The Scottish Government

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1. INTRODUCTION

Throughout history, influenza pandemics have swept across the world. They affect every country in the world, causing illness, deaths and severe disruption to society, lasting from three months to a year. Managing the impact of an influenza pandemic therefore presents us with unique and difficult challenges if we are to save lives and keep our society running.

Planning to deal with the consequences of a pandemic is critical and this plan sets out the Scottish Executive's approach.

1.1 Why do we need a plan?

The UK Health Departments Pandemic Influenza Contingency Plan was last updated in October 2005. There have been a number of developments since then including -

• developments in scientific advice;
• advances in our national and local planning;
• developments in our communications plans;
• experience gained from UK and Scottish wide pandemic flu exercises, including a major exercise "Winter Willow" held in February 2007.

It makes sense to reflect these developments and our collective knowledge in our strategic planning framework.

However, this plan is primarily about saving lives and reducing the impact on individuals, communities and our society that a pandemic will have. This plan is about ensuring that, when (not if) a pandemic arrives we have planned to meet the consequences together and can therefore respond effectively together. Those consequences may be severe, but, as this plan shows, working together, making the most of our available resources and responding in a flexible way to the pandemic will help us to reduce its impact with benefits for all of us.

All of our planning effort is about keeping our services running in a sustainable way for as long as it is safe to do so. However, we must be realistic - if a pandemic is particularly severe, some services may find it very difficult to cope.

1.2 Who is this plan for?

This plan is primarily directed at those who are planning our response to an influenza pandemic and those who will, ultimately, be required to put those plans into action. This covers, for example, local and national Government, the NHS and community care services, transport providers, financial institutions and many other private and public bodies.

When pandemic influenza arrives in this country, we will be calling upon a wide range of individuals to help us to cope effectively. There will be expectations placed on frontline staff to continue to contribute their skills and knowledge during a pandemic at a time when resources are severely depleted and when everyone has to balance their responsibilities at work against their responsibilities at home. Frontline staff, in the NHS, for example, may also be asked to work flexibly and to undertake new roles for the duration of the pandemic.

There will also be expectations placed on members of the public, whose support and confidence will be crucial if we are to respond effectively. This will include - helping to tackle the pandemic by using infection control measures such as hand washing; helping to ease the strain on the NHS and community care services by caring for ill relatives at home; collecting drugs and prescriptions for ill friends and family; behaving responsibly to maintain public order; and, listening to and acting on Government advice and announcements.

If we want to place expectations on others then we also need to be prepared to offer support.

For frontline staff such as NHS and local authority staff, we need to ensure that arrangements are in place to cover alternative workforce arrangements, that pay agreements are in place, that appropriate protective equipment is provided, that counselling services are available and that relevant training is made available. It should be our aim to ensure that staff, are, in every way, supported to continue to come to work.

Members of the public must be given clear, consistent and regular information about the pandemic and the actions they should take. We must ensure that individuals and families are confident about the actions we will be taking across the country to enable us to continue to provide key services as far as we can. Our aim is to be as open as possible about the wide extent of planning that is taking place and about the measures we have available to use to deal with the impact. This plan sets out how information will be provided to the public during a pandemic and also provides information about infection control and policy on the use of masks, vaccines and antivirals.

1.3 The UK approach

This Scottish Framework is based on the published UK National Framework for Responding to an Influenza Pandemic.

That framework sets out the strategic approach to dealing with an influenza pandemic, provides information on the impact of the pandemic, sets out key planning assumptions and proposes a planning framework.

For the first time, this plan is a cross Government plan that illustrates the breadth of planning across many different sectors.

The Devolved Administrations work closely with the UK Government across the broad spectrum of planning activities. This includes attendance at all UK level planning groups and committees covering policy, operational planning, ethics and scientific advice. We all recognise very clearly that, since a flu pandemic knows no boundaries, we must also work effectively across administrative boundaries to ensure that our planning works in practice and that the strategic aims and fundamental principles of how we will respond to a pandemic apply equally across the UK.

The strategic aims, scientific advice and key planning assumptions for the Scottish Framework are therefore the same as those which appear in the UK Framework. In addition, fundamental planning principles apply equally across the UK, for example the key principles underlying the approach to care.

