Summary of the impact

The North Atlantic Treaty Organisation (NATO)/Euro-Atlantic Partnership Council (EAPC) Guidance on "Psychosocial Care for People Affected by Disasters and Major Incidents: a Model for Designing, Delivering and Managing Psychosocial Services for People Involved in Major Incidents, Conflict, Disasters and Terrorism" is a conceptual and practical resource for: developing government policy; planning services, and providing training for health and social care staff. It was informed by underpinning research conducted in Aberdeen following the 1988 Piper Alpha oil platform disaster and evidence briefings generated from a comprehensive review of the world literature. Adopted as best practice guidance by all 28 NATO Members and Partner Nations, it has had regional, national and international impact by: enabling authorities to deliver integrated psychosocial care and mental health services; enhance training; raise awareness, and facilitate the effective utilisation of resources in responding to psychosocial/mental health needs post- incident.

Underpinning research

The contents of the NATO/EAPC Guidance is based on evidence briefings produced by the Aberdeen Centre for Trauma Research (ACTR), which included the outcome of a comprehensive review of the world literature comprising: (i) papers published in peer-reviewed journals; (ii) articles written by recognised authorities in the field (including clinicians, researchers, other academics, and administrators); (iv) existing guidelines, models of disaster response, (v) and related documents in the public domain. A key source of the underpinning research was the peer-reviewed outputs from a comprehensive programme of research conducted by the ACTR; a unique UK venture established in 1999 by Professors Alexander and Susan Klein to support evidence-based practice. It builds on the seminal study undertaken by Professor Alexander after the 1988 Piper Alpha oil platform disaster, which comprised a long term follow-up of police officers involved in the retrieval of bodies of those who perished [1]. This research has been influential in demonstrating the extent to which organisational and managerial practices are powerful antidotes to adverse post-traumatic reactions. It also remains unique due to the inclusion of both a pre-disaster baseline and a control group of police officers (by virtue of participation in the first ever, occupational health survey of an entire UK Police Force commissioned by the Police Foundation from 1987-90 [2]).

Subsequent Chief Scientist Office funded research involving a novel evaluation of the impact of dealing with critical incidents on Scottish ambulance personnel challenged the myth that careful selection, good training, altruistic motivation and experience are necessarily protective factors in terms of mental health and wellbeing [3]. This work initiated the implementation of a national peer support and welfare network within the Scottish Ambulance Service as part of its Human Resources and Development Strategy [4]. Organisations are required in law (i.e., statutory "duty of care") to develop a systematic approach to addressing individual needs post-incident according to best practice. Because no single traumatic event necessarily causes psychosocial and mental health problems in all those exposed to it (as evidenced by a 10 year follow-up study of the Piper Alpha survivors [5]), there is a clinical and economic need for the selective use of interventions applied only to those who are at risk of developing psychosocial and mental health problems. Relatedly, the ACTR developed a unique brief screening tool for use by non-mental health professionals [6]. From an international perspective, the ACTR (as part of the Pakistan-Aberdeen Collaborative Trauma Team [PACTT]) undertook a needs-based assessment/epidemiological survey to develop an appropriately delayed mental health and psychosocial intervention for survivors of the 2005 Pakistan Kashmir earthquake [6] under the aegis of 3-year Higher Education Commission and British Council Joint Higher Education Link Programme award.

By virtue of its international reputation in trauma research and disaster management, the ACTR was commissioned by the Department of Health (DH; Emergency Preparedness Committee) from 2007-08 to review the literature and produce evidenced briefings for the contents of the NATO/EAPC Guidance. The Research Assessment Team was led by Professor David A Alexander (Director, ACTR); a member of the Guidance Development Advisory Group (GDAG) and the Guidance Development Editorial Group. Professor Klein (Then Reader in Trauma Research, ACTR) contributed to the evidence synthesis and was a GDAG member. Thereafter, a team from the expert group were responsible for its development under Dr Penny Bevan (Director Emergency Preparedness Division, DH, England) as the UK Civilian Representative on the NATO Joint Medical Committee and Chair of the GDAG. Professor Richard Williams (Professor of Mental Health Strategy, University of Glamorgan and the Gwent Healthcare NHS Trust, Scientific Adviser on Psychosocial and Mental Health to DH) and Dr Verity Kemp (Project Manager, Review of NHS Emergency Planning Guidance, Emergency Preparedness Division, DH; England Project management support to the GDAG) drafted the guidance.

