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The impact of pandemic influenza on community care

The community care response to pandemic influenza

28. In the event of an influenza pandemic, community care services will be under particular strain. Community care supports people who are likely to suffer disproportionately from the impact of the pandemic in its early phase. It is also likely that it will adversely affect other services, such as transport, health services and schools.

29. The disparate nature of community care services means that planning for an outbreak of pandemic influenza may arguably be more difficult in this sector than in many other sectors. Community care covers a wide range of services for a wide range of user groups, including care provided at home, in care homes and in day/drop-in centres, as well as services such as meals on wheels, home help/home care, personal assistant schemes and adult placement schemes.

30. Many of these services are not provided directly by local authorities but by registered social landlords and voluntary and private sector organisations. Some are provided under commission from local authorities, but many operate on an entirely private/independent or voluntary basis. However, all forms of community care services will need to be factored into local contingency plans, and not just those services that are provided directly or indirectly through local authorities.

What impact will pandemic influenza have on community care?

31. It is impossible to predict the precise impact that pandemic influenza will have on the UK population, much less its impact on community care. Much will depend on the characteristics of the virus, its clinical attack rate, the severity of the illness it causes and the resulting case fatality rate.

32. Given the highly uncertain nature of a pandemic, we cannot know in advance the scale of the disruption it will cause and whom it will most affect. All health and community care services are likely to experience severe pressure. The impact of a pandemic will not be uniform over the wave or across regions; it may take the form of a rising tide, depending on the attack profile. Any age-specific differential attack rate will affect the overall impact. If working-age adults are predominantly affected, this will have a more direct impact on provision of services and business continuity, whilst illness in very young children and older people is likely to have an indirect impact and will present a greater burden on health and community care services.

Key challenges in managing community care services

33. To meet the key challenges, careful coordination, robust leadership and effective multi-agency working will be essential. Local planners should follow the eight key principles outlined in The ethical framework for the response to pandemic influenza when developing their responses to those challenges. These are:

• respect
• minimising the harm that a pandemic could cause
• fairness
• working together
• reciprocity
• keeping things in proportion
• flexibility
• good decision-making.

34. Key challenges in managing community care services include:

• maintaining essential community care services in the community with reduced staff, including all the services that are not about direct care but that form an essential lifeline for some people, eg meals on wheels, shopping schemes, transport services, provision of community equipment, community alarm services, telecare, etc
• recognising and planning for individuals and groups who may be particularly at risk and hard to reach, examples of whom might be:
  - people with mental health problems
  - people who are homeless or living in temporary or insecure accommodation
  - people with communication difficulties
  - people with sensory loss
  - some black and minority ethnic communities
  - isolated and older disabled people living alone
  - gypsies and travellers
  - migrant workers
  - older carers of adults
  - people with learning disabilities and/or physical disabilities
  - adult survivors of abuse

• managing the inevitable additional demand placed on local community care services and intermediate care services. Additional pressure on acute hospital beds created by the pandemic will likely result in all but the most critical clinical cases being cared for outside the hospital setting
• ensuring that the necessary lines of communication exist to disseminate national, regional and local messages on pandemic planning. Ensuring that messages are clear, so that organisations from a diverse range of community care services across all sectors (statutory, voluntary and private) can respond to them
• additional pressures on time needed to support care home and hostel residents and people cared for in their own homes when they have influenza
• sustaining people with complex disabilities who are currently supported with intensive care packages in the community, including those using their own personal assistants
• providing emergency short-term care for people who are looked after at home by informal carers if their carers become ill
• maintaining a balance between taking appropriate safety and infection control measures and ensuring that people's quality of life is maintained as far as possible
• ensuring risk management and business continuity.

35. Directors of Social Work have a particularly crucial role in coordinating the planning and response of community care. They should begin by holding a scoping exercise, involving other council departments and stakeholders, to ensure that their plans will include all actual and potential service users. It will be essential for the Directors of Social Work to liaise with the Directors responsible for children services (if different) to ensure an appropriately joined-up approach to planning for the needs of adults and children. They may need to consider the costs involved in managing an influenza pandemic. We are particularly concerned that individuals or groups who are already disadvantaged or at particular risk should be fully considered and planned for. (Please refer to the list of these groups under the second bullet point at paragraph 34.)

