Recent concerns raised by ambulance service leaders have brought NHS emergency preparedness back into sharp focus, highlighting the governance and resilience challenges facing organisations responsible for responding to major incidents.

Anthony Marsh, Chief Executive of West Midlands Ambulance Service University NHS Foundation Trust, has warned that the ambulance sector is not sufficiently trained, equipped or resourced to respond immediately to an incident comparable with the Manchester Arena attack or the London 7/7 attacks. His concerns come almost a decade after the Manchester Arena attack and subsequent recommendations aimed at strengthening the response to mass casualty incidents.

For NHS boards and senior leaders, the issue extends beyond emergency response capability. It raises important questions about how effectively organisations identify, assess and manage high-impact risks, and how boards gain assurance that their emergency preparedness arrangements will work when they are needed most.

Preparedness under pressure

The Manchester Arena Inquiry called on ambulance trusts to review their ability to respond to mass casualty incidents and identify the funding required to address capability gaps. However, discussions around the additional resources needed have continued for several years.

The scale of the challenge is significant. West Midlands Ambulance Service has identified a requirement for an additional £32 million per year in revenue funding, alongside £23 million in capital funding, while the ambulance sector collectively has indicated that a nine-figure investment may be required to implement the relevant recommendations fully.

The requirements are not solely financial. Additional capacity includes specialist personnel such as hazardous area response teams and tactical commanders within emergency operations centres, alongside appropriate equipment and infrastructure.

Meanwhile, NHS England guidance earlier in 2026 required acute trusts designated to receive casualties to be capable of clearing 10% of their beds within six hours.

Together, these pressures demonstrate why emergency preparedness cannot operate in isolation. It is closely connected to workforce capacity, financial sustainability, business continuity, operational resilience and wider organisational risk management.

From emergency plans to meaningful assurance

For boards, having an emergency or major incident plan in place is only the starting point.

Strong governance requires leaders to understand whether those arrangements are realistic, adequately resourced and regularly tested. Organisations should be able to demonstrate not simply that a plan exists, but that staff understand their roles, critical dependencies have been identified and lessons from exercises and previous incidents have translated into measurable improvements.

Boards and Audit Committees may therefore want to consider:

  • Are major incident risks adequately reflected within the organisation’s risk management arrangements?
  • When were emergency and business continuity plans last tested, and what did those exercises reveal?
  • Are gaps in staffing, equipment, training or infrastructure clearly reported and escalated?
  • Do senior leaders understand the organisation’s dependencies on neighbouring NHS bodies, emergency services and other partners?
  • Is there clear ownership and oversight of actions arising from exercises, incidents and external reviews?
  • Can the organisation provide evidence that its planned response remains achievable under existing operational pressures?

These questions are particularly important where organisations are already managing constrained capacity. A theoretically robust plan may provide limited assurance if the people, equipment or capacity required to deliver it are unavailable in practice.

Learning must lead to action

One of the most important principles arising from any major incident is the need for organisations to demonstrate that lessons learned result in lasting change.

Reviews, exercises and inquiries can identify weaknesses, but effective governance depends on recommendations being translated into actions with clear owners, realistic timescales and appropriate executive and board oversight.

This is where internal audit and assurance can add significant value. Independent review can help organisations examine whether emergency preparedness arrangements are properly embedded, whether identified actions have been completed and whether boards are receiving meaningful assurance about resilience rather than relying solely on the existence of policies and plans.

Strengthening organisational resilience

Major incidents are, by their nature, difficult to predict. That makes robust preparation even more important.

NHS organisations should continue to challenge whether their emergency preparedness, resilience and response arrangements accurately reflect their current risk environment and operational capacity.

For boards, the central question is straightforward: if a major incident happened tomorrow, what evidence provides assurance that the organisation could respond effectively?

Being able to answer that question confidently requires more than a plan. It requires effective governance, tested arrangements, appropriate resources, organisational learning and clear lines of accountability.

How Tiaa can help

Tiaa works with healthcare organisations to strengthen governance, risk management, assurance and organisational resilience. Independent assurance can help identify gaps, test whether controls and plans are operating effectively, and provide boards and senior leaders with greater confidence in their organisation’s preparedness.