References to the research

*References [1], [3], [5], and [6] are cited in The British Psychological Society "Database of Disaster Resources"(2008) and compiled by the Working Party on Disaster, Crisis and Trauma:
http://www.bps.org.uk/sites/default/files/documents/database_of_disaster_resources.pdf

Funding received to support underpinning research:

Police Foundation £49,060 (1987-90); CSO £12,063 (1997-98); Grampian Healthcare NHS Trust £18,976 (1997-98); CSO £8,805 (1998-99); CSO £154,489 (1998-2001); Tenovus (1999-2001); Millar McKenzie Trust £9,470; Pakistan Higher Education Commission and British Council Joint Higher Education Link Programme £30,000 (2007-10), and DH/NATO £46,700 (2007-8).

Details of the impact

Typically, major incidents are characterised by substantial loss, physical and psychological injury and economic hardship, as well as by extensive internal displacement and damage to the social and economic infrastructure [1]. Considerable evidence now exists to show that technological and natural disasters, terrorist incidents and military conflict are complex and increasingly common events. For example, in 2012, 357 natural disasters resulted in: 9,655 deaths (annual average 2002-11:107,000); 124.5M victims worldwide (annual average 2002-11:268M), and economic damages estimated at $143 billion (CRED 2012 Annual Disaster Statistical Review). The severity and extent of such incidents has potential to challenge the coping abilities of individuals and communities and may result in a wide range of psychosocial/mental health consequences in the immediate, intermediate and long term [5]. Despite the frequency of major incidents worldwide, and their potential to affect large numbers of people, it is only relatively recently that national policies, strategies and local operational practices for emergency preparedness, response and recovery, have been developed. Two factors, in particular, have led to this development. First, a burgeoning body of empirical evidence bears testimony to the wide reaching effects of disasters and major incidents on the mental health and psychosocial adjustment of those affected. Second, a number of international bodies (e.g. the World Health Organisation [WHO], International Agency Standing Committee [IASC], and the North Atlantic Treaty Organisation [NATO])/Euro-Atlantic Partnership Council [EAPC]) have sought to address risk and disaster prevention by recommending the application of measures to promote personal and social resilience in the face of major incidents. To this end, a substantial amount of work has been undertaken in the development of key European policy papers and international guidelines, which includes the 2009 NATO/EAPC Guidance [A].

The purpose of the NATO/EAPC Guidance is to enable national authorities to adopt a joined-up approach that encompasses a stepped model of care. Based on core principles in providing psychosocial care and mental health services, specific prominence is given to: strategic leadership and planning; developing collective community resilience, and providing services proportionate to the individual needs of those affected by disasters and major incidents. This joined-up approach also enables full integration into wider emergency planning policy in respect of the four levels of: (i) governance policies; (ii) strategic policies for service design; (iii) service delivery policies, and (iv) policies for good clinical practice. With all 28 NATO Members and Partner Nations now signed up to the NATO/EAPC Guidance, this development has been of signal importance in fulfilling the 2010 Council of the European Union call upon Member States to include psychosocial support as a means of mitigating the adverse psychosocial effects of major incidents on affected populations and first responders. It has had impact in terms of both reach and significance at regional, national and international levels, as evidenced by the following examples.

