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Planning principles

Ethical considerations

72. In preparing for and responding to an influenza pandemic, governments, policy makers, public and private sector organisations, professional leaders, clinicians, health workers and many others involved in the caring professions and/or leadership roles will face difficult decisions and choices that may impact on the freedom, health and in some cases the prospects of survival of individuals. Many people are also likely to face individual dilemmas and tensions between their personal, professional and work obligations. Given the expected levels of additional demand, capacity limitations, staffing constraints and potential shortages of essential medical material, hard choices and compromises are likely to be particularly necessary in the fields of health and community care.

73. People are more likely to accept the need for and the consequences of difficult decisions if these 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, and the choices that may become necessary should be discussed openly as plans are developed so that they reflect what most people will accept as proportionate and fair. At the request of the Department of Health, an independent committee with cross- UK representation has developed an ethical framework to inform the development and implementation of health and social care (community 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 at all levels.

74. The ethical framework for the response to pandemic influenza is available at www.dh.gov.uk/pandemicflu.

Key planning assumptions

75. The precise characteristics and impact of an influenza pandemic will only become apparent as the virus emerges. Therefore, some assumptions and presumptions of its likely response in a number of key areas are necessary to describe the impact the Government is currently planning for. For more information refer to the Scottish Framework for Responding to an Influenza Pandemic.

76. The use of common assumptions and presumptions for planning across all public and private sector organisations avoids confusion and facilitates integrated preparation. Given the uncertainties, these should be regarded as working estimates rather than predictions, and response arrangements must be flexible enough to deal with a range of possibilities and capable of adjustment as they are implemented. Provided that the origin of a pandemic is outside the UK, emerging surveillance data might also allow the use of real-time modelling to confirm and/or refine these assumptions and presumptions.

77. Some key planning assumptions for community care are set out below. Comprehensive planning assumptions are available in the Scottish Framework for Responding to an Influenza Pandemic. Some of these assumptions are based on a uniform attack rate across all age groups. Whilst they should assist in impact assessments and developing contingency plans, the attack rate may not be uniform across all age groups, so plans will need to retain flexibility to adapt as information emerges.

78. In previous pandemics, the overall UK clinical attack rate has been of the order of 25% to 35%, compared with the usual seasonal influenza range of 5% to 15%. Cumulative clinical attack rates of up to 50% of the population in total are possible spread over one or more waves of around 15 weeks, each some weeks or months apart. If they occur, a second or subsequent wave could possibly be more severe than the first.

79. In Scotland, there are around 2,000 "excess winter deaths" each year. There is a clear link between "excess winter deaths" and the level of influenza activity ¹. During a pandemic, assuming a clinical attack rate of 25%, the number of excess deaths due to influenza in Scotland may be between 5,100 and 31,700. However, if the clinical attack rate is as high as 50%, the number of excess deaths is likely to be between 10,200 and 63,700.

80. The actual extent (clinical attack rate) of illness will only become evident as person-to-person transmission develops, but response plans should recognise the possibility of a clinical attack rate of up to 50% in a single-wave pandemic.

Geographical spread

81. You may wish to note the following points about how an influenza pandemic can spread:

• once a pandemic is declared ( WHO Phase 6 - see paragraph 94 for more detail on the WHO phases), even if - as seems likely - it originates abroad, a pandemic will probably have reached the UK within a month
• from arrival in the UK, it will take a further one to two weeks until sporadic cases and small clusters occur across the whole country that will act as initiators of local epidemics
• the pandemic may occur in one or more waves

Severity and extent (clinical attack rate) of illness and death

82. You may wish to note the following planning assumptions for the severity and extent of an influenza pandemic:

• all ages are likely to be affected, but children and otherwise fit adults could be at relatively greater risk, particularly if older people have some residual immunity from previous exposure to a similar virus earlier in their lifetime
• although the potential for age-specific differences in the clinical attack rate should be noted, they are impossible to predict, and a uniform attack rate across all age groups is assumed for planning purposes
• up to 50% of the population may show clinical symptoms of influenza over the entire period of a pandemic and up to 25% of these people may develop complications
• up to 2.5% of those who become symptomatic may die
• up to 22% of influenza cases can be expected to occur during the peak week of a pandemic wave

