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Document control information
Policy Name: On-call Policy
Policy Number: EICB C021
Version: 1.0
Status: Final
Author / lead: Associate Director, Emergency Preparedness Resilience and Response
Responsible Executive Director: Accountable Emergency Officer
Responsible Committee: Audit, Risk and Compliance Committee
Date approved by Responsible Committee: 24 March 2026
Date ratified by the ICB Board/ Effective Date: TBC
Next review date: March 2029
Target audience: All ICB Board members and staff (including temporary/bank/agency/work experience staff, students and volunteers)
Stakeholders engaged in development of policy (internal and external):
– Accountable Emergency Officer
– Emergency Preparedness Resilience Response and System Coordination Centre Teams
-Workforce
Impact assessments undertaken:
– Equality Impact Assessment (see Appendix A)
– Quality Impact Assessment
– Privacy Impact Assessment
Version history:
Version: 0.1
Date: March 26
Author (Name and title): Associate Director EPRR
Summary of amendments made: First Draft for comments
Version: 1.0
Date: April 26
Author (Name and title): Head of EPRR
Summary of amendments made: Final approved version
Introduction
The NHS needs to plan for, and respond to, a wide range of incidents and emergencies that could affect health or patient care. These could be anything from extreme weather conditions, an infectious disease, or a major transport accident. This is underpinned by legislation and is referred to in the health services as Emergency Preparedness Resilience & Response (EPRR).
The Essex Integrated Care Board (the EICB), as a ‘Category 1 Responder’ under the Civil Contingencies Act (2004), must demonstrate it can deal with such incidents while maintaining services through its compliance with the NHS Core Standards for EPRR, and stand ready to coordinate the local NHS response. This includes maintaining robust 24/7 on-call arrangements to ensure leadership and decision making capability is continuously available.
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Purpose / Policy statement
This policy sets out the on-call arrangements for the EICB to ensure compliance with its responsibilities as a ‘Category 1 Responder’ and requirements under the NHS England EPRR Framework.
This policy should be read alongside the EICB EPRR and BCM Policy, which sets out the wider set of organisational responsibilities for how the EICB prepares for, responds to and recovers from incidents and emergencies.
This policy has been developed in accordance with the principles for On-Call Arrangements in Annex 29 of the NHS Agenda for Change.
Scope
This policy applies to all ICB staff at Agenda for Change Band 8c and above including VSM roles.
Definitions
This Policy uses definitions detailed within the EICB EPRR and BCM Framework. However, the following are specific to this policy:
- On-call – a suitably trained member of staff is on-call when, as part of an established arrangement with their employer, is available at their workplace, home or elsewhere. They hold a reasonable state of readiness while on-call to respond to escalations, incidents and emergencies.
Roles and responsibilities
EICB, as a Category 1 Responder under the Civil Contingencies Act (2004), maintains 24/7 on‑call arrangements to ensure effective NHS strategic and tactical leadership during incidents and emergencies, supported by appropriate escalation procedures for service disruptions and clear mechanisms for coordinating system‑level response and recovery.
The organisation ensures that suitably trained staff are available on‑call to lead the organisation and local NHS in an incident and emergency, as well as representing the system at a regional level and representing local NHS services at local multi-agency Strategic Coordination Groups (SCGs) and Tactical Coordination Groups (TCGs).
Further detail on the organisation’s broader statutory duties, governance arrangements, roles and responsibilities, and other supporting processes can be found within the overarching EICB EPRR and BCM Policy.
Accountable Emergency Officer (AEO)
This role, designated as the AEO, is held by the Executive Director for Corporate Services.
The AEO is a board‑level director with executive authority for ensuring that the EICB meets all legal, regulatory and policy requirements for EPRR. This explicitly includes having effective 24/7 on-call arrangements.
EPRR team
The EPRR team are responsible for maintaining and updating this policy in line with legislation and guidance. The EPRR team will collaborate with Workforce to ensure the policy is in line with NHS Agenda for Change and other organisational HR policies.
Additionally, the EPRR team are responsible for the day-to-day management of the EICB on-call rota and model including training and associated documentation.
System Coordination Centre (SCC)
It is the responsibility of the SCC to ensure an appropriate handover to on-call prior to its closure at the end of each day.
The SCC will also work in collaboration with the EPRR Team to ensure that on-call training and documentation used by on-call in relation to operational pressures and escalation processes are up to date.
Tactical commander
Refers to the role undertaken by a trained senior manager at Band 8C and 8D level who acts as the first point of contact when on-call for escalations, incidents and emergencies.
