This article explores the legislative development of health care preparedness and resilience in the United States and the United Kingdom. Research data devoted to understanding the evolution of the different systems with regard to emergency management legislation are rare in the literature. The major legislation that established resiliency forums in the United Kingdom (2004) and health care coalitions (2006) in the United States are silent on international models and influences due to the relatively short history of development and implementation. In each country the legislation is explicitly discussed and described in response to recent internal catastrophic events. This article explores the underlying events and legislative outcomes that helped to formulate significant policy considerations and governance guidelines resulting in unique but at times similar outcome approaches adopted in each country (Table 1).
TABLE 1 US and UK Events and Enacting Legislation (1960s-2000s)Footnote a
a Abbreviations: CCA, Civil Contingencies Act; CCS, Civil Contingencies Secretariat; EPRR, Health Emergency Preparedness, Resilience, and Response; HFA, Hyogo Framework for Action; IRA, Irish Republican Army; LHRP, local health resiliency partner; LRF, Local Resiliency Forum.
SIGNIFICANT EVENTS AND MAJOR LEGISLATION: THE US PERSPECTIVE
For much of the history of the United States, federal government assistance was often nonexistent. Natural disaster relief and response was left to local government, churches, and civic groups, and individuals were considered the primary delivers of management and relief activities.
Between 1803 and 1947, 128 specific pieces of disaster relief legislation were passed.Reference Wood-Heath and Annis 1 In 1934 Congress authorized the establishment of the Reconstruction Finance Corporation and the Disaster Loan Corporation in 1937 for the purpose of granting loans for the rebuilding of public facilities damaged by disasters. The Texas City fertilizer explosion in 1947 led to establishment of many of today’s liability criteria for government disaster responsibility.
In 1979 the Federal Emergency Management Agency (FEMA) was created by executive order. Executive Order 12127 in 1988 established the Stafford Act which is an amended version of the Disaster Relief Act of 1974 and established authority for disaster declaration protocols. Further amendments include the Homeland Security Act of 2002, Post Katrina Emergency Management Reform Act 2006, and the Sandy Recovery Improvement Act of 2013.
With the initial decade of the 21st century came the need for responding to a series of biological attacks and for preparing the United States for the continued threat of pandemics. Congress passed a number of public health preparedness pieces of legislation, consisting of the Biological Weapons Anti-Terrorism Act of 1989, Public Health Security and Bioterrorism Preparedness Response Act (2002), Biodefense and Pandemic Vaccine and Drug Development Act of 2005, and Public Readiness and Emergency Preparedness Act (2005). The Pandemic and All-Hazards Preparedness Act (2006 subsequently reauthorized in 2013) established the Office of the Assistant Secretary for Preparedness and Response (ASPR) and codified the concept of the health care coalition.
SIGNIFICANT EVENTS AND MAJOR LEGISLATION: THE UK PERSPECTIVE
The United Kingdom has adopted a decentralized approach to emergency management. This approach since approximately 1998 has been defined by the term resilience. Soon after its creation in 2001, the Civil Contingencies Secretariat defined resilience as “the ability at every level to detect, prevent and if necessary handle disruptive challenges.”Reference Ekici and Ekici 2
Resilience has not always been a concept associated with decentralized emergency management in the United Kingdom. An evolution came as national crises exposed deficiencies in the emergency management approach of the United Kingdom. Government reports encouraged policy changes with a greater focus on preparedness and recovery rather than response.
The impetus and focus of UK emergency powers legislation was on civil unrest and strikes. The focus continues to have a large influence on the United Kingdom’s emergency management development as has domestic terrorism also. The enactment of the Prevention of Terrorism Act (PTA) of 1974 was a response to the bombing campaign moving from Northern Ireland to other parts of the United Kingdom.Reference Wagstaff 3 The PTA was substantially revised due to civil rights issues in much the same way the US Patriot Act was to be a generation later as the original terrorist threat receded.
In the early 2000s the United Kingdom adopted the concept of resiliency with a clear focus on preparedness and recovery. The fuel crisis and the flooding of 2000 led to the creation of the Civil Contingencies Secretariat (CCS).Reference Bosher 4 The CCS reports directly to the Prime Minister’s Office and replaced the Home Office (closest US equivalent is the Department of Homeland Security) as controller of emergency planning and response.
The responsibilities of the CCS encompassed the coordination of risk identification through the use of the National Risk Assessment and the National Risk Register. The CCS is responsible for contingency planning and for developing a resilient national infrastructure and private sector.
Response to the 2000 floods and the foot and mouth outbreak (2001) was determined to be deficient. In 2004, the Civil Contingencies Act (CCA), which was a major overhaul of the current emergency management system, was enacted.