Infectivity and mode of spread

83. Influenza can infect people and spread amongst the population in the following ways:

• influenza spreads through the respiratory route by droplets of infected respiratory secretions when an infected person talks, coughs or sneezes
• it may also spread by hand/face contact (nose, mouth or eyes) after touching a person or surface contaminated with infectious respiratory droplets
• finer respiratory aerosols (which stay in the air for longer and are therefore more effective at spreading infection) may occur in some circumstances such as during the use of nebulisers, some dental procedures etc
• people may be infectious between 24 and 48 hours before the onset of symptoms and are highly infectious for 4 or 5 days from the onset of symptoms (longer in children and those who are immunocompromised)
• children have been shown to secrete virus for longer and at higher levels than adults
• some people can be infected without showing symptoms, and may shed (excrete) the virus and therefore be able to pass on the infection
• the incubation period is in the range of one to four days (typically 2-3)
• without intervention, and with no significant immunity in the population, historical evidence suggests that one person infects about two other people on average (the Ro or 'basic reproduction number'). This number is likely to be higher in communities such as prisons, care homes or boarding schools

Health and community care demand

84. An influenza pandemic will place an increased demand on health and community care organisations. You may wish to note the following:

• all health and community care organisations will need to adapt and reorganise to provide treatment, care and support for the large numbers likely to suffer from Influenza or its complications whilst maintaining other essential care
• most health and community care will need to be delivered in a community setting, with hospital capacity protected and preserved for the most seriously ill who are likely to benefit
• given a 50% clinical attack rate, demand for hospital admission can be expected to increase by as many as 440 new cases per 100,000 population per week at the peak and will exceed available hospital capacity
• given a 50% clinical attack rate, demand for critical care beds could rise up to 110 per 100,000 population per week at the peak and would exceed available capacity
• up to 4% of those who are symptomatic may require hospital admission if sufficient capacity were to be available
• those who become symptomatic will be advised to stay at home and make telephone contact with health services for initial assessment
• most patients will be treated at home with antiviral medicines initially
• according to the 2001 Census, in Scotland over 60,000 people care for a relative or friend for between 20 and 49 hours per week, and almost 116,000 people provide care for a relative or friend for over 50 hours per week. Many of these informal carers will be infected during the pandemic period and alternative community care may need to be provided for those they care for. Of course many community care staff are also carers

Note: for more information on planning presumptions you may wish to refer to additional planning presumptions contained in A Scottish Framework for Responding to an Influenza Pandemic.

Impact on workforce

85. We anticipate that an influenza pandemic will have a significant effect on the health and community care workforce. The full details of this are at the 'Managing staff absences' section at paragraphs 97-102. For instance:

• 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)
• additional staff absences are likely to result from such things as care responsibilities, family bereavement, or practical difficulties in getting to work
• the Scottish Government may advise schools and group childcare settings in an area to close in order to reduce the spread of infection among children, meaning that some staff may need to stay off work in order to care for their children

Vaccination and antiviral drugs

Pandemic-specific vaccination

86. Vaccination is widely used in the UK to offer protection against the seasonal influenza strains most likely to be circulating that particular year. As a pandemic will result from the emergence of a new or modified strain, these routine vaccines are unlikely to offer protection. It is not possible to develop a matching vaccine until the emerging influenza strain has been identified. The Government has finalised advanced supply contracts with manufacturers to make sufficient supplies of a matching vaccine available as soon as it is developed and is also working actively with the international community and pharmaceutical industry to speed development, testing and licensing.

87. However, it may take four to six months before an effective vaccine is available and considerably longer before it can be manufactured in sufficient quantities for the entire population given that international demand will be high. Realistically, it is therefore unlikely that a specific vaccine will contribute much to dealing with the initial wave of a pandemic - unless its evolution, or the effectiveness of early control measures, result in a significantly slower developing pandemic than anticipated.

88. For planning purposes, the presumption should be that a mass pandemic vaccination campaign during the first pandemic wave is unlikely, but may contribute to reducing the impact of subsequent waves if they occur.

89. For information about pre-pandemic vaccination, refer to the Scottish Framework for Responding to an Influenza Pandemic.

Antiviral medicines

90. Antiviral drugs can be used to treat certain viral infections, including influenza. The existing UK stockpile allows for the treatment of all symptomatic patients at clinical attack rates of up to 25% and arrangements to make antivirals rapidly available are a critical part of the health response.