The Tactical Commander will provide tactical leadership of the organisation and/or local NHS response to an incident or emergency.
They may also be required to represent the EICB or local NHS at multi-agency or health sector meetings.
Strategic commander
Refers to the role undertaken by a trained director at Band 9 and VSM who acts as the second point of contact when on-call for escalations, and providers strategic leadership in the event of an incident or emergency.
They may also be required to represent the EICB or local NHS at multi-agency or health sector meetings.
Line managers
Line Managers of staff undertaking on-call responsibilities will ensure that staff are released to undertake appropriate training, maintain their competencies through appropriate continuing professional development (CPD) activity and attend debriefs relevant to their on-call duties.
On-call training will hold the same level of importance as mandatory training.
Policy detail
On-call model
The EICB’s on-call model operates 24 hours a day, 7 days a week, 365 days a year. Consisting of the following tiers:
- Tactical commander
- Strategic commander
The on-call model is underpinned by the following key elements:
- 24 hours a day, 7 days a week Switchboard – the EICB operates a dedicated, resilient 24 hours a day, 7 days a week emergency switchboard service. Upon receipt of a call the service will contact on-call staff based on the on-call rota following an agreed process to ensure a timely response including escalation if required.
- SCC – the SCC operates 7 days a week between 8:00am to 6:00pm and provides a central co-ordination service to providers across the EICB footprint. During its hours of operations, the SCC may become aware of an incident or emergency and initially coordinate the organisation and/or system response. In the event of an incident or emergency the SCC will escalate in line with the ECIB Incident Response Plan. In addition, on-call roles should liaise with the SCC during its hours of operation upon receipt of a call to discuss and agree approach.
- EPRR – during normal office hours the EPRR Team may initially coordinate the organisation and/or system response. Once an appropriate command structure is established the EPRR will provide subject mater advice and guidance.
Administration
An on-call shift is defined as a 24-hour period between 8:00am until 07:59am the following day.
On-call shift pattern for both Strategic and Tactical tiers will be:
- Monday from 8:00am to Friday until 7:59am; and
- Friday from 8:00am to Monday until 7:59am.
The EPRR Team will coordinate and maintain the EICB on-call rota for Strategic and Tactical on-call roles.
The on-call rota will be accessible at all times to all on-call staff using MSTeams / SharePoint. A fortnightly rota will be communicated each week to all on-call staff and shared with the 24/7 Switchboard Service Provider.
On-call rotas will be maintained at least 3 months in advance to provide sufficient notice of on-call duties. The EPRR Team will request annual leave prior to developing the rota and once published it is the responsibility of on-call staff to arrange cover and notify the EPRR Team of any changes.
It is the responsibility of on-call staff to inform the EPRR Team of any changes to contact details.
Expectations
On-call staff should ensure their work issued mobiles remain operational and suitably charged while on-call.
On-call staff are expected to respond within 15 minutes of a call and initiate any actions immediately.
There is no restriction on how far away from Essex on-call staff should be when on-call, however they will be expected to have access to a laptop and travel to face-to-face meetings while on-call if required.
On-call staff must maintain their fitness to discharge on-call duties, drive a vehicle and make defensible decisions.
If a staff member falls sick or is unable to fulfil their on-call shift (due to a personal emergency), they must ensure the EPRR Team are notified during normal hours to arrange cover, or other on-call tier so that a replacement to be arranged.
Documentation and accessibility
The EICB will ensure that on-call staff have the appropriate equipment to be contacted and undertake on-call duties – this usually includes a smartphone and a laptop.
The EPRR Team will ensure that on-call staff have access to appropriate documentation while on-call both on MSTeams / SharePoint and ResilienceDirect for local multi-agency documentation.
Record keeping
All on-call staff are expected to keep accurate, contemporaneous notes of escalations, incidents and emergencies they have been involved with in accordance with their training, Incident Response Plan and other supporting documentation.
Continuous Improvement – training and exercising
All on-call staff will be trained and participate in exercises in accordance with the EICB EPRR Training Needs Analysis (TNA) to ensure competence with the Minimum Occupational Standards for EPRR.
Staff undertaking on-call are expected to demonstrate competence against the required standards in line with the EICB EPRR TNA.
Staff undertaking on-call are also strongly encouraged to maintain a CPD portfolio.
The EPRR Team will maintain a central record of on-call training and exercising for the organisation.
On-call must maintain up-to-date training and competencies in line with the TNA. Where an individual fails to meet or maintain these standards, the organisation may temporarily – or, where necessary, permanently – remove that individual from on-call duties. Any such removal will also result in the withdrawal of associated on-call payments until full compliance with training requirements is restored.
