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2 The Context Of Influenza Planning In Primary Care

2.1 Civil Contingencies Act 2004

NHS Boards are identified as Category 1 responders in the Civil Contingencies Act 2004. Boards therefore have a responsibility to prepare for emergencies, which include infectious disease emergencies such as an influenza pandemic.

An emergency as defined by the Civil Contingencies Act is: 'An event or situation that threatens serious damage to human welfare in a place in the UK or to the environment of a place in the UK, or war or terrorism which threatens serious damage to the security of the UK.'

To constitute an emergency, this event or situation must require the implementation of special arrangements by one or more Category 1 responder. An NHS Board therefore has responsibility for developing and maintaining a major incident plan that is built on the principles of risk assessment, cooperation with partners, emergency planning, communicating with the public and information sharing.

2.2 The operational challenge

An influenza pandemic will present unique international, national and local challenges to the delivery of health and community care, producing case numbers likely to be far in excess of the capacity and capability of both systems to cope in conventional ways. Although curtailing non-urgent activity will release some hospital capacity it is likely that it will become quickly oversubscribed. This means that, in the majority of cases, influenza sufferers' initial assessments and subsequent care and support will have to be provided outside of hospital. This will therefore create particular pressures on primary and community care.

Even when there are small numbers of people infected or potentially infected, it is likely that public concern and demand for information (and potentially treatment and/or medication) from primary care services will be high.

As a pandemic spreads, primary health care organisations will find that, because of the parallel pressures on hospital services, there are more people with acute care needs that need to be treated and cared for within the community setting. This will occur at a time when community healthcare resources in terms of staff, consumables and utilities are likely to be compromised.

Primary Care services are likely to be faced with:

• the increased workload of patients with influenza and its direct complications
• the particular needs for infection control facilities and equipment
• additional pressure on health services caused by anxiety and bereavement
• depletion of the workforce and of numbers of informal carers, due to the direct or indirect effects of influenza on themselves and their families
• logistical problems due to possible disruption of supplies, utilities and transport as part of the general disruption caused by an influenza pandemic
• delays or difficulties in dealing with other medical conditions
• longer-term shortages in supplies due to the macroeconomic effects of an influenza pandemic on the national (and global) economy
• an increase in deaths and pressure on mortuary facilities (possibly exacerbated by delays in death registrations and funerals)
• pressure on social services, which will impact upon the health-community care interface, and on integrated health and community care teams.

It is crucial that NHS Boards plan with other local and regional stakeholders so that they can respond in a coherent, effective, coordinated and ethically appropriate way to an influenza pandemic.

2.3 Key planning assumptions

Planning should be based on the national set of assumptions and the ranges of possible impacts that are outlined in A Scottish framework for responding to an influenza pandemic. These are reproduced below for reference.

Planners should be aware, however, that the epidemiology of an emergent influenza pandemic virus and its clinical behaviour cannot be predicted with certainty. The actual behaviour of the virus, extent of illness and excess deaths will only become evident as a pandemic develops. Response arrangements must be flexible enough to deal with the range of possibilities and be capable of adjustment as necessary.

A graded response to an increasing threat, with certain 'trigger points', would also be appropriate so that all partners understand at what stages of a pandemic certain functions will start/cease. Providing the origin of a pandemic is outside the UK, emerging surveillance data may also allow the use of real-time modelling to confirm and/or refine these assumptions.

2.3.1 Severity and extent

• Up to 50% of the population may show clinical symptoms of influenza over the entire period of a pandemic (planning range 25-50%), and up to 25% of these may develop complications (planning range 10-25%).
• Up to 2.5% of those who become symptomatic may die (planning range 0.4-2.5%).
• Up to 22% of influenza cases can be expected during the 'peak week' of a pandemic wave.
• Up to 27.5% of symptomatic patients (including all symptomatic children under three years of age) will require assessment and treatment by a GP or suitably experienced nurse (planning range 13% - 27.5% of cases).
• Up to 4% of those who are symptomatic may require hospital admission if sufficient capacity is available (planning range 0.55% to 4.0% of cases with 25% of hospital admissions expected to require critical care). The average length of stay for those with complications may be six days (ten days if in intensive care).

2.3.2 Health and community care demand

• Most health and community care will need to be delivered in the community setting, with hospital capacity protected and preserved for those in most clinical need.
• Hospitalisations and deaths are likely to be greatest if the highest attack rates are in the elderly. The lowest burden on health care may be associated with higher attack rates in adults aged 15-64.
• Most patients will be treated at home with antiviral medicines initially.
• Children of three years and under will need to be assessed by a GP or suitably experienced nurse, because weight-related doses of antiviral solution must be specifically prescribed. Alternative formulations are being investigated.
• Assuming a complication rate of 25%, an attack rate of 50% and those under three years needing to see a health professional, general practices can expect to see 3,025 influenza patients per 100,000 population per week at the peak.
• Demand for hospital admission can be expected to increase to 440 new cases per 100,000 per week at the peak and is unlikely to be met from current available acute hospital capacity.
• An increase in the numbers suffering with influenza and its direct complications may be accompanied by other demand, caused by anxiety and bereavement, and service provision challenges exacerbated by depletion of the workforce and logistical difficulties.