COALITION UTILIZATION AND RESILIENCY: US APPROACH
Throughout US disaster history the military has played a role in response and recovery. The 1906 San Francisco earthquake and subsequent fire illustrates the military’s vital response and support function, building tents, feeding survivors, and fighting fires. The amending of the Civil Defense Act in 1976 allowed state and local governments to spend funds other than preparing for nuclear attacks. This funding expansion began the shift in emergency management leadership responsible for state and local preparedness.
Since 9/11 the use of military assets and resources for disaster coordination, preparedness, and response has grown significantly. Whether these are natural or manmade disasters, interaction between civilian and military planning and collaboration is increasing. However, merging and overlapping of civilian/military functionality is a concept faced with both political and legal challenges. This collaborative relationship has evolved and expanded into one component of the coalition framework utilized for US preparedness and response operations. 5 , 6
In more recent years the ASPR maintained the lead role in the administration of the Hospital Preparedness Program, the predecessor to the coalition shift within the United States. The Hospital Preparedness program resulted in the refocus of health care preparedness from bioterrorism to enhancing hospitals’ response to an all-hazards environment. Presently, ASPR provides the framework for developing and implementing a coalition-based approach for health care system preparation, response, and resiliency. The framework aligns 15 Public Health Preparedness Capabilities and the 8 aligned Healthcare Preparedness Capabilities. This framework is intended to enhance and promote community resilience and preparedness efforts for building intercollaborative networks designed to function in a better coordinated manner during disaster events. 7
COALITION UTILIZATION AND RESILIENCY: UK APPROACH
Through the framework of resiliency, the CCA encompassed a multi-disciplinary and multi-hazard planning approach to emergency management, with 8 underlying principles: preparedness, continuity, subsidiarity, direction, integration, communication, cooperation, and anticipation.Reference Bosher 4
The CCA has 2 major parts:
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∙ A framework for local-level civil protection that introduced leaders of multi-agency partnerships for each police area, known as Local Resiliency Forums (LRFs). The National Health Service is considered a Category 1 responder and required to participate in the LRF. Each LRF is charged with promoting resilience through coordinating the identification, assessment, and planning procedures necessary to mitigate risk and ensure continuity following a disaster.
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∙ An update of national emergency powers (updating to the previous Emergency Powers Acts of 1920 and 1964. These powers are considered a “last resort and shall be applied only in exceptional circumstances.”Reference Bosher 4 (p284)
In 2011 the CCA established a Resilience and Emergencies Department to facilitate communication between LRFs. 8
In the last 11 years the CCA has been fully reviewed twice. The Pitt Review was a comprehensive evaluation of the emergency management response to the 2007 English flooding (13 deaths and 55,000 properties flooded). Among the 92 recommendations were that each Local Resiliency Forum should review and share their lessons learned in order to inform them for future planning.Reference Pitt 9 In 2013 The United Nations Hyogo Framework for Action was also applied to the United Kingdom.
The UK model of emergency management assumes a primary role for government. Increasingly local government and local resilience forums are given primacy, but private sector contributions are assumed to be small.
THE US HEALTH CARE COALITION AND EMERGENCY MANAGEMENT MODELS
The US currently maintains an all-hazard approach to planning and response operations consisting of a unified command structure with multi-agency coordination. This system is utilized for all natural, manmade, technological, and public health emergencies.
The coalition model has a shorter history with a focus on developing a nongovernmental structure. Governance models consisting of 501(c)3 private foundations or public charities, 509(a)3 supporting organizations, 501(c)6 business league/trade organizations, or private embed within an existing organization framework have each been proposed.Reference Hanfling and Stephens 10 Statewide utilization of coalitions within existing individual state health department systems is also a model that is becoming more frequently implemented. Health care coalitions and emergency management agencies work closely in all phases of the disaster paradigm within the US disaster system.
THE UK HEALTH CARE RESILIENCY FORUMS AND EMERGENCY MANAGEMENT MODELS
It was not until 2013 that health care–specific resiliency forum activities were proposed by CCA. In April of 2013, the newly enacted Health and Social Care Act took effect. The Act made significant changes to the emergency management model associated with health care organizations by establishing Health Emergency Preparedness, Resilience, and Response (EPRR) in order to ensure a safe and consistent emergency management system in the health sector. 11 Local health resiliency partners were also established. Local health resiliency partners specifically deal with the health care sector at the local level and aid LRFs in the coordination of disaster preparedness, response, and recovery. 11
CONCLUSION
Perhaps it is self-evident that the development of major emergency legislation is reactive as well as nation-specific, because the societal shocks that demand legislative change are so profound at the time. Hurricane Katrina, 7/7, and 9/11 all fall into this category. The legislation then sets in motion responses that refer back to those events, but not always forward to future challenges. This article attempted to provide a detailed account of the development of emergency legislation in the United Kingdom and the United States. With this complete, it may be appropriate to propose for future research a complete comparative analysis of the developed frameworks in which each country’s system strengths, weaknesses, and best practices are identified.
