« Previous | Contents | Next »
Listen
4 Core Primary Care Services
Core primary care services, 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 the problem of designing community health services for a pandemic situation. Identifying an appropriate configuration of general practice and pharmacy as a starting point will determine what roles are usefully played by other health providers, and what the needs for support and coordination will be.
In the event of a pandemic, cooperation among professionals will be essential at every level. Planners and practitioners must work together to produce primary care structures which will respond to increased demand as effectively as possible.
4.1 General Practice roles
The issues for general practice to address in a pandemic include:
- Consolidation of practices
- Business continuity
- Ceasing non-essential activities
- Personal protective equipment ( PPE)
- Hours of operation and out of hours services ( OOH)
- Guidelines for clinical practice
- Home visiting
- Staff roles
- Workforce monitoring
- Pandemic activity monitoring
- Death certification
- Vaccination
These issues should be considered by general practices both at the individual level and in collaboration with other primary care providers and NHS Boards.
General practice will be subject to a very high level of demand, at a time when the practice workforce will be under considerable stress. However, the principle of building upon existing services dictates that general practice will play a central role in providing community based health services in a pandemic and that general practice will also be essential in governing the flow of patients into and out of secondary care services and care homes. Such roles will have to be carefully coordinated with other health and non health services such as Local Authorities, the voluntary sector and others.
4.1.1 Consolidation
Where general practices are not able to maintain their usual services in the face of extreme demand, consolidation across practices will be required, particularly where small practices are involved. In those circumstances Local Response Management Teams will coordinate services across practices at a local level to ensure continuity of service. To facilitate this, practices will need to ensure Local Response Management Teams routinely have timely access to information about practice and workforce status and supplies.
NHS Boards should work with general practices to establish local consolidation plans and protocols. These should be capable of rapid activation and implementation in order to cope with worst-case planning assumptions. These arrangements should, where practical, build on existing networks for covering practice services. Plans and protocols should address de-escalation and recovery arrangements in the post and inter-pandemic phases.
4.1.2 Business continuity
Practices will wish to have in place arrangements to make their service as robust as possible in a pandemic situation. The RCGP/ BMA have produced guidelines for this purpose and these are available from the RCGP website ( http://www.rcgp.org.uk/default.aspx?page=3908).
Specific consideration should be given to the telephony resources of practices and pharmacies. It will be important that mechanisms for professional-to-professional communication remain open. In an emergency situation it may be appropriate for professionals to use personal mobile telephones for such communication. Ensuring that practices have an adequate number of telephone lines, and the staff to operate them, will require attention at an early stage of pandemic planning. Key service areas, including those services which are time sensitive, which will need to be maintained to some level include the following:
- Acute clinical disease management
- Screening
- Procedures
- Monitoring (i.e. of certain therapies such as anti coagulation therapy)
- Childhood immunisations
- Child protection
4.1.3 Ceasing non-essential activities
Practices will not have the resources to conduct all of their usual activities during a pandemic and will need to cease services which are not immediately relevant to patient care. In some cases patients who do not have immediately life threatening conditions may have to have their care postponed which otherwise would have been provided in normal circumstances. People will be encouraged, supported and enabled to self care wherever possible, by the Scottish Government, NHS Boards and healthcare professionals.
The Royal College of General Practitioners ( RCGP) and the British Medical Association ( BMA) have issued service continuity guidance, which those working in primary care will wish to refer to. The guidance suggests that the following functions and activities could be ceased, reduced, or delivered by alternative means to enable practices to focus on delivering essential work:
- cancellation of outside activities (meetings, teaching, etc)
- defining minimum safe staffing levels
- suspension of (some) chronic disease management
- suspension of (some) new routine referrals
- suspension of (some) minor surgery
- providing mainly emergency-only open surgeries
- team working with neighbouring practices
- identifying recently retired or non-practising colleagues who might be utilised.
It is important that practices have clear guidelines to support their decision in providing or denying care to individual patients. It must be clear to patients that such decisions are made consistently and equitably, and are not a whim of the individual practitioner, who may otherwise find themselves in an invidious position. To assist NHS Boards and front line providers with these issues, UK guidance is being developed for issue in mid-2008. Provisional guidance will be published in Autumn 2007.