In this plan, our planning assumptions are based on 3 attack rates, as in previous versions of the plan - 25%, 35% and 50%. It is important to emphasise that planning should take place across the range of possible attack rates, including the upper end of the scale. To inform planning, we have considered the potential impact of fatality rates of 0.4%,1%,1.5% and 2.5%. At a 25% attack rate we could expect between 5,100 and 31,700 additional deaths in Scotland. At a 50% attack rate this could rise to between 10,200 and 63,700 additional deaths.

The estimates given in the plan for GP consultations and hospitalisations have increased. This is consistent with feedback we have received over the last 12 months from the NHS and has been taken into account, for example, in the approach to a primary care model.

1.4 The Scottish plan

The Scottish framework, whilst based on strategic aims and principles agreed across the UK, applies those aims and principles more specifically to Scotland - our population, our geography and the structure of our services, including our health and community care services.

The Scottish framework also sets out the conclusions of some of the national planning work which is taking place across all sectors.

Within health and community care services, the framework sets out where possible, the conclusions of a range of planning activities which the Scottish Executive is taking forward in partnership with the NHS and others. Those planning activities are based on a project plan led by the Scottish Executive Health Department.

The SEHD plan is based on ensuring that Scotland is well prepared to respond effectively to a pandemic, employing a range of measures in advance of and during a pandemic to mitigate its impact on health and community care services. To achieve that aim, the programme seeks to provide assurance of our preparedness in two key areas - SEHD and health and community care services. We want to ensure that SEHD is ready and able to respond to a pandemic and that health and community care services are ready and able to minimise loss of life and suffering. Additionally, good communications are required to promote confidence in Government and NHS Scotland both during preparations and in an outbreak so the plan also seeks to ensure that our communication arrangements promote stakeholder and public confidence.

Work on health and community care services includes a range of activities including prioritisation of services, care in the community, surveillance and vaccination. Whilst the conclusions of some areas of work are reflected in the framework, others are ongoing and more information will be available in due course.

Further details about Scottish Executive pandemic influenza planning activities can be found at: www.scotland.gov.uk/Topics/Health/health/AvianInfluenza/PandemicFlu

You can also sign up to our newsletter to obtain regular notice of new developments and best practice planning guidance at: http://register.scotland.gov.uk/?rt=187

STRATEGIC APPROACH

1.5 Aim and scope

Aim

This framework sets out the strategic approach of the Scottish Executive to planning for and dealing with an influenza pandemic. It proposes a framework for local decision making which should ensure the appropriate levels of national consistency and local flexibility. This includes a framework for the model of care which should be provided during a pandemic.

The primary aim of this framework is to guide and support those in health and community care and related organisations and agencies who are involved in planning for an influenza pandemic or who will be involved in delivering our response during a pandemic. It also provides information and key planning assumptions which will assist contingency planning and preparations for pandemic influenza across government and public and private sector organisations who will be dealing it's wider social and economic impact. The framework provides guidance both for those working at a policy or management level and those working at operational level on the frontline.

Fundamentally, it should also help organisations to work together across boundaries to ensure that our response is workable and effective in practice.

The response is based on the phases defined by the World Health Organisation ( WHO) in 2005 which trigger an escalation in the actions that need to be taken in the pre-pandemic, pandemic and post-pandemic phases.

Scope

This framework relates specifically to preparations for dealing with an influenza pandemic. It does not deal with avian flu. The section on the background to pandemic flu explains the links between the two.

1.6 Strategic objectives

The overarching objectives in planning and preparing for an influenza pandemic must be to reduce illness and save lives. However the Governments strategic objectives also recognise the need to prepare in accordance with the risk and resources available and to support the continuation of normal life as far as we realistically can.