36. In addition to planning for these groups, Directors of Social Work will need to give thought to how some of these groups will need to be protected from negative public opinion or stigmatisation if they are perceived as posing a particular threat to public health. For example, the perception may be that influenza is more prevalent amongst homeless people, and as such other groups may be reluctant to come into contact with them at communal facilities. We have offered some checklists for Directors of Social Work and others to consider when planning. These are not definitive, but we hope that they go some way to assist planners in thinking about the scope of their responsibilities. In carrying out your planning please refer to the checklists at the back of this document on pages 40-47.

Key planning considerations

37. Local authorities will be responsible for preparing the community care response to pandemic influenza locally, in the context of their wider responsibilities for performing functions under the Civil Contingencies Act 2004. (The duties under the CCA apply to all Category 1's equally (including NHS). If pandemic flu is a recognised risk they must prepare. If the risk is such that joint planning would be appropriate they must consider if that is the case and, if so, plan together under the regulations (Regulation 16)). In preparing for pandemic influenza they must co-operate with other local responders and take into account the activities of the voluntary sector. Preparation should be undertaken within the management framework established by the Strategic Co-ordinating Group ( SCG) and national structures as outlined in Section 4 of Preparing Scotland http://www.scotland.gov.uk/Resource/Doc/94471/0022783.pdf

38. Advance planning is essential to establish and rehearse contingency arrangements to enable normal business to continue as far as possible. Contingency arrangements will need to be proportionate, resilient and flexible enough to deal with a wide range of possibilities.

39. Response arrangements should be based on strengthening and supplementing normal delivery mechanisms, in so far as this is possible. To be effective they will need to be developed on an integrated multi-agency basis with risk sharing and cross-cover between organisations where possible, supported by strong local leadership and coordination when implemented.

40. Local advice and information should complement wider national messages. The Civil Contingencies Act duty to warn and inform the public applies to the impacts of pandemic flu.

41. Local authorities should work with local providers to ensure they have robust business continuity plans in place. Having strong relationships with local providers is key to managing an influenza pandemic.

Carers

42. Disruption is likely to be less severe if individuals with responsibility for caring for others know what to expect and what to do in the event of an outbreak. Up-to-date and authoritative information should be available to these individuals. This should include advice on where carers can go to for help if they feel unable to cope anymore due to increased demands arising from an influenza pandemic.

People using community care services

43. It is essential to inform people who use services that contingency care arrangements may need to be in place. This may include relying more heavily on families and informal carers if normal care arrangements are disrupted by the onset of pandemic influenza. Eligibility criteria for care during a pandemic should be transparent and applied in a consistent and equitable way that reserves capacity for those in the greatest need. The ethical framework for the response to pandemic influenza will be important here.

Key organisational and individual roles and responsibilities in community care

44. Planning for and responding to the challenges faced by community care services during an influenza pandemic will require a combined, coordinated effort using experience and expertise at all levels across a wide range of organisations in the statutory, voluntary, independent and private sectors. It will require the active support of communities, and individuals will need to take personal responsibility for protecting their health, supporting each other and contributing to the containment of disease.

45. To ensure an effective response, local authorities and their partner organisations need to understand their roles and responsibilities and be able to plan accordingly and jointly where necessary. Each organisation will need to agree its priorities and take proactive steps to ensure the continuity of its services.

46. This section describes the roles and responsibilities of the main participants in planning for community care during an influenza pandemic.

Wider local authority

47. Local authorities have specific civil protection duties and responsibilities under the Civil Contingencies Act 2004 and the Contingency Planning (Scotland) Regulations 2005 - see http://www.scotland.gov.uk/Publications/2006/02/27140215/0. They are directly responsible for the provision of a wide range of the functions that will be essential when responding to the health and wider impacts of an influenza pandemic. They also exercise a crucial community leadership role. Local authorities have a responsibility for planning and preparing to maintain community care and housing services in a pandemic scenario.

48. Individuals who have responsibility for community care functions within local authorities will need to work closely with their emergency planners to ensure the integration of their planning and that of the SCG and its partners. In the event of an outbreak of pandemic influenza, it is essential that community care is adequately represented in local authority planning and that adequate business continuity management arrangements are in place to enable community care functions to continue in the event of an emergency.