In the context of social distancing and to reduce routine workload, repeat prescriptions for people with some long term conditions could be written in advance of a pending pandemic, for an increased prescribing interval (up to three months) provided this was supported by endorsements on the prescription to allow instalment dispensing. Any changes to routine prescribing intervals must not place avoidable pressures upon the pharmaceutical supply chain.
The local response management function will need to determine when resources are stretched to the point at which activities should be scaled back or suspended among local practice. Equally, a decision will need to be made about when to reinstate suspended activities as a pandemic wave declines.
4.1.4 Personal protective equipment ( PPE)
Although national discussions are continuing about stockpiling of PPE, it is the responsibility of employers to source adequate types of PPE for their staff. Infection control is covered in more detail in section 7.2.
4.1.5 Hours of operation and out of hours services ( OOH)
Decisions about modifying hours of operation, including temporary extension of general practice hours at the point of greatest demand and arrangements for resourcing Out of Hours services will be for Pandemic Influenza Coordinating Committees to make as the pandemic progresses and on the advice of Local Response Management Teams.
Decisions about hours of operation of usual daytime services must acknowledge that many GPs and other professionals are also likely to be involved in providing OOH services or contributing to influenza phone line response.
Good communication between practices and Local Response Management Teams will be crucial to maintaining and sustaining core services in the face of rapidly evolving circumstances as the pandemic progresses.
4.1.6 Guidelines for clinical practice
The British Thoracic Society and The British Infection Society have worked with the Health Protection Agency and Department of Health to develop clinical guidelines. These are available at: http://www.scotland.gov.uk/Pandemicflu
4.1.7 Home visiting
While planning is based upon the principle of taking care to patients rather than vice versa, the need for home visits will have to be carefully prioritised to avoid placing excessive pressure upon health professionals. Mobilising and utilising the skills of the whole healthcare team, using telephone assessment and triage and linking practices to specific care homes and residential settings may all help to spread the additional home visiting work load.
4.1.8 Staff roles
Nursing and clerical staff may be required to work outside their usual roles, whether by working directly with influenza patients or by taking on aspects of care for non influenza patients in order to relieve other primary care staff. NHS Boards may wish to give thought to training, contractual and indemnity requirements for the primary care workforce. Training initiatives could appropriately be delivered from WHO Phase 5.
4.1.9 Workforce monitoring
The local response management function will be required to monitor the primary care workforce in order to collect information about how practices are coping on a daily basis. This information will be required for Health Board situation reports, and ultimately for national assessment of how capacity and resources are being used across Scotland. NHS Boards should liaise with General Practices to establish pandemic reporting arrangements.
4.1.10 Pandemic activity monitoring
Local information will need to be collated and communicated to central planning agencies to allow Health Protection Scotland ( HPS) to describe the pattern of clinical presentations with pandemic influenza and allow estimation of the impact of pandemic influenza and any control measures (including the clinical effectiveness of antivirals and antibiotics and the effectiveness of any pandemic influenza vaccine if it becomes available) implemented across Scotland.
NHS Boards will also need to monitor the distribution and stockpiling of antiviral and antibiotic medication so that measures such as the number of people responding or not responding to medication can be known.
4.1.11 Death certification procedures
National advice has been prepared to provide assistance and support to medical practitioners with their clinical responsibility for the appropriate certification of death during a flu pandemic. Medical practitioners and other relevant people e.g. registrars of births and deaths, have been informed of these procedures via a Chief Medical Officer's letter a copy of which is reproduced at: http://www.scotland.gov.uk/Pandemicflu
4.1.12 Vaccination ( see also 5.3)
NHS Boards should work with general practices to develop operational delivery arrangements for targeted vaccination when/if a suitable pre-pandemic or specific vaccine becomes available. Further guidance on pandemic vaccination will be made available at: http://www.scotland.gov.uk/Pandemicflu
4.2 Community Pharmacy roles
Key Points
Community Pharmacy will be a key front line provider of primary care in the event of a flu pandemic. Plans for the local organisation of pharmacy services in the event of a pandemic should reflect local needs and service configurations.
Major issues for community pharmacy will include:
- Maintaining medicine supplies
- Local coordination of services
- Business continuity
- Providing augmented services and managing Patient Group Directions
- Pandemic activity monitoring
Community Pharmacy plays a central role in front line primary healthcare, and as such will be an integral part of services which respond to an influenza pandemic. Demands upon pharmacies are likely to arise in a number of different ways including; patients seeking information or over the counter symptomatic relief; patients exhibiting influenza symptoms and seeking assessment and patients seeking prescription medicines and antivirals. As well as these influenza related demands, there will be a need to manage existing patients who have a regular need for pharmacy services. As with the rest of the health sector, these pressures will have to be managed in circumstances of limited resources, as pharmacy staff themselves may experience illness and be unavailable for work. Dispensing Doctors may also find this section helpful to their planning.
