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4 Specific Challenges
4.1 A pandemic will place significant strain on all services and as a consequence it is unlikely that psychiatric in-patient and other residential care services will be able to transfer patients to acute facilities unless they have significant physical health needs. Psychiatric services may need to cope themselves with patients suffering from influenza and may also need to deal with patients with other physical health needs.
Training
4.2 People with mental health problems will continue to suffer from physical conditions other than pandemic flu. Due to the pressure on other acute and community NHS services, mental health staff may have to provide care for these conditions to avoid compromising patient care due to a lack of access to physical healthcare. This will require psychiatrists, and other staff to operate outside of their clinical governance remits. Training will be needed for staff on basic and enhanced skills.
4.3 For training at a basic level, mental health services should consider training staff on recognising and managing common healthcare emergencies. In particular, staff should have a grounding in diagnosing and managing flu and the methods for limiting spread. All professional staff in mental health services are likely to require update and refresher courses on basic physical healthcare including assessment and examination techniques, common complications of flu, hand-washing and clinical cleanliness skills. Starting basic training in advance of a pandemic is good practice as it helps to build capacity and to develop guidelines.
4.4 In the community setting, it is likely that, from a clinical perspective, key skills required for handling influenza pandemic cases will include:
- emergency care;
- basic nursing care;
- medicine management;
- infection control;
- venous access;
- basic respiratory care/monitoring;
- supporting self-care;
- care of older people; and
- pharmacy.
4.5 In the medium secure, secure and other in-patient care settings, it is likely from a clinical perspective, that key skills required for handling influenza pandemic cases will include:
- emergency care;
- critical care skills;
- basic nursing care;
- medication handling;
- infection control;
- venous access;
- basic respiratory care/monitoring;
- advanced respiratory support/monitoring;
- advanced nursing care;
- pharmacy; and
- counselling.
4.6 Key non clinical skills will also be required during an influenza pandemic and these include:
- Catering;
- food handling;
- maintenance and engineering;
- transport;
- records handling;
- information technology;
- logistics/stores handling/requisitions;
- finance;
- security;
- linen handling;
- waste disposal - clinical and non-clinical;
- telephone/call handling; and
- chaplaincy and other religious or spiritual support.
Access to Medication
4.7 Mental health service users who rely on medication for their treatment will need continued access to their medicines throughout a pandemic. Recent crises, such as Hurricane Katrina in New Orleans, have demonstrated that maintenance of access to pharmaceuticals is paramount. Continued access to medicines requires a local response. In Scotland, community pharmacists can currently provide up to one cycle of a repeat prescription to a patient without recourse to a doctor under an Unscheduled Care National Patient Group Direction. 1 This means that patients with mental health problems will be able to access repeat medicines directly from their local community pharmacy in an emergency situation without a GP prescription
4.8 NHS Boards are already working with community pharmacy services as part of the contingency planning process. They should co-ordinate pharmacy responses that include specific plans for mental health service users. These plans should anticipate community pharmacies closing due to staff absence and that the global distribution chain may be affected with orders for medicines only coming in a month in advance of stocks supplied. Mental health services interests on local flu pandemic planning groups or committees should ensure standardisation of practice and access across their area.
4.9 There are certain drugs that may require additional contingency planning. For example, there may be an issue regarding Clozapine, which is used to treat treatment-resistant schizophrenia. This treatment requires on-going monitoring. Access to laboratories and the taking, and transport of blood could also be affected by staff absences. Infection control issues arise if patients need to attend clinics for monitoring.
Other current services may be affected in a similar way e.g. Clozapine clinics, memory clinics and alcohol day services. These may all have to be re-provided during a pandemic. Logistical issues also arise in the collection and distribution of prescriptions.In plans, mental health services should identify those commonly prescribed drugs that require additional contingency planning.
4.10 Mental health services may choose to individually or collectively create a reserve of priority drugs, in the event of the global supply chain being disrupted. Such planning should be done in conjunction with NHS Boards. In this regard NHS Boards and mental health services should consider the possibility of an influenza pandemic occurring sooner rather than later. Both should seek reassurance from suppliers that they have robust contingency plans in place in order to continue supplying their services in a prolonged emergency.
4.11 Even where suppliers can give assurances, NHS Boards and mental health services should discuss whether there is a need to stockpile some supplies especially where items are of critical importance. Issues regarding storage, prescribing and dispensing would also need considered. Community pharmacists should of course be involved in all planning regarding maintenance of medicine supplies.
4.12 Contingency planning for maintaining the medicines supply chain, including medicines for mental health is being taken forward on a UK basis by the Department of Health
4.13 The Scottish Government is reviewing available stock levels of both flu-specific medicines (including those used to treat illness associated with the complications of influenza) and non-flu medicines, and is working with the pharmaceutical sector and others to increase supply chain resilience and consider options for enhancing stocks.