49. Local authorities will also have a leading role in coping with the increased numbers of deaths. Local authorities will want to ensure arrangements for services, such as registrars, burial and cremation authorities, work together with Procurators Fiscal, the health services (e.g. GPs and NHS Mortuaries) and can be supported by local businesses, such as funeral directors and privately owned cemeteries and crematoria. The Home Office will be developing guidance on managing excess deaths following a consultation exercise and it is expected that the Scottish Government will issue similar guidance in due course.

The Civil Contingencies Act 2004 and Strategic Co-ordinating Groups

50. The Civil Contingencies Act 2004 and its accompanying non-legislative measures provide a single framework for civil protection. Regulations under the Act require organisations, including health boards and local authorities, that will be involved in responding to an emergency to come together to form SCGs. These have been established in each of the 8 police force areas in Scotland to co-ordinate and develop/maintain links between partner agencies and to co-ordinate planning at local level. The SCGs provide an effective mechanism for developing integrated plans and responding within the management framework outlined in Preparing Scotland.

Response structure for national emergencies

Directors of Social Work/Chief Social Work Officer

51. Directors of Social Work will have ultimate responsibility for planning and coordinating the community care response for adults at a local level. They will keep the Directors responsible for children's services (if different) informed and involved, and will ensure that decisions and plans operate for optimum benefit across both services. Planning the community care response should take full account of the impact of such events as school and early years group childcare facility closures. Directors of Social Work will play a key role in cascading messages from the centre and ensuring that all community care providers within their authorities are aware of and involved in local contingency plans.

52. As part of their overall strategic coordination of plans, Directors of Social Work will need to ensure that local contingency plans don't make unfounded and unrealistic assumptions that other areas will have spare capacity to assist them in providing services during the pandemic period.

53. Directors of Social Work should be in regular dialogue with their emergency planners and other colleagues (e.g. housing), their health partners ( NHS Boards/Community Health Partnerships), and voluntary sector agencies to establish what is required of them and their teams in the pandemic alert period.

54. As most influenza sufferers will need to be cared for in a community setting (rather than in a hospital setting), developing integrated health and community care planning to allow for this is particularly important in order to reduce the burden on community care services. The Scottish Government has directed all NHS Boards to designate an Influenza Pandemic Coordinator, and it would be advisable for local authorities to approach contingency planning for community care in the same way by appointing a designated officer for contingency planning in community care. The designated community care officer should work alongside their own local authority emergency planners, NHS organisations and independent community care providers to fully integrate community care planning with health and other local-level contingency planning.

55. Directors of Social Work will be responsible for communicating the alert stages of a pandemic and the key messages to community care providers in their localities (see Figure 2). Figure 3 sets out the role of the Directors of Social Work in disseminating key messages and information flows. (Note: NHS Boards are on the SCGs and will therefore be aware of key messages and information.)

Figure 2: Information flows - communicating the alert stages of a pandemic

Figure 3: information flows - communicating key messages during the pandemic period

56. The Scottish Government will contact community care provider representatives and umbrella organisations to help disseminate key messages to community care providers through their networks; however, the primary responsibility for ensuring that key messages reach providers remains with the Directors of Social Work. Similarly, Directors responsible for education and children's services will be responsible for communicating key messages to schools and group childcare facilities. Guidance on the role of the Directors responsible for education and children's services has been produced by the Scottish Government. Directors of Social Work (if different) are encouraged to refer to this guidance in order to be aware of the role of the Directors responsible for education and children's services will be performing during a pandemic. Directors responsible for children's services and the Directors of Social Work (if different) should agree between them what roles each Director will perform during a pandemic in order to avoid any overlap or issues being missed.

57. It may be helpful for community care providers to be able to access a central source of information about pandemic preparedness in their local area, e.g. the content of the local authority contingency plan. Directors of Social Work may wish to consider how their local authority can best ensure that their local providers have access to useful and up-to date information to aid them in their planning and preparedness, e.g. information on the authority's website.

58. Local authorities will also need to consider how they convey messages locally, particularly during pandemic alert Phase 6. Some local authorities operate a text messaging service to disseminate certain key messages.