A particular issue for pharmacists will be the maintenance of medicine supplies. Pressure upon supplies is likely to arise both from increased public demand as well as from potential interruptions to the supply chain at international, national and regional levels. Supply chain resilience and public information messaging are being considered on a UK basis. Further advice on these topics will be provided in due course.
Plans for community pharmacy in the event of a pandemic must reflect local configurations of services. The geographic distributions of population and the location and size of individual pharmacies may dictate that different approaches to business continuity and emergency planning are needed in different locales.
NHS Boards, working with local pharmacy groups, will wish to carefully consider the role that community pharmacy should play in the local distribution of antiviral medicines. Antiviral distribution options are discussed further in chapter 5.
4.2.1 Coordination
As pandemic progresses through local populations the impacts of additional demand and staff absence may mean that some pharmacies are not able to maintain their usual services. In those circumstances Local Response Management Teams will coordinate services across pharmacies at a local level to ensure continuity of service e.g. to vary/stagger opening hours or make arrangements for emergency redeployment of stocks and manpower. To facilitate this, pharmacists will need to ensure that Local Response Management Teams routinely have timely access to information about service availability and supplies.
NHS Boards should work with local pharmacists' groups to establish local coordination arrangements. These should be capable of rapid activation and implementation in order to cope with worst-case planning assumptions. These arrangements should, where practical, build on any existing local arrangements.
4.2.2 Business continuity
As is the case with general practice, community pharmacies will wish to have in place arrangements to make their service as robust as possible in a pandemic situation. The Royal Pharmaceutical Society of Great Britain has produced guidance documents on Service Continuity for Community Pharmacists and these are available from the RPSGB website: http://www.rpsgb.org/informationresources/downloadsocietypublications/#g
Specific consideration should be given to the telephony resources of pharmacies. It will be important that mechanisms for professional-to-professional communication remain open. In an emergency situation it may be appropriate for professionals to use personal mobile telephones for such communication.
There will be great pressure upon pharmacies to provide a range of services, and prioritisation may be required. In the event of a pandemic, the services that will need to be given priority may include:
- support for self care including advising on the use of over-the-counter medicines for symptoms of flu and other conditions, including managing shortages by for example, limiting the number of packs sold
- dispensing and repeat dispensing
- sign-posting to other available NHS and local authority services
- acceptance of unwanted medicines
- supply of regular medicines to vulnerable people such as residents of care homes or those with long-term conditions
- maintenance of medicines supplies under contracts with other bodies, e.g. hospices, prisons etc.
- support and promotion of national public health campaigns on basic hygiene measures such as hand hygiene and other positive health messages.
- access to medicines out of hours
- subject to further consideration nationally, pharmacists may additionally be required to help maintain public confidence in supplies of medicines by managing short-term supply problems or substitutions of products in accordance with nationally agreed algorithm or cascade protocols.
4.2.3 Augmented services
NHS Boards already have the benefit of pan-Scotland Patient Group Directions ( PGD) to deal with the urgent supply of repeat prescription medicines to patients in emergency situations. Further PGDs may be deemed necessary or desirable at either national or local level to more rapidly deal with pandemic situations. Advice and guidance on the preparation and use of PGDs can be found at the Medicines and Healthcare products Regulatory Agency's web site at http://www.mhra.gov.uk. Boards' plans should also recognise the role of the Minor Ailment Service in reducing pressure upon other parts of primary care and ways in which that might be affected / extended during a pandemic.
NHS Board and Community Pharmacists' plans should recognise that there may be a need for increased prescribing intervals with repeat dispensing for a period of three months or more to patients with chronic diseases such as asthma, diabetes, COPD, CHD, or for other circumstances such as oral contraception. However, any such changes to routine prescribing intervals must not place avoidable pressures on the pharmaceutical supply chain.
4.2.4 Pandemic activity monitoring
As with a range of other health professionals, community pharmacists should ensure that they have arrangements in place to contribute to centrally collated information about care provided for individual patients, and to the monitoring of supplies and patient outcomes.
« Previous | Contents | Next »