91. Although the targeted and effective use of antiviral medicines or other definitive pharmaceutical interventions is an important countermeasure, they may be in limited supply. When used to treat seasonal influenza, antiviral medicines reduce the length of symptoms (by around a day) and usually their severity, as long as they are started within two days of the onset of symptoms. Whilst it is impossible to predict whether antiviral medicines will be equally effective against a new or modified pandemic virus, it is reasonable to anticipate a similar effect and associated substantial reductions in severe morbidity.

Supporting access to antivirals and vaccines

92. The current community care model for pandemic planning proposes that people identify, in advance of a pandemic, friends or family who could collect medicines on their behalf should they fall sick.

93. For more information about the effect and use of anti-virals and vaccines refer to the Scottish Framework for Responding to an Influenza Pandemic.

How will key messages be communicated during a pandemic?

World Health Organisation ( WHO) international phases and UK alert levels

94. WHO is responsible for declaring the various international phases of a pandemic according to the following model:

95. This model describes the progression of an influenza pandemic starting from the identification of a new virus strain and ending with widespread activity in the UK. The six phases allow for effective communication of the worldwide situation and enable governments, and other relevant organisations, to adopt an incremental approach to preparedness planning.

96. Strategic Co-ordinating groups will be mobilised to lead the local response in Scotland see diagram on page 15

Specific issues to be considered by community care organisations

Managing staff absences

97. The level of staff absence from work during a pandemic will depend significantly on the nature of the pandemic virus when it emerges. The impact of a pandemic on absenteeism in community care is likely to be severe. Not only will staff be ill but the profile of the workforce is such that some people will be absent from work due to the need to care for children and/or other family members who are ill with influenza. Employers should consider whether their policy on absence is clear to staff so that they are aware of the boundaries.

98. In addition, schools and early years group childcare facilities may be advised to close during the pandemic period in order to reduce the spread of the virus amongst children, or may close because of staff shortages. This is likely to compound staff shortages in community care, as many members of the workforce have young children and parents will need to care for their children or find substitute care. The Scottish Government produced guidance called Planning for a Human Flu Pandemic - Guidance for Schools, Childcare and Children's Services in Scotland. Because such closures will have huge impact on the workforce planners are advised to consider the guidance when making assumptions about staffing levels. Planners should check with Directors responsible for education and children services what the approach should be to taking appropriate local decisions about if/when to close schools and early years group childcare facilities.

99. The planning assumptions set out below are based on current knowledge, analysis of past pandemics, published evidence and scientific modelling. Organisations should ensure that their business continuity plans have the flexibility to accommodate the expected levels of staff absence. Local authorities should ensure that all contracts have clauses that require business continuity plans.

100. During a pandemic, staff will be absent from work if:

a) they are ill with influenza. Numbers in this category will depend on the clinical attack rate. 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. Absenteeism 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 due to having influenza, and then decline. Modelling suggests that small organisational units (5 to 15 staff) or small teams within larger organisational units are likely to suffer higher percentages of absenteeism due to having influenza - up to 30-35%
b) they need to care for children or other dependants who are ill with influenza
c) they need to care for (well) children due to local school closures (in light of July 2006 guidance from the Scottish Government Education Department which advises schools and childcare settings to plan for possible closure on a regional basis during a pandemic). Regardless of whether or not the Government advises schools to close, it is likely that some schools will have to close due to shortages of staff or parents not being willing to send their children to school
d) they have non-influenza medical problems
e) their employers have advised them to work from home
f) they decide to absent themselves for other reasons, eg family bereavement, other psychosocial impacts, fear of infection, or practical difficulties in getting to work.

101. Contingency planning should allow flexibility and include a strategy for coping with widespread staff shortages - our aim must be not to leave people without essential care during the pandemic phase.

102. Community care organisations should consider taking the following measures during the planning stage:

• estimating the number and categories of staff needed to maintain a satisfactory (rather than ideal) level of care for the service as a whole and/or for a single service user or a small group of service users
• identifying a network of people who would be prepared to work in an ancillary care capacity during a pandemic. These could include:
  - other service users
  - relatives and friends of service users
  - retired staff
  - local students and trainees in the sector
  - people within the organisation currently undertaking back-office tasks, e.g. some administrative staff
  - local voluntary or faith groups
  - disclosure checked staff working in the education and leisure sectors
  - student volunteers (16 years and upwards) from schools or colleges that have been closed.