Public policies and services improved: The NATO/EAPC Guidance has been key to informing the NATO-TENTS Guidelines of Principles, which incorporates work conducted under the European Union by the European Network for Traumatic Stress (TENTS) project (http://www.tentsproject.eu/) to combine the common principles and recommendations of both sets of guidance in a single 2009 document, "Guidance for Responding to the Psychosocial and Mental Health Needs of People Affected by Disasters or Major Incidents" [B]. Within the UK, it has enabled: (i) English Government 2009 Guidance "Department of Health interim national strategic guidance on NHS emergency planning" [C], which is being rolled out progressively by the Health Protective Agency (HPA) and the Ambulance Services. It is cited as the core text for informing DH 2009 guidance on the "Psychosocial care for NHS staff during an influenza pandemic" [D], and the HPA 2011 report on "The Effects of Flooding on Mental Health" [E]; (ii) Welsh Government Assembly 2012 Guidance [C]; (iii) Scottish Government 2013 Guidance on "Preparing for Emergencies: Planning for the Psychosocial and Mental Health Needs of People Affected by Emergencies" by an Expert Advisory Group (which included Professors Williams and Klein) under the auspices of the Scottish Government Health and Social Care Directorates. Its purpose is to provide best practice national strategic guidance for Scotland and is designed to be used in conjunction with the Resilience Advisory Board for Scotland (RABS) documents ("Preparing Scotland"; Recovering from Emergencies in Scotland", and "Preparing Scotland: Care for People Affected by Emergencies") with particular relevance to the Care for People Teams in their key co-ordinating role within 8 Strategic Co-ordinating Groups (responsible for incorporating the guidance into local plans including the 14 regional NHS Boards of NHS Scotland) [F]. The guidance will be published in December 2013 and launched at an event at the Scottish Police College (06.12.13) organised under the aegis of the Scottish Resilience Development Service (ScoRDS) with 105 funded places over the 3 Regional Resilience Partnerships, and (iv) Republic of Ireland Guidance, which is currently being developed. Training improved: Through Professor Williams and Alexander, the NATO/EAPC Guidance has influenced: (i) TENTS teaching and practice (TENTS-TP EU funded project [2009-9011]) [G]; (ii) course content and examination for the Diploma in the Medical Care of Catastrophes (The Worshipful Society of Apothecaries of London [2009-present]) [H]; (iii) Short course on "Managing Disasters" (Royal College of Psychiatrists [2011]) comprising 4 levels of training for mental health professionals [I], and (iv) Psychosocial Resilience and Ambulance Service Seminar organised by Heads of Ambulance Education UK (HEDS) Group at the University of West England (18.07.13) to report findings from a Psychosocial Tools Project (sponsored by the DH) as an evidence-base for new education and guidance materials for NHS staff and patients. Awareness improved: Through Professors Alexander and Klein, the NATO/EAPC Guidance has been the basis for raising awareness in organisations regionally (e.g., 5 workshops to oil and gas companies); nationally (e.g. Scottish Government: RABS [2009]; BASICS Scotland 2012), and internationally (e.g. Norwegian International Conference on Disaster Psychology [2010],Pakistan School of Military Intelligence [2012]; CISM Network Ireland [2012]).

Humanitarian response improved: Through Professors Alexander and Klein, the NATO/EAPC Guidance has enhanced the provision of 2 Humanitarian Assistance Centres (HACs) established in Aberdeen following 2 major helicopter incidents in 2009 and 2013. The HAC is a facility set up by a local authority to provide a seamless multi-agency response to anyone affected by the incident by enabling the access of information and support (e.g. www.stish.org) in a timely and co-ordinated manner. For example, 160-70 people who had been affected by the 16 deaths (2 crew and 14 offshore workers) of the 2009 incident visited the HAC over a 3-week period. Most recently, the principles have been applied in the care of those affected by Nairobi mall massacre which left 72 people and more than 200 injured. Professor Williams is engaged in related work with the Foreign Office in dealing with diplomats post-incident.

Sources to corroborate the impact

[A] NATO/EAPC 2009 Guidance: http://www.healthplanning.co.uk/nato/

[B] NATO-TENTS Guidelines of Principles: http://www.healthplanning.co.uk/nato/

[C] DH 2009 Guidance: https://www.gov.uk/national-recovery-guidance-humanitarian-aspects

[D] DH 2009 Influenza Pandemic Guidance:
http://www.psychosocialresilience.org.uk/files/files/dh_103189(1).pdf

[E] HPA 2011 flooding report:
http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1317131788841

[F]Guidance for Health Boards in Scotland: http://www.scotland.gov.uk/Resource/0043/00434687.pdf

[G] TENTS-TP — The European Network for Traumatic Stress Training & Practice:
http://www.tentsproject.eu/index.jsp?USMID=109

[H] Apothecaries of London Diploma in the Medical Care of Catastrophes:
http://www.apothecaries.org/examination/diploma-in-the-medical-care-of-catastrophes/

[I] Royal College of Psychiatrists — Short courses on "Managing Disasters"
https://www.estss.org/uploads/gravity_forms/1/2011/08/CETC_Managing%20Disaster.pdf