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3 Impact
3.1 The key role of mental health services will be to ensure that core mental health services are maintained at safe levels in all sectors of care.
3.2 The early planning stages should include consideration of and decisions on what is deemed to be critical activity and develop appropriate models of care in response. Reduced staff numbers will affect maintenance of essential services and local plans will need to consider the minimum operating level. Redeployment of staff across the service should be planned for in this regard. Patient prioritisation will need to be taken into account.
3.3 Contingency plans should include infection control measures to minimise the spread of influenza in residential settings including small group homes. These have an attendant risk of more rapid spread of influenza. In the 1957 pandemic, some residential schools (which were closed environments) had attack rates reach up to 90%, affecting the whole school within a fortnight. This potential impact will need specific attention. More information on infection control measures can be found within the guidance on infection control in hospitals and primary care settings (www.scotland.gov.uk/pandemicflu)
3.4 There will be difficulties attached to moving patients with special needs or from secure care to other settings. Plans should cover explicit arrangements to identify and prioritise resources for vulnerable individuals, and those where forensic considerations apply so that precautions are put in place against infection and provide appropriate support should they develop influenza.
3.5 The welfare of patients being cared for in the community depends significantly on their ability to access support and the supply of medicines necessary to maintain their physical and mental health.
3.6 The need to provide speedy diagnosis and care for patients presenting at A&E or primary care with mental health related symptoms will continue despite the influenza pandemic.
3.7 The overall responsibility for NHS influenza pandemic preparedness within the community rests with NHS Boards, (in consultation with partners). However, given that mental health service users may also be service users of social services and other healthcare services, partnership working between all providing care support or services for people with a mental illness is essential.
3.8 It follows that decisions about service provision and contingency arrangements should not be made unilaterally.
3.9 All NHS Boards in Scotland have already produced pandemic influenza contingency plans which are available at: www.scotland.gov.uk/pandemicflu.
3.10 Emergency planners should review their plans to ensure the potential impact on the mental health services has been included. Planners should also ensure that planning is an integrated activity and that all plans are regularly updated and tested involving all partners. Any gaps, areas of concern and actions identified through the planning process and later reviews should be acted on, with regular updates to the NHS Board and partner agencies. Wider interests will include:
- Partner agencies;
- Mental health service lead;
- Influenza Pandemic Coordinator;
- Emergency planner;
- Infection control lead;
- Clinical lead with representation from in-patient care and community care as appropriate;
- Nursing lead;
- Pharmacy lead;
- General management;
- Pharmacy;
- Primary care practitioners; and
- Others as appropriate.
3.11 NHS Boards and mental health services should ensure they have robust systems capable of acting once an influenza pandemic is declared, with mental health services ready to activate appropriate responses. Nominated NHS Flu coordinator staff should be easily contactable and have clear lines of communication both in the declaration of a pandemic and in subsequent information and guidance to all staff and partners.
3.12 It is vital to have robust reporting pathways so that decision makers and frontline care providers have timely information to enable them to take prompt action. Command and control plans should allow for eventualities such as key personnel falling ill so that decisions can continue to be made and resources committed. Mental health services are recommended to develop plans to help facilitate effective delegation.
Communications
3.13 Preparing for, responding to and recovering from an influenza pandemic will depend significantly on co-operation between Government, public authorities, business, non-governmental organisations, the voluntary sector and individuals. An effective two-way communication strategy that positively engages each of these key groups prior to and during a pandemic is therefore a major strand of the needed preparations.
3.14 The Department of Health, England ( DH) will inform the Scottish Government of any changes in the World Health Organization pandemic phases. The Scottish Government will cascade information to NHS Boards and to other organisations via the eight regional Strategic Coordinating Groups. Communications of clinical information to Scotland's NHS Boards would be via the Chief Medical Officer ( CMO) network.
3.15 Effective internal two-way communication will also be vital for an effective response in a pandemic. Regional Strategic Co-ordinating Groups will have a key part to play in linking to health and other services and will support and co-ordinate the activities of local NHS Boards in delivering locally tailored press notices, key fact sheets and identifying suitable spokespersons. All mainstream information and campaign materials need to be accessible to the widest possible audience, including all hard-to-reach groups.
3.16 Clearly there are specific difficulties around effective communication with this patient group which should not be underestimated. Certain groups may require special arrangements to be put in place (e.g. people who are taking Clozapine and attend blood monitoring clinics) and communicated quickly to patients, carers, support workers and mental health staff.
3.17 To provide public information and advice before and during a pandemic, UK Governments, in conjunction with NHS Direct and NHS24, will establish a National Flu Line service at WHO international phase 5. 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 situation has returned to normal.