If such networks or 'volunteer pools' can be identified, providers will need to consider how they can be equipped and trained to undertake their roles, eg shadowing of staff, volunteer work placements, cross-training between existing staff, etc

• considering suitability of replacement staff (specific communication skills/expertise/cultural understanding - eg is gender an issue for certain groups or individuals?).
• involving the main employment agencies providing temporary community care staff locally
• agreeing risk-sharing/staff-pooling arrangements and protocols with other local organisations

Occupational health and staff welfare issues

103. People are the most important resource in maintaining community care support for those who need it. Staff who know that they are valued and supported during a pandemic will be more likely to maintain their goodwill and commitment during periods of extreme pressure. Some measures providers may consider taking during planning to support the welfare of their staff include:

• being proactive in providing staff with, or helping staff to access, information relevant to their own health before and during a pandemic (eg posting advice on the latest developments on the local authority website)
• implementing a non-punitive sick leave policy for managing staff who have symptoms, or a confirmed case, of influenza. If staff members suspect that they may have the symptoms of pandemic influenza they should be instructed to stay away from work until reviewed by a doctor or other healthcare worker and told otherwise. Please note that it may not be possible to arrange a review by a doctor or healthcare worker prior to return to work unless the employer's occupational health scheme allows for this.
• agreeing with staff that, where possible, those who have had and recovered from pandemic influenza (and may have therefore acquired antibodies which might guard against future infections) will most likely be the first managers called upon to offer personal care as they will themselves be healthy and able to care for ill people and will also be unable to infect healthy people
• where possible, putting in place plans to safeguard the health of staff who are at high risk of complications of pandemic influenza, eg pregnant women, people with chronic conditions, other immunocompromised persons. This could include informing them about their medical risk and offering them alternative low-risk duties or consideration for administrative leave until pandemic influenza has abated in the community. This would need to be handled very sensitively as in the usual course of events managers and colleagues would not necessarily know a member of staff's personal health information. Considerable thought needs to be given to protecting personal data - particularly if someone is, say, HIV positive or from an ethnic group experiencing higher prevalence of certain conditions such as hepatitis
• considering home working for administrative staff who would be of most benefit if they continue with their administrative duties rather than be transferred to a caring role
• agreeing in advance, and seeking the wide support of staff for, measures limiting time off during the pandemic whilst meeting staff needs for essential rest and recuperation
• identifying local mental health, faith-based or other voluntary sector resources for counselling of staff during a pandemic to help them deal with issues such as management of grief and fear
• developing procedures to support staff in the resolution of ethical dilemmas arising during the course of their work
• where appropriate, developing a strategy for accommodating and feeding staff who might be on-site for prolonged periods
• developing a strategy to accommodate and support staff who have unavoidable responsibilities to care for children or older people.

Health and safety legislation - protection in an occupational setting

104. In a pandemic setting, employers still have a duty to provide a safe place of work for their workers: they are required to maintain safe working systems and implement protective measures based on a local risk assessment, taking account of the Control of Substances Hazardous to Health Regulations 2002 as appropriate. A risk assessment should be completed to consider whether the employee's work activity increases the risk of exposure beyond that of community-acquired exposure and if so, control measures proportionate to this should be implemented.

105. Consultation, jointly conducted risk assessments by employers, staff and their representatives and documented procedures during the planning phase, can help ensure that employees are well educated and informed. Joint risk assessments can also assist in identifying and exploring any subjective perceptions of risk, the opportunities for more flexible working arrangements, and training requirements to help cover staff absences. Identifying those staff with co-morbid conditions or other factors that may put them at higher risk may also allow proportionate individual precautions. Authorities should note that they are responsible for the health and safety of any volunteers appointed during a pandemic, and for ensuring that the correct health and safety practices are in place for any organisation contracted to provide additional support.

106. Making temporary changes to working practices, eg reducing close face-to-face contact, providing physical barriers to transmission, enhancing cleaning regimes, ensuring that the necessary protective equipment is available, having hand washing, waste disposal and other hygiene facilities in place and actively promoting these and other similar measures, can help to encourage and maintain attendance at work during the response phase. Further guidance for employers is available on the Health and Safety Executive ( HSE) website at www.hse.gov.uk/biosafety/diseases/influenza.htm .