The Government's key overarching strategic objectives are to:

• protect UK citizens and visitors against the health and wider consequences as far as possible
• prepare proportionately to the risk, taking into account both the likelihood of the emergence of a virus that could cause a pandemic and the likely impact

• support international efforts to prevent and detect its emergence and prevent, slow or limit its spread
• minimise the potential health, social and economic impact on the UK
• organise and adapt the health and community care systems to provide treatment and support for the large numbers likely to suffer from influenza or its complications whilst maintaining other essential care
• cope with significant numbers of deaths
• support the continuation of everyday activities as far as practical by protecting the ability of our critical national infrastructure to provide essential services
• uphold the rule of law and the democratic process
• instil and maintain trust and confidence by ensuring that the public and media are engaged and well informed in advance of and throughout the pandemic period
• promote a return to normality and the restoration of disrupted services at the earliest opportunity

For those planning their operational response to a pandemic, your aims should be to:

• develop an integrated response, working across boundaries
• respond promptly to changes in the pandemic alert levels
• develop a response which is flexible and proportionate but can be "ramped up" according to the severity of the pandemic, whilst acknowledging and addressing issues around scarcity of resources
• base your response on existing services, systems and processes wherever practical as this will be more easily understood by staff and by the public
• ensure you have also planned for the "recovery phase" between pandemic waves and for the post-pandemic phase
• test the effectiveness of your planned response against the views of your frontline staff and others
• consider the adaptability of your response to other emergencies and threats provided this won't compromise your pandemic response

The Health and Community Care Response

The challenge of reducing illness and saving lives during a pandemic will be to do so whilst also coping with the inevitable scarcity of both professional skills and resources. Professional health and community care skills are likely to be in short supply due to illness. In addition, depending on the severity of a pandemic, health and community care resources may be stretched far beyond their usual capacity. Therefore, although we must strive to maintain services as far as possible, the potential impact of a pandemic and the expected duration of one or more pandemic waves, will mean that available resources must be prioritised. This framework sets out the steps we recommend in order to deal with and prioritise the use of scarce resources. This covers:

• prioritisation of services; and the resulting impact on performance targets the utilisation of workforce skills and capacity
• dealing with staff absences.

In particular this framework recognises that it may be necessary to suspend any elective surgical work during a pandemic and that should this be the case, the emphasis will be on caring for flu patients and offering essential care for other illnesses .

Planning should also incorporate actions to be taken in the post pandemic phase to ensure that service recovery is built in and takes place as quickly as possible.

The health and community care aims are to reduce mortality and morbidity by:

• maintaining surveillance to detect the emergence of a novel virus strain or any illness attributable to it
• providing prompt access to rapid and reliable diagnostic tests
• providing data to monitor the impact and effectiveness of interventions, adjusting our response to reflect emerging data
• reducing disease transmission and rates of illness by applying infection control measures
• developing surge capacity to meet expected demand and making effective use of potentially scarce medical skills and resources
• reducing or ceasing non essential activity as demand increases but maintaining essential care
• assessing and treating all symptomatic patients promptly
• providing effective treatment for those suffering complications
• providing vaccination if and when suitable vaccines become available
• providing public advice, education and information

The response to an influenza pandemic in Scotland should be based within the overall context of emergency planning in Scotland and follow as closely as possible "Preparing Scotland: Scottish Guidance on Preparing for Emergencies" and the guidance on "Managing Incidents Presenting Actual or Potential Risks to Health" issued by SEHD in January 2003.

1.7 Scientific advice to underpin policy and operational plans

Scientific Advisory Group

To ensure that the best scientific advice is fed into policy and the development of operational plans the Department of Health, the Scottish Executive Health Department and other UK Health Departments are advised by a Pandemic Influenza Scientific Advisory Group ( SAG). The SAG meeting minutes and a regularly updated summary of the current position on mathematical modelling are published on the DH website.

Continued improvement in the scientific evidence base, and applying the result of ongoing research and modelling to the development of policy and operational plans, is of critical importance to the UK's strategic and operational response and that of Scotland working within a UK context. As scientific knowledge and information are constantly advancing regular revision and review of the Scottish framework and plans at all levels are essential.

UK National Influenza Pandemic Committee

The Chief Medical Officers of all 4 UK Health Departments receive specialist advice on the health response from the UK National Influenza Pandemic Committee ( UKNIPC). UKNIPC consists of clinical, scientific and other experts drawn from a range of relevant organisations and agencies. The Pandemic Influenza Scientific Advisory Committee ( SAG) and other UK expert advisory committees (such as the Advisory Committee on Dangerous Pathogens ( ACDP), National Expert Panel on New and Emerging Infections ( NEPNEI) and Joint Committee on Vaccination and Immunisation ( JCVI) on vaccination issues) also inform and support the work of UKNIPC.

