance service, civil service, and the HPA. Someinterviewees operated at the frontline locally, whilstothers participated at more senior levels in governmentas well as internationally. We are confident that a broadand appropriate range of informants were included andcovered.The interview schedule was developed from our pre-liminary conceptual mapping and scoping of the litera-ture done as part of the wider study [13]. The scheduleconsisted of several broad themes to be explored thatincluded those themes we had identified as potentialissues. An iterative approach was adopted and the inter- view guide was modified over the course of the projectto explore emergent themes that had not been identified a priori .Interviews were carried out initially by two researcherstogether to standardise the interview process and for Table 1 Profiles of the key informants interviewed Interviewee Practitioner Technical expert Scientific or academic expert Policymaker Member of the public A  √  B  √  C  √ √  D  √  E  √  F  √ √  G  √  H  √  I  √  J  √  K   √ √  L  √ √ √  M  √ √ √  N  √ √  O  √  P  √  Q  √  Lee  et al. BMC Public Health  2012,  12 :884 Page 3 of 11  familiarisation with the process. Subsequent interviewswere conducted by the researchers individually. Bothresearchers were dually experienced as academics aswell as in the field of emergency planning. This wasconsidered important as it would help facilitate discus-sions that could be technical in nature. The researcherswere mindful throughout of the potential for observerbias in view of their previous expertise and experiencein this field and how this could influence their inter-pretation of findings. To mitigate this, periodic discus-sions between the researchers were held to compareand contrast findings.Most of the interviews were carried out face-to-faceeither at the participants ’  workplace or at a university  venue to suit the participants ’  convenience. A small pro-portion of interviews were conducted over the telephoneas agreed with the interviewees in advance. Interviewswere recorded using digital audio recorders and tran-scribed verbatim with the participant ’ s informed consent.Concurrent notes were also made during the course of the interviews. Quotes were anonymised to protect theidentities of participants.Data from interviews were then analysed using a mixof thematic analysis to explore and describe issues andthemes, as well as using a constant comparison groundedapproach to try and identify a conceptual framework.After familiarisation with the material, coding was under-taken. This utilised several variants of coding thatincluded descriptive coding, in vivo coding, and versuscoding approaches [14]. We were especially interested intrying to identify contrasting views from respondents orissues raised where there were tensions or uncertainty.The codes were then categorized and amalgamated intohigher level thematic categories, and re-iterated as new codes where appropriate. These were then mapped outto display their linkages. Results From the key informant interviews we identified 4 emer-gent thematic categories relevant to emergency planningin health (Figure 2): (i) the knowledge (or evidence-) base for emergency planning,(ii) how individuals and organisations react and behavein emergencies,(iii)the healthcare system in which the emergency management occurs, and(iv) issues related to the public served by the system. The knowledge base Many issues were raised pertaining to various aspects of the knowledge base for emergency management. Firstly,there was an issue of how knowledge was acquired.Unlike traditional biomedical science where knowledgeis built up from research, this was not the case for emer-gency management. Due to the unpredictability of emer-gencies, and the inherent slowness in current researchcommissioning processes, the status quo does not facili-tate the accumulation of research-based knowledge. “    It  ’    s very difficult to, you can ’   t do a randomised control trial. You can ’   t compare because every situation isvery different. ”   (Emergency Planning Technical Expert 1) “    Emergency planning is an unusual area  . . .  If you do sort of medical research you test your hypothesis and then you sort of devise the treatment or devise a drug and you test it etc. Emergency planning is nothing likethat at all. ”   (Emergency Planning Policymaker 2) “   Those quick response reports (research in the US) arethen published online for people to see, so you can seewhat is happening and there is this much more  “    joined up ”    thinking between government and research and the practitioner in the United States. National Science Foundation funds an awful lot of work in disasters and emergency management, which we do not do here. ”   (Emergency Planning Academic and Technical Expert 1)There were inter-professional differences in how theexisting knowledge is viewed, valued and used, as well asthe  “ appetite ”  for evidence.  “ Blue light ”  emergency ser- vices practitioners equated experience of dealing withincidents with expertise and as evidence. In contrast,stakeholders from a health background (e.g. medicineand nursing) valued  “ knowledge ”  that had been peer-reviewed and published. “   You ’   ve got with a lot of practitioners this brick wall that you have to kick them through so that they canopen their eyes you know. It  ’    s very much  ‘   Why do I need to know that? What  ’    s that gonna help me? Why  should I read a book about the way disasters may happen or about social vulnerability? What will that do for me in terms of helping respond to anemergency?  ’”   (Emergency Planning Academic and Technical Expert 1) “   Well a lot of people (emergency planners and managers) don ’   t see the relevance (of evidence) or howit can be done. ”   (Emergency Planning Technical Expert 2) “   . . . the difference in cultures and the like and theknowledge and evidence it comes out of the culture Lee  et al. BMC Public Health  2012,  12 :884 Page 4 of 11  aspects of how (the different organisations) do it. Someare sort of disorganised   . . .  This is part of the problem I  ’   ve noticed in the exercises we ’   ve had as to what each see as the evidence they need and how they approach it. ”   (Public representative 3)There were also differences in how the knowledgewas valued; the former valued practical  “ knowledge ” more than academic literature for example. The degreeto which information was scrutinized also differed.Emergency planning practitioners tended to be lesscritical of their information sources, accepting them at ‘ face value ’ . “    People talk about stuff as if this is the way we did it and therefore it  ’    s right when that is simply anecdotesor based on experience. It hasn ’   t been evaluated independently and found to be something that isapplicable universally in other situations  . . .  Theevidence base is only anecdotal and perhaps that  ’    s symptomatic of the field itself    . . .  To me it reflects the fact that what people take as quality assured knowledge is different from what they may just glean from all sorts of different sources. The question is how far they actually can judge what is good quality information and procedures and what is just what they have picked up from somewhere else  . . . ”   (Emergency Planning Academic and Technical Expert 2)This raises the issue of not just how practitioners ac-quire knowledge, but also how they may sufficiently discern its credibility and value. Consequently, the useof evidence in emergency planning, as one respondentdescribes, is  “ often patchy and impoverished ” .There were also issues with how knowledge was trans-ferred from academia to practitioners, how it is cascadedwithin organisations and communicated between organi-sations. Problems with these  ‘ knowledge transactions ’ often hinder the dissemination of knowledge. In turn,the knowledge needed to be adopted and implemented,as well as retained within organisations, and again pro-blems were reported. This also includes issues with how knowledge is contextualised and occasionally mis-applied to local situations. “   We don ’   t share our research with our practitionersin a good way.  . . .  (We need to) develop that mechanism for knowledge exchange  . . .  It  ’    s getting the knowledge out there about what happens, why it happens, making people aware. ”   (Emergency Planning Academic and Technical Expert 1) “    A lot of people do research in this area and then arevery frustrated that they don ’   t get their research into policy practice because they actually don ’   t share it with the people who need to know what  ’    s there becausethey don ’   t know how to share it. ”   Figure 2  Summary of thematic categories identified.  The key thematic categories identified include the knowledge-base used for emergencymanagement, individual and organisational behaviour, health care system issues and matters relating to the public in crisis/disaster situations. This figure further maps out the major themes linked with each category. Under the knowledge-base, it includes issues of how knowledge isacquired, appraised, disseminated, adopted and retained. The category of behaviour in emergencies includes decision-making, organisationalbehaviour in crisis as well as risk management. Health care system issues cover organisational set up and configuration of the emergencymanagement system, process issues of how the system operates, implementation challenges, as well as problems with how outcomes areidentified and measured in emergencies. The final category, the public dimension, covers public attitudes and expectations, communication withthe public, public engagement and the development of community resilience. Lee  et al. BMC Public Health  2012,  12 :884 Page 5 of 11
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