Training and education for staff

107. A workforce that is well-informed and trained is likely to manage the additional pressures and challenges arising during a pandemic. Topics for staff education and training should include:

• good hygiene practices to limit the spread of the virus as far as possible
• general information about pandemic influenza, including information about vaccination and antiviral drugs
• infection control strategies for influenza, including respiratory hygiene/cough etiquette, hand hygiene and other precautions, specific training for cleaners and their roles in helping reduce the spread of infection
• specific training for telecare and community alarm call centre staff in helping to identify and support people isolated at home
• opportunities such as job shadowing to help prepare staff and volunteers to take on additional roles and responsibilities in the short term to cover staff absences
• how to respond to ethical dilemmas
• how best to train duty and on-call staff, eg whether or not this is best done face to face.

Infection control and personal hygiene

108. Once efficient person-to-person transmission is established, preventing an influenza pandemic developing is unlikely to be possible as most people are likely to be exposed to the virus at some stage during normal activities. In order to protect others and reduce the spread of infection, anyone with influenza-like symptoms should stay at home, minimise social/family contact and go out only if absolutely necessary (eg for medical care) until symptoms have resolved. Those who are not symptomatic should continue normal activities and can reduce - but not eliminate - the risk of catching or spreading influenza by avoiding unnecessary close contact with others and adopting high standards of personal and respiratory hygiene.

109. Applying basic infection control measures and encouraging compliance with public health advice are likely to make an important contribution to the UK's overall response.

Simple measures will help individuals to protect themselves and others. The necessary measures include:

Hand Hygiene

• Washing hands frequently with soap and warm water to reduce the spread of the virus from the hands to the face, or to other people, particularly after coughing, sneezing, blowing your nose or disposing of tissues. Making sure children follow the above advice
• Washing hands before, and after, contact with clients on leaving the care setting.
• An alcohol hand rub or hand towelettes containing a soap/detergent solution can be used instead of soap and warm water if access to a sink is restricted.
• Hand hygiene should be performed even if disposable gloves have been worn for any contact as described above.

Coughing/Sneezing

• Covering the nose and mouth with a tissue when coughing or sneezing
• Disposing of dirty tissues promptly and carefully - bagging and binning them

Environment

• Ensure patient/client's immediate environment is clean and not contaminated with respiratory secretions
• Cleaning frequently touched hard surfaces (eg kitchen worktops, door handles, television controls) frequently using warm water and detergent or normal cleaning product

Others

• Crockery/Utensils should be washed in the normal way with hot soapy water (or in a dishwasher).
• Laundry that may be contaminated, for example clients' clothing and bedding, should be washed in the usual way, as per local policy.
• Avoiding crowded gatherings where possible, especially in enclosed spaces
• If someone is symptomatic (has pandemic influenza) and it is essential to go out, they should consider wearing a disposable face mask to protect others

110. Adopting such measures can help mitigate the overall health and wider impact of a pandemic by lowering the clinical attack rate and slowing its development, thereby spreading peak demand and enabling services to respond more effectively.

The use of face masks and respirators

111. Surgical face masks or respirators (masks that incorporate a filter) provide a physical barrier against the influenza virus provided that they are of an appropriate type, are worn correctly, changed frequently, removed properly, disposed of safely and used in combination with good universal hygiene behaviour. Face masks can be used to help protect those who may, for example, be at occupational risk from close or frequent contact with symptomatic patients and by those who are symptomatic to avoid contaminating others if they have no choice but to leave their home, though significant communication, supply, logistic and training aspects would need to be addressed. Disposable masks or respirators should generally only be worn once, for no longer than the time recommended by the manufacturer, and then discarded in an appropriate receptacle.

112. Although the perception that wearing a face mask in public places may be beneficial is widely held, there is little actual evidence of proportionate benefit from widespread use. The Government will not therefore be stockpiling facemasks for general use. If individuals who are not symptomatic choose to purchase and wear facemasks in public places, they should be worn properly and disposed of safely to reduce infection spread. Wearing masks at all times is not practical; so decisions in occupational settings must take account of the degree of risk associated with particular occupations or activities and be based on joint risk assessments carried out by employers and staff representatives.