4.14 In order to ensure, as far as possible, that people have ready access to the medicines they need, it is proposed that once a pandemic flu is declared by the World Health Organisation, amendments to medicines and related legislation will be brought into force for the duration of the pandemic flu.
4.15 These changes are outlined in the document: Pandemic influenza - Possible amendments to medicines and associated legislation during an influenza pandemic2 , and if agreed to, would include:
- Protocols for the mass supply of key flu rated medicines; and
- New powers of emergency medicines supply for pharmacists.
4.16 Giving drugs for flu to mental health service users follow consent procedures, Adults with Incapacity (Scotland) Act 2000 and Common Law. When the treatment concerns conditions other than mental illness the patient must give consent if s/he is able to do so. Medical practitioners have a general authority under Part 5 of the Adults with Incapacity (Scotland) Act 2000 to treat patients who are incapable of consenting to the treatment in question. Proposed treatment must be consistent with the general principles laid down in the Act. This general authority does not apply where the medical practitioner is aware that there is a proxy under the 2000 Act (e.g. a welfare attorney) with relevant powers and does not obtain the proxy's consent, where it would be reasonable and practicable to do so. The Act contains procedures to be followed where there is disagreement between the doctor and the proxy.
Impact on mental health conditions
4.17 There is some evidence that major events or crises enhance morbidity in terms of mental health. It is possible that an influenza pandemic may place additional requirements for mental health services at a time when resources and services are strained.
4.18 Mental health service users' needs for services and treatments will vary. It is expected that there would be short, medium and long term effects:
- In the short term, there are indications that people will behave as they would do in any crisis. Such distress is not a mental disorder per se. Remove the crisis, and the stress for most will be reduced/removed.
- In the medium and long term, the pandemic may leave some with a mental illness. People may suffer increased anxiety and/or depression. Those people who are vulnerable to a serious mental illness may relapse. Caseloads would be likely to include new service users as well as existing users. It is also possible that help will be sought both during a wave of a pandemic and in the aftermath.
- There may be an increased need for bereavement counselling, which is not normally the domain of the mental health services. When working with partners in developing pandemic flu plans, any assumptions regarding bereavement counselling should be clarified. Experience of palliative care staff at hospices in bereavement care and relevant voluntary organisations may be of possible help.
4.19 It is difficult to estimate the likely increase in demand on services. Whereas (as noted in 1.5) there is likely to be increased demand on mental health services both from those who are mentally healthy but have 'mental distress' (e.g. anxiety, bereavement) and those with existing mental health problems, there is some evidence that social support and resilience may improve in a crisis, There is conflicting evidence on demand for drugs and therapies from other events (e.g. flooding). Some studies indicate there are no changes to prescriptions for antidepressants whilst others suggest a 15% increase in demand for drugs. After the pandemic, NHS Boards and mental health services should review the effects for their area. Staff resilience will be an issue to plan for and review after the event.
Prioritisation and ethical considerations
4.20 Eligibility criteria for care during a pandemic should be transparent and applied in a consistent and equitable way that reserves capacity for those in greatest need. Staff should familiarise themselves with : Responding to an pandemic influenza - The ethical framework for policy and planning3
This document is designed to assist clinicians (who will also be guided by their own professional codes of ethics) and others in thinking about the ethical dimensions of their work in relation to a pandemic.
4.21 It may be difficult to sustain those people on intensive care packages in the community during a pandemic and despite best efforts there will be people whose care will be compromised due to staff absences or other effects.
4.22 Consistency of care and support is key for all service users and will be strained during any pandemic, perhaps particularly for those who receive care in the community. Community mental health nurses have an important role as patients' advocates to the primary care services. Since community and primary services will be severely depleted, roles as advocates may need to be balanced against the needs of essential mental health services. Alternative arrangements for advocacy such as current volunteers or befriending systems could be utilised.
4.23 The particular needs of those with severe mental illness and high rates of physical morbidity may require short notice intervention and timely access to appropriate care. This need should be accounted for in the determination of eligibility criteria.
Informal Carers
4.24 A large number of mental health service users rely on family members or friends for part or all of their support structure. These family, and other carers are an important group within mental healthcare and they carry a large burden of care.
4.25 Mental health services should identify the carers within their areas and have contingency plans wherever possible to respond where this network breaks down or needs added support. There may also be new carers when others fall ill.
4.26 Provision of information to informal carers and training in infection control may help ease the effects of the pandemic. It is likely that there will be a marked increase in demand for emergency short-term care for service users when their informal carers fall ill. This will be a difficult challenge during a time when capacity and staffing are limited.
4.27 NHS Boards and mental health services should liaise with local authorities and other partners to plan and prioritise how they may meet this increased demand. Specific care plans may need to be written (e.g. what the patient likes to eat, etc). This would support the transition from one lead carer to another.
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