Further consideration is being given to the need for scientific advice in Scotland.

1.8 Legal framework

International

Recently-revised International Health Regulations 2005 ( IHR) place a duty upon States to notify WHO of all events - irrespective of cause - occurring in their territory that potentially constitute a public health emergency of international concern. They also set out core requirements for surveillance and response. Annex 2 of the Regulations requires States that are parties to the IHR to notify WHO of any case of 'human influenza caused by a new subtype'. All WHO Member States are bound by the IHR unless they have rejected or entered a reservation.

The IHR come into force formally on 15 June 2007 (though States can have another year to adjust their legislative and practical arrangements if needed) but the World Health Assembly in May 2006 passed a resolution urging States to implement certain provisions of the IHR that are deemed relevant to pandemic flu earlier. The goal is to create a framework within which WHO and others can actively assist States in responding to international public health risks by directly linking the regulations to the WHO's alert and response activities.

The European Commission funds a European Influenza Surveillance Scheme ( EISS) that monitors and reports on influenza activity in the EU. Article 4 of Decision 2119/98/EC of the European Parliament requires Member States to inform the Commission and each other via the Communicable Diseases Early Warning and Response System of any relevant infectious disease threats with public health implications for other Member States and the control measures applied. The decision also requires member states and the Commission to collaborate in the control of communicable disease threats. The EU Centre for Disease Prevention and Control ( ECDC) in Stockholm provides supporting capacity and capability.

National

Public health powers in Scotland are provided by the Public Health (Scotland) Acts of 1897 (c.38), 1945 and Health Services and Public Health Act 1968 (c.46).

Powers under public health acts generally rest with the designated medical officer in Scotland. Key provisions include:

• powers to seek orders from a sheriff requiring a person to be medically examined and to be removed to and detained in hospital
• powers for a sheriff to request a person not to work with a view to preventing the spread of infection, to require a child who has been exposed to infection not to attend school
• the creation of criminal offences where people expose others to the risk of infection
• some powers to require the provision of information to help control the spread of disease

In Scotland, those powers are available for infectious diseases generally.

Part 2 of the Civil Contingencies Act 2004 established a new generic emergency powers framework. Emergency powers allow the Government to make special temporary legislation (emergency regulations) as a last resort in the most serious of emergencies where existing legislation is insufficient to respond in the most effective way. Emergency regulations may make provision of any kind that could be made by an Act of Parliament or by exercise of the Royal Prerogative, so long as such action is needed urgently and is both necessary and proportionate in the circumstances. Further information about the powers and safeguards in Part 2 of the Civil Contingencies Act please consult Chapter 13 of Emergency Response and Recovery or the Short Guide to the Civil Contingencies Act which can both be found on www.ukresilience.info/

For planning purposes, the presumption should be that the Government will rely on voluntary compliance with national advice and is unlikely to invoke emergency or compulsory powers unless they become necessary, in which case the least restrictive measures will be applied first.

1.9 Ethical considerations

In preparing for and responding to an influenza pandemic, people working at all levels from government to those on the front line will face difficult decisions and choices that will impact on the freedom, health and in some cases prospects of survival of individuals. Many people are also likely to face individual dilemmas and tensions between their personal, professional and work obligations. Given expected levels of additional demand, capacity limitations, staffing constraints and potential shortages of essential medical supplies, hard choices and compromises are likely to be particularly necessary in the fields of health and community care.

People are more likely to accept the need for and the consequences of difficult decisions if those have been made in an open, transparent and inclusive way. National and local preparations for an influenza pandemic should therefore be based on widely held ethical values, with the choices that may become necessary discussed openly as plans are developed so that they reflect what most people will accept as proportional and fair.

The UK Ethics Committee was established to provide advice and has developed an ethical framework to inform the development and implementation of health and social care and public health response policy. The systematic use of the principles it contains can act as a checklist to ensure that all the ethical aspects have been considered.

Further details of the ethical framework are available on the Department of Health website http://www.dh.gov.uk/PandemicFlu/fs/en

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