113. Although further clarification and guidance on the use of face masks may become available in due course, the planning presumptions should be that anyone who is ill with influenza like symptoms will be advised to stay at home. The general wearing of face masks in public places by those who do not have influenza symptoms will not be recommended and the Government will not supply facemasks for that purpose. Judgements on respiratory protection in specific occupational or other settings will need to be based on joint risk assessments. Guidance to employers is available via the Health and Safety Executive website at www.hse.gov.uk/biosafety/diseases/influenza.htm

Emergency short-term breaks

114. It is estimated that there are over 60,000 people caring for a relative or friend for between 20 and 49 hours per week and almost 116,000 people providing care for a relative or friend for over 50 hours per week. There is likely to be a marked increase in demand for emergency short-term breaks for service users where their 'informal' carers have contracted the disease. A substantial number of community care employees are likely to be informal carers too.

115. Local authorities with community care services responsibilities will need to consider, plan and prioritise for how they may meet this increased demand, with a view to people remaining in their own homes if possible.

Supporting access to antivirals and vaccines

116. The current community care model for pandemic planning proposes that people identify, in advance of a pandemic, friends or family who could collect medicines on their behalf should they fall sick. Whilst community care services will not have a direct responsibility for the distribution of antivirals and/or vaccines to people using services, they could play a key role in advance of a pandemic by supplementing primary care in their arrangements.

Identification and referral of individuals with pandemic influenza to health services

117. Individuals in receipt of community care services presenting symptoms of pandemic influenza should approach health services in the same way as the rest of the general population. For many people who cannot do this directly, neighbours, community care staff and families will need to be particularly vigilant. However, unless an individual is presenting particularly severe symptoms or is developing complications, they should be advised to contact the National Flu Line Service.

118. A widespread public awareness campaign will be initiated to inform the public of when and how to contact local health services.

119. In preparation for widespread activity ( UK alert level 4), the Government will activate and publicise a flu information line. The Flu Information Line will be available from WHO phase 5 to provide public information, updates and access to literature and at UK alert level 2 ( WHO Phase 6) to provide initial patient assessment and, where necessary, access to anti-virals. This will be maintained until the impact of the pandemic subsides and there is no threat of further waves. Further information on the National Flu Line Service is outlined in the Scottish Framework for Responding to an Influenza Pandemic,

Pandemic planning in different community care settings

120. Whilst some issues, such as managing staff absences, will be generic to all community care settings, each setting will have service-specific issues to take account of in its plans. This section sets out what some of those service-specific issues may be and how providers may start to address these. Services which are required to register with the Care Commission should consider what is required in the context of that registration and discuss any proposals or issues with the Commission.

Care homes

121. There is likely to be pressure on all care homes and intermediate care facilities to operate at full capacity during a pandemic. Temporary admissions to care homes are rarely likely to be ideal and should not be the first option. Therefore, care in the person's usual home should be encouraged and offered wherever possible unless there are complications.

122. Other aspects of maintaining a minimum level of service within the care home will also need to be planned, eg:

• continuity of meals provision
• continuity of other essential supplies/maintenance, eg cleaning of linen etc
• possible plans to house some workers on-site to enable extended shifts and minimise travelling from outside.

123. It may be sensible for care homes to 'pair up' with other care homes in the area and agree staff sharing arrangements to mitigate staff shortages where possible. In reality, however, we expect each service to concentrate on keeping the service for which it is immediately responsible running.

Home care

124. Given the additional pressures on both hospitals and care homes, many more people are likely to need to be supported at home. This will raise specific issues for additional carer support in the home setting and lead to an increased demand for domiciliary care services. Care providers are likely to have to arrange for some people to be supported at home at short notice and may need to develop reciprocal arrangements with other care providers.

125. Some assistive technologies and community equipment, eg community alarms, telecare, grab rails etc, may help people to manage in the short term in their own homes.

126. A number of other services that support people in the community are also likely to be affected; these include meals on wheels and home shopping schemes, without which people are likely to go without essential food and drink.

127. Domiciliary care providers will need to prioritise their services and staff and perhaps postpone some services, eg some general cleaning, and replace them with basic personal care, infection control, ensuring access to food etc.

128. When pandemic influenza is in their locality, home care agencies will need to consider contacting their clients before undertaking home visits to determine whether people within the household have influenza-like symptoms.

129. If service users have pandemic influenza, agencies should consider:

• discussing with the service users the postponing of non-essential services
• assigning staff who have already contracted and recovered from the influenza
• staff being designated to care for either influenza or non-influenza individuals wherever possible.

