« Previous | Contents | Next »
Listen
3 Organisation Of Care In A Community Setting
Core primary care services, most particularly general practice and community pharmacy, will bear a considerable burden of expectation from the community in the event of a pandemic. Configuring front line primary care services is therefore at the heart of healthcare preparations for a pandemic.
3.1 Patient pathway
Key Points
- The line of first contact in the patient pathway will be an influenza telephone service, which will provide information, assess patients, and prescribe antiviral medication where appropriate.
- Patients who require face-to-face care or assessment from a health professional will be referred to front line primary care or secondary care services.
- The telephone service should be used as widely as possible in order to ensure consistent public access to assessment and antiviral medication, and to manage demand for primary care services.
This document presents a model of care which is based upon primary care augmented with telephone and web services. From this starting point, a pathway of care for an individual patient can be defined, and in light of this a number of issues in the organisation of care can be identified. The patient pathway is therefore the starting point for the operational guidance provided in this document.
The patient pathway begins with the national telephone service which provides general advice, and prescribes antivirals for non complex cases. The patient will be directed to ask a friend, relation, carer or neighbour to collect an antiviral from a local antiviral collection point. Home delivery of medication will be restricted to the seriously ill who are housebound without access to help from other people. In some cases the pathway may begin with a healthcare professional's assessment of a patient for a condition unrelated to pandemic influenza, but in which influenza like illness emerges as the issue for the patient or a member of the household.
If the case cannot be dealt with by the automated telephone system or assessed by non clinicians working to the telephone algorithm, the call will be transferred to a clinician who will conduct triage over the telephone. The triage will result in either direct prescription of an antiviral, or a recommendation for face-to-face assessment through either general practice or via the Out Of Hours ( OOH) service, whichever is appropriate for the time of day. In some cases the triage service may identify a need for an ambulance and hospital admission.
If referred by the national flu line for a face-to-face consultation, GPs, practice nurses and other community based nurses, whether in usual practice or operating from an OOH service, will assess patients and may advise, dispense or refer patients to pharmacy or antiviral collection points to receive antivirals, antibiotics, or other symptomatic treatment e.g. analgesics or refer the patient to a number of levels of care including home care services, care homes or hospital.
Usual emergency services must not represent an easier route or short-cut into medication or referral services for influenza patients. The main principle for emergency services must be to conduct their usual assessments with criteria which are consistent with the criteria for accessing influenza services through other parts of the pathway. They should also make use of the national telephone service for influenza patients wherever possible.
For example, influenza patients calling 999 would be diverted back to the national telephone service for assessment and possible prescription. If the ambulance service attends a patient, their clinical protocol must allow a decision to made about either taking the patient to hospital, as would be usual practice, or treating the patient and leaving them at home, possibly with supplies of an antiviral. Similarly, Accident and Emergency services will need to refer uncomplicated influenza patients to the telephone assessment service and may wish to consider telephone access arrangements on site to accommodate.
Overall, apart from the telephony service which acts as a point of first contact and directs patients with lower level of need from pandemic influenza directly to the local antiviral collection point, the main clinical pathway is focussed around usual and familiar primary care services with the usual range of treatment and referral options.
Figure One: Overview of Patient Pathway
3.2 National influenza telephone line services
Key Points
- A national influenza information line will be provided at WHO international phase 5.
- The information service will expand to provide initial patient assessment and antiviral authorisation from UK alert level 2 ( WHO phase 6).
Telephony and internet technology represent one of the central techniques for deploying health care resources quickly and safely in the event of a pandemic. The use of telephone and web services will allow timely triage, access to information (such as infection control advice for the public or self care advice for people with uncomplicated influenza) and will allow health professionals to provide clinical advice without risking infection themselves.
Face-to-face clinical assessment for every patient will not be feasible at the peak of a pandemic. Department of Health analysis suggests that general medical practices will not be able to expand their collective telephone call-taking capacity sufficiently to meet the level of additional demand that is anticipated. Whilst patients may still choose to make contact via their GP surgery, call centres using trained call takers operating to a clinically-based algorithm offer a viable and acceptable alternative.
To provide public information and advice before and during a pandemic, the Government - in conjunction with the Central Office of Information, NHS Direct and NHS24 - will establish a national influenza information line service at WHO international phase 5 1
From UK alert level 2 ( WHO phase 6) the service will expand to provide initial patient assessment and antiviral authorisation and both functions will then remain operational until the impact of the pandemic and the threat of further waves subside.