2.3.3 Impact on the workforce

• Up to 50% of the workforce may require time off at some stage over the entire period of the pandemic, with individuals absent for a period of seven to ten working days. Absence patterns should follow the pandemic profile, with an expectation that it will build to a peak lasting for two to three weeks, when between 15% and 20% of staff may be absent, and then decline.
• Modelling suggests that small organisational units (5 to 15 staff ) or small teams within larger organisational units should allow for higher percentages of absenteeism - up to 30% to 35% over a two to three-week peak period. Even higher rates are possible in very small organisations.
• Additional staff absences are likely to result from other illnesses, taking time off to provide care for dependants, family bereavement, other psychosocial impacts, fear of infection and/or practical difficulties in getting to work.
• The Scottish Government may advise schools, nurseries and childcare settings in an area to close in order to reduce the spread of infection among children. Any such advice would probably be to close for a few - probably 2-3 - weeks, but closures may be extended if the pandemic remains in the area.
• National guidance is currently being prepared on human resource issues for health services in a flu pandemic, to support local planning and will be made available at: http://www.scotland.gov.uk/Pandemicflu.

2.4 Key planning principles

Effective contingency arrangements developed jointly by health and community care agencies will be critical to the relief of suffering and to achieving the wider public health aims of keeping symptomatic patients at home, caring for them in a community setting and reducing the demand on healthcare facilities. Plans should encourage multi-agency working and seek to mobilise the capacity and skills of all public, voluntary and private sector healthcare staff (including retired GPs, nurses, pharmacists, contractors and volunteers).

Response arrangements should be based on expanding normal delivery models to retain the advantages of familiarity, maintainability, reliability and local flexibility for as long as is possible. Plans must also recognise that peak demand - compounded by peak sickness absence means that normal delivery models will need significant augmentation as the pandemic wave(s) develops.

Advising symptomatic patients to remain at home is agreed to be the most practical and effective way of slowing or limiting the general spread of infection. It facilitates the delivery of standard and simple public messages, allows for the fact that many patients may not be well enough to travel, and avoids creating infection 'hot spots'. For these reasons, response plans should aim to provide initial assessment and most treatment without requiring symptomatic patients to attend a surgery or community pharmacy facility.

In order to limit the spread of infection and maximise individual health benefits, patients should take an antiviral medicine as soon as possible after the onset of symptoms - ideally within 12 hours but, if that is not possible, within 12 to 48 hours. During the initial stages of a pandemic, any patient who has been symptomatic for less than two days should be offered treatment with antiviral medicines unless contraindicated. This policy will be reviewed as information on the attack rate, clinical impact, optimum dosage regime, stock consumption, any resistance and the timeframe within which treatment remains useful emerges.

To sustain the availability of essential care for emergencies and patients with chronic or other illness, reducing or ceasing non-essential care will be required. Pre-planned measures to both maintain core service/business continuity and to adjust activity levels to cope with additional demand should feature in local planning.

Local plans should be based on:

• strengthening and supplementing normal delivery mechanisms as far as is practicable
• applying interventions where they achieve maximum health benefit, but may also be required to help maintain essential services
• developing an integrated multi-agency approach with risk sharing and cross-cover between all organisations
• encouraging pan-organisational working, seeking to mobilise the capacity and skills of all public and private sector healthcare staff (including students and those who are retired), contractors and volunteers
• influenza patients avoiding leaving home as far as possible
• initial telephone-based assessment being necessary to meet demand
• primary care response strategies focussing the available clinical capacity and skills primarily on treating those suffering with the complications of influenza or requiring other essential clinical care and assessing young children or patients in groups identified as being at particular risk
• antiviral medicines initially being available to all patients who have been symptomatic for less than 48 hours and ideally within 12-24 hours of reporting symptoms
• developing response measures that maintain public confidence and feel fair
• treatment and admission criteria remaining clinically based and hospital admission criteria being applied in a transparent, consistent and equitable way that utilises the capacity available for the seriously ill and most likely to benefit
• recognising the need to respond to psychosocial issues and concerns such as anxiety, grief and distress and for sympathetic arrangements to manage additional fatalities.

National arrangements are based on having in place national telephone and web based services for influenza patients and worried-well. These services are described in more detail in chapter 3.

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