Day care

130. Day care centres play a vital role in helping to provide additional support to vulnerable people living at home. They can enable people to remain at home without the need for a full-time carer. They can help support carers and enable them to continue working or take breaks, and they provide a vital lifeline for many vulnerable people, reducing their social exclusion and enabling them to have wider contact with others and participate in meaningful activities.

131. However, day care services will have to consider the point at which the need to protect staff and the people attending day care outweighs the benefits to people of attending. For planning purposes, it may be sensible to recommend that, during the pandemic phase, the provision of day care should cease and staff available for work should be redeployed elsewhere, eg to support domiciliary care services, to support usual day care attendees at home or join peripatetic networks.

Self-directed support (direct payments)

132. Local authority self-directed support services will need to ensure that individuals are not left without support if their staff become ill with influenza. Support services should consider the role their local centres for independent living can play.

Legal issues

Suspension of statutory services

133. Under the Civil Contingencies Act 2004, local authorities are required to plan for the continuing performance of their functions in the event of an emergency. Whilst it will be desirable for local authorities to maintain normal levels of service, this is likely to be impossible in the event of a pandemic. Therefore, all local authorities will need to review their services and take a risk-based approach towards which services are the most essential and therefore must continue, and which services might be reduced or even stopped during the pandemic period. However, decisions of this nature must be taken within existing legal and ethical frameworks.

Disclosure Scotland and Protection of Vulnerable Groups checks

134. Staff will be required to work flexibly when the pandemic hits Scotland. Staff may be required to cover additional tasks and, in particular, office-based staff may be required to take on caring roles.

135. Proposals in the Protection of Vulnerable Groups (Scotland) Bill lay the foundations for the creation of a new vetting and barring scheme for people working with children and protected adults. This new scheme, which is likely to be implemented from late 2008 onwards, will replace the existing Disqualified from Working with Children list (the DWCL list) and will introduce, for the first time in Scotland, a list of those unsuitable to work with adults. The new vetting and barring scheme will replace enhanced disclosure checks for those who work with children or protected adults to create a centralised and continuously updated system of pre-employment vetting and referral-based barring. This new scheme will be delivered in Scotland by an Executive Agency of which Disclosure Scotland (who carry out Disclosures check now under the Police Act 1997) will be part. The Agency will access the equivalent lists from elsewhere in the UK.

136. Among the new features that the scheme will introduce, will be a system of continuous updating, and in time once an individual has entered the scheme, employers will be able to view a short scheme record via an online facility. This feature in particular will improve the speed and responsiveness of the current system and, in the event of a pandemic, will make it easier for employees to move between jobs as circumstances dictate. This new scheme mirrors the Safeguarding Vulnerable Groups Act 2006 which introduces a similar vetting and barring scheme covering England and Wales.

137. In the event of an influenza pandemic occurring before implementation of the new scheme, and where staffing levels in relation to community care are adversely affected, care service providers will still need to ensure that any arrangements put in place to deal with this ensures that individuals charged with looking after vulnerable people have been properly disclosure checked. Providers should consider with the Care Commission what this means for their service.

138. More generally the Scottish Government could consider issuing directions pursuant to Section 1(2)(a) of the Regulation of Care (Scotland) Act 2001. Such directions could instruct the Care Commission to ensure that people working to provide essential community care services are able to operate as flexibly as possible to avoid staffing gaps, and to ensure that services are maintained to the requisite level in order to protect the health and wellbeing of service users.

Performance management

139. All local authorities will be assessed against the requirements of the Civil Contingencies Act 2004 through normal management audit arrangements.

140. Community care services are regulated by the Care Commission under the Regulation of Care (Scotland) Act 2001 and its associated regulations. During the pandemic period, it may be necessary to suspend routine Care Commission inspections of community care services. In part, this will be due to the widespread disruption to services that an outbreak will cause and in part it will be for preventative and logistical reasons. Restricting visits to community care environments will help to minimise the spread of disease, whilst logistically it may be difficult for inspectors to travel for such visits as unnecessary travel will be discouraged during the pandemic period.

141. The Care Commission is prepared to take a flexible approach to inspection during the pandemic period and will work with the Scottish Government to develop appropriate arrangements based on a risk management approach.

142. The Care Commission inspection regime for operation during the pandemic period will be placed on its website at the time a pandemic occurs.

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