Care Commission

59. The Care Commission maintains a register of all community/social care services registered with it under the Regulation of Care (Scotland) Act 2001. The information is available on their website ( Care Services on menu bar, then Care Services List on left hand menu; or direct link here - http://www.carecommission.com/index.php?option=com_content&task=view&id=24&Itemid=45

NHS Boards

60. NHS Boards are responsible for developing, maintaining and testing robust, resilient and integrated local response plans within national guidelines and in conjunction with partner agencies. NHS Boards also provide a health input to Strategic Co-ordinating Groups. Each NHS Board has a pandemic influenza plan which has been submitted and reviewed by the Scottish Government and operational level planning is progressing in all areas. The plans can be found at www.scotland.gov.uk/pandemicflu. As part of their contingency planning NHS Boards, working with Community Health Partnerships ( CHPs), also have a responsibility to consider the impact of pandemic outbreak on the primary care sector as most of the assessment, treatment, care and support will be outside hospital settings.

61. In the event of a pandemic, NHS Boards, assisted by CHPs and other agencies, will co-ordinate the health response in their area, provide advice and information, working within the current national guidelines and responding in a coherent, effective, co-ordinated and ethically appropriate way. They will also collate and report information related to the health services and the outbreak to the Scottish Government.

Voluntary sector organisations not providing 'core' community care services

62. The voluntary sector is a key provider of services in community care, with many organisations providing a wide range of operational support to ease the pressure on statutory responders.

63. The voluntary and community sector may be able to help support the response to pandemic influenza at a local level. Local authorities, with their local partners, will need to consider how to involve voluntary organisations in their area with whom they do not usually have business arrangements. Examples of organisations that may be able to offer assistance include the Salvation Army, Women's Institute, and WRVS as well as small, local self-help groups, community groups and faith-based organisations and places of worship.

64. Such organisations may be able to support a response by:

• putting in place initiatives for 'good neighbour' schemes
• providing a useful route in some areas for access to hard-to-reach individuals and groups, such as travellers, asylum seekers, homeless people, people with mental health problems/learning disabilities and those with little or no English or understanding of the state system
• helping in the communication of key messages, information and advice both before and during a pandemic, eg through websites, their volunteers, shops, etc
• contributing valuable information and expertise to aid local pre-pandemic preparations and simulation exercises
• helping to provide social support to maintain sufferers in a community setting or assisting those suffering from stress, anxiety or grief.

65. Voluntary sector support should be coordinated via designated officer for contingency planning in community care (see paragraph 54).

66. Community care organisations will also need to understand that voluntary organisations themselves are likely to be under pressure and limited in their capacity to provide additional help and services during the pandemic period. There are limited numbers of volunteers available and the pandemic will affect them too, not only in terms of the number of volunteers who may actually catch the virus but also in their willingness to become involved due to the fear of catching it. Organisations benefiting from the support of volunteers will need to ensure that they have adequate briefing, training, skills and personal protection for the role they are expected to perform. They should also ensure that volunteers are properly indemnified for insurance purposes.

Employers, Trades Unions and other staff or professional organisations

67. Working together, employers; trades unions and other staff or professional associations have a significant role to play in preparing for and responding to a pandemic by educating and informing the workforce, promoting measures that reduce the spread of infection, helping to maintain essential services and minimising social disruption.

Private and independent sectors

68. In addition to providing community care services, many private and independent sector organisations are responsible for providing supplies and services that are critical to maintaining community care services, particularly in the area of protective clothing, etc. Planning to ensure the maintenance or even expansion of these supplies and services, as far as is possible, is an essential part of developing effective response arrangements as part of a joined-up approach with the health service.

Community care providers (statutory, voluntary and private sector)

69. Community care providers will need to ensure that they plan for how they will maintain their services and ensure that people relying on them are not left unsupported during a pandemic. As far as is possible, they should plan in consultation with service users and carers and other key local organisations. Some providers may wish to undertake joint planning with other local care providers to explore risk sharing and pooling arrangements.

Community and individual responsibility

70. Well-prepared and informed communities and their leaders can play a major role in supporting the response to and recovery from an influenza pandemic. Community networks can be particularly effective in such areas as disseminating information, providing reassurance and identifying/supporting those who are particularly at risk, and should therefore be fully involved in developing response plans. Involvement of community networks and key local leaders in planning and providing a response will be particularly important for people who are harder to reach through normal channels; these include some homeless people, some ethnic groups, travelling communities and some migrant workers.

71. The cooperation of individual members of the public and their willingness to follow advice, to take responsibility for their own health and to support each other are likely to be critical determinants of the overall success of the response.

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