The key objectives for the national influenza line services are to:
- provide pandemic influenza related advice and information
- provide access to pandemic related literature
- provide situation reports and daily updates
- provide access to a mechanism for rapidly assessing those suffering influenza-like symptoms
- authorise access to antiviral treatment (if that is indicated)
- give information on the nearest antiviral medicine collection point
- refer to some other part of the health and social care system if that is a more appropriate disposition
- facilitate the capture of critical surveillance information (number of people calling who are symptomatic, demographics of those accessing treatment, take-up of treatment etc.) to inform the local and national pandemic response.
Initial assessment will focus on confirming that the patient has signs and symptoms of influenza, no indicators of complications, is aged three or over, has been symptomatic for less than 48 hours and antiviral treatment is not otherwise contraindicated. Suitably trained staff using a clinically based decision tree algorithm will perform these tasks and authorise the collection of antiviral medicines for the patient.
Analysis suggests that, at a 50% clinical attack rate, such a service might need the capacity to handle a minimum of 11,000 influenza-related telephone calls per 100,000 of the population. This would require 28 staff per 100,000 of the population per day to provide 24-hour cover during the peak week.
The Department of Health is developing a suitable national algorithm and producing model protocols/guidelines to allow the supply of oseltamivir following a telephone assessment. It also proposes to make the necessary amendments to medicines legislation to enable alternative prescription and supply arrangements in a pandemic and a consultation will take place on the proposals.
Studies into the technical feasibility of providing helpline services have been carried out by Department of Health and the Central Office of Information. These have demonstrated that a national flu line service is technically feasible.
The Scottish Government and NHS24 will work with territorial NHS Boards to develop local delivery arrangements for national influenza helpline services. This will involve identifying, assessing and selecting operational delivery options, sourcing and resourcing the required call handling capacity, training and systems testing.
3.3 Local response management
Key Points
- NHS Boards have specific roles in coordinating local services.
- Community Health Partnerships will be an important mechanism for coordinating local services, collecting information and feeding local information back
- Tested arrangements will need to be in place by the time WHO Phase 5 is declared.
A critical factor in delivering a successful local response will be the effective coordination and cooperation of community based services. Each NHS Board's Pandemic Influenza Coordinating Committee has the role of maintaining oversight of health services, making strategic decisions, and liaising with local authorities, police and other emergency services.
In addition to these strategic arrangements, each territorial board will need to establish and resource an effective mechanism for directing and coordinating the local operational response. Unless other local arrangements are in place, Community Health Partnerships, under the direction of their NHS Board, should convene a Local Response Management Team to carry out the local coordination of community services. The general functions they will need to be capable of delivering are outlined below.
Functions of local response management
- Act as a focal point, providing a link to and oversight of the local health response.
- Monitor and coordinate the overall health response on a pan organisational, whole systems basis.
- Maintain the continuing provision of general practice and primary care services both in and out of hours;
- monitor business continuity among practices and pharmacies, and act as a conduit for information to the Health Board and higher level planners
- communicate to practices and pharmacies when non essential services may be suspended (and when they are re-commissioned)
- coordinate any consolidation that may be required among general practices and pharmacies if business continuity fails, including the redeployment of both staff and stock resources
- coordinate cooperative arrangements, such as staff redeployment or changed opening hours specified in business continuity plans
- coordinate regional implementation of measures such as Patient Group Directions.
- Collect, collate and report information on the local health situation.
- Ensure that national messages are cascaded, reinforced and that the public are well informed and advised of local response arrangements.
- Link with local authority services, particularly community care services but potentially also including transport, housing and others.
In many NHS Boards, Community Health Partnerships are in a strong position to conduct these roles within the broader scope of NHS Board strategic plans. While alternative mechanisms might be appropriate in some Board areas, the coordination roles which are identified here must be explicitly assigned to Local Response Management Teams at some level within each territorial Board.
Local response management arrangements should be included in NHS Boards' routine exercising and testing of pandemic response plans; should be placed on stand-by upon the declaration of WHO Phase 5 and be ready to "go-live" at the declaration of WHO Phase 6 - UK Alert Level 1.
Pandemic Influenza Coordinating Committees will need to consider what local conditions would need to be evident to support their decisions to relax consolidation arrangements and return to normal activities.
« Previous | Contents | Next »