Antiviral Medicines
3.18 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 start to be taken within two days of the onset of symptoms. The UK has already established national stockpiles of Tamiflu which will allow for the treatment of 25% of the population, and intends to increase this to 60% population coverage.
3.19 Public access to antiviral drugs will be via the National Flu Line. The current community care model proposes that people identify in advance of a pandemic, a relative or friend who could collect medicines on their behalf should they fall ill with influenza. If it is anticipated that some people with mental health problems may have difficulty in using the National Flu Line, then it may be necessary to provide assistance on a local level.
3.20 NHS Boards will need to work closely with mental health services to ensure that the population they serve get access to antivirals. Like other members of the public, community based patients will be expected to access antivirals via the National Flu Line. However, people with mental health problems may require additional support to gain access to a telephone line. Community mental health teams should know all individuals who will need help in gaining access. Voluntary organisations and district nurses may also be able to provide assistance.
3.21 NHS Boards will need to establish an arrangement for access to the antivirals for: medium secure: secure; and other in-patient care.
3.22 TamifluTM can be taken with drugs prescribed for mental health problems. Where there are concerns about possible contraindication of antiviral drugs with drugs already prescribed for a particular condition, clinicians can consult the BNF. Recent studies in Japan found a possible association between Tamiflu and increased suicides. To date, there is no evidence of a causal link. Nevertheless, mental health services should be aware that it may heighten suicide risk in suicidal patients and should refer to best practice guidelines in preventing suicides.
Pandemic-specific vaccine
3.23 Vaccination is widely used in the UK to offer protection against the seasonal influenza strains that are the most likely to be circulating in any particular year. However pandemic influenza will result from a new or modified strain and the routine vaccinations are unlikely to offer protection. Therefore it will not be possible to develop a vaccine for pandemic flu until the influenza strain has been identified. It may then take four to six months before an effective vaccine is available.
3.24 Given that international demand will be high, it may take longer to obtain sufficient quantities for the entire UK population. For planning purposes, the presumption should be that a pandemic vaccination during the first pandemic wave is unlikely but may contribute to reducing the impact of subsequent waves if they occur
3.25 Once vaccines are available in the UK, they will be distributed through general practices. However, there may be instances where people with mental health problems are not registered with a general practitioner or may have difficulties accessing GP services. NHS Boards should agree with mental health services prior to the pandemic on how vaccinations of mental health patients and staff will be carried out. Within medium secure, secure and other in-patient care, it may be necessary to identify mental health staff who can administer vaccinations or agree for an outside vaccination team to give the vaccines on the premises.
3.26 Antibiotics are the most effective means of treating the secondary bacterial complications of flu but these should be prescribed appropriately. The Scottish Government is reviewing available stock levels and options for enhancing these levels.
Self Care
3.27 The promotion of self-care will be crucial in encouraging all to take the necessary steps to avoid contracting and spreading the influenza virus. There are specific challenges to promoting self-care for people with a mental health problem who may experience heightened mental distress. A second component will be supporting those showing symptoms at home or within residential settings. Promotion of self-care will enable primary care services to focus on those with more urgent or critical healthcare needs. This will form part of the national communications strategy.
3.28 For mental health services to continue to function, the public will need to follow advice on protecting themselves and their families, and will need to comply with public health measures and messages on when and how to seek medical advice or care. In addition, every community pharmacy in Scotland provides a Minor Ailment Service which allows patients who are exempt from prescription charges to register with the community pharmacy of their choice for the treatment of common presenting conditions, including colds and flu.
3.29 NHS Boards and mental health services have a role to play in encouraging and supporting self-care among staff, service users and in the local population. There will be difficulties in communicating to some mental health service users. Messages should be simple and clear.
3.30 Some service users will be more vulnerable to flu (e.g. rough sleepers) or may have addictions that complicate prevention and communication regarding flu and self-care. It cannot be assumed that all vulnerable service users are able to fully comprehend or comply with the advice on self-care. Alternative forms of communication to written information may need to be considered.
3.31 In the medium secure and secure facilities, the population can be more prone to physical ill health. One-to-one education with a staff member that they know well can be of benefit.
Legislation
3.31 There are currently no powers in the Mental Health (Care and Treatment) (Scotland) Act (2003) to derogate the statutory timescales which must be met by all concerned in relation to compulsory measures for patients. Consideration on this aspect continues. If the decision is taken to provide such powers Primary legislation will be required and emergency powers under the Civil Contingencies Act 2004 ( CCA) may be used until these are in place. Further advice will issue in due course.
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