On-call payment
All Agenda for Change staff undertaking on-call will receive a set payment of £2,000 per annum plus staff are paid for time worked. This is dependent on maintaining their competencies to fulfil on-call.
VSM staff will receive no on-call payment.
Monitoring compliance
The Audit, Risk and Compliance Committee is responsible for monitoring the implementation of this policy and ensuing it is reviewed as required.
Implementation and staff training
The EPRR Team lead operationally on the implementation and monitoring of this policy, reporting compliance to the AEO and the Audit, Risk and Compliance Committee.
There is a requirement as part of local inductions to ensure that staff are made aware of the importance of policies and procedures and their adherence to them.
Compliance with specific training requirements detailed in this policy will be monitored by the Audit, Risk and Compliance Committee.
Arrangements for review
This policy will be reviewed no less frequently than every three years. An earlier review will be carried out in the event of any relevant changes in legislation, national or local policy/guidance, organisational change or other circumstances which mean the policy needs to be reviewed. Policy reviews should seek input from relevant stakeholders, including Staff Side/Staff Engagement Group for HR policies, and other appropriate fora including the Executive Team.
If only minor changes are required, the sponsoring Committee has authority to make these changes without referral to the EICB Board. If more significant or substantial changes are required, the policy will be ratified by the relevant committee before final approval by the EICB Board.
Associated policies, guidance and documents
For this policy the associate documentation is:
- Incident Response Plan
- Business Continuity Management System
- Essex ICB EPRR and BCM Policy
- Essex ICB Risk Management Policy
- Essex ICB Information Governance Policy
- Essex ICB Health & Safety Policy
- Essex ICB Incident Reporting Policy
References
- NHS England EPRR Framework
- NHS England Core Standards for EPRR
- NHS England Business Continuity Management Toolkit aligned to ISO 22301
- Joint Doctrine: The Interoperability Framework (JESIP)
Equality impact assessment
The EIA has identified no equality issues with this policy.
The EIA has been included as Appendix A.
Appendix A – Equality impact assessment
Initial information
Name of policy and version number: Essex ICB On-Call Policy
Directorate/Service: Corporate Services
Assessor’s Name and Job Title: Associate Director EPRR
Date: 1 April 2026
Outcomes
Evidence
Analysis of impact on equality
The Public Sector Equality Duty requires us to eliminate discrimination, advance equality of opportunity and foster good relations with protected groups. Consider how this policy / service will achieve these aims.
N.B. In some cases it is legal to treat people differently (objective justification).
- Positive outcome – the policy/service eliminates discrimination, advances equality of opportunity and fosters good relations with protected groups
- Negative outcome – protected group(s) could be disadvantaged or discriminated against
- Neutral outcome – there is no effect currently on protected groups
Please tick to show if outcome is likely to be positive, negative or neutral. Consider direct and indirect discrimination, harassment and victimisation.
| Protected group | Positive outcome | Negative outcome | Neutral outcome | Reason(s) for outcome |
|---|---|---|---|---|
| Age | X | Duties under this policy are fulfilled on a banding/voluntary basis. | ||
| Disability(Physical and Mental/Learning) | X | An individual assessment of ability to undertake duties outlined in this policy is undertaken with the option of reasonable adjustments. | ||
| Religion or belief | X | Duties under this policy are fulfilled on a banding/voluntary basis. | ||
| Sex (Gender) | X | Duties under this policy are fulfilled on a banding/voluntary basis. | ||
| Sexual Orientation | X | Duties under this policy are fulfilled on a banding/voluntary basis. | ||
| Transgender / Gender Reassignment | X | Duties under this policy are fulfilled on a banding/voluntary basis. | ||
| Race and ethnicity | X | Duties under this policy are fulfilled on a banding/voluntary basis. | ||
| Pregnancy and maternity (including breastfeeding mothers) | X | An individual assessment of ability to undertake duties outline in this policy is undertaken with the option of reasonable adjustments. | ||
| Marriage or Civil Partnership | X | Duties under this policy are fulfilled on a banding/voluntary basis. |
Monitoring outcomes
Monitoring is an ongoing process to check outcomes. It is different from a formal review which takes place at pre-agreed intervals.
Review
Implementing the policy/service
Negative outcomes – action plan
If there are no negative outcomes, please remove this section.
An Equality Impact Assessment cannot be signed off until negative outcomes are addressed. What actions you have taken/plan to take to remove/reduce negative outcomes?
- Action to be taken: N/A
- Date: N/A
- Person responsible: N/A
Signed off by: Associate Director EPRR
Date: 1 April 2026