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6 Continuity of care
6.1 A phased approach consisting of immediate and recovery plans is recommended when developing continuity plans. The aim should be to maintain normal services for as long as possible and then activate a proportionate response to the pandemic. Early decisions should be made by NHS Boards and mental health services on which services are 'essential' and which could be scaled down or stopped during a pandemic.
6.2 Decisions should be informed by projected staff absence of up to 50% at some stage during the period of the influenza pandemic. Models of care should be developed and modified to incorporate staff absence, increased demand (surge management) and patient prioritisation. Care continuity plans should be reviewed and updated regularly - as should be the case for all aspects of the pandemic plans.
6.3 New ways of working will need to be considered - including phone contact to follow up patients in the community rather than CPN visits. Flexible working practices will need to apply to minimise the spread of disease while continuing to provide essential care.
Training and support
6.4 A well-informed and trained workforce is more likely to manage the additional pressures and challenges arsing during any emergency including a pandemic.
6.5 Infection Control and Occupational Health should work together to ensure that staff education and training starts as early as possible covering: pandemic influenza awareness; good hygiene practices; information on vaccinations and antiviral drugs; and the importance of staff ill with flu staying at home.
6.6 Training is necessary for all staff in relation to the recognition of pandemic influenza symptoms and infection control measures. Early detection and treatment of staff and patients presenting with flu symptoms is essential to limit the spread of infection. Key messages on availability of vaccine and antivirals and use of personal protective equipment should also be communicated.
6.7 Pre-first wave immunisation with an influenza vaccine related to, but not specific to, the pandemic strain might offer some limited, but nonetheless useful, protection. Currently, (October 2007) the UK has very limited stocks of an A/H5N1 vaccine purchased specifically for the protection of healthcare workers.
6.8 Redeployment of staff may result in staff working in an environment or role different from usual. This, of course, has potential risks for both staff member and patients. Appropriate training for working in settings or roles different from usual will be required. Plans will need to be developed to ensure that reallocated staff who are working in fields beyond their normal realm have appropriate supervision. The wider health and safety of all staff needs to be considered.
6.9 The resilience and stamina of staff will be tested and possibly over a prolonged period. As previously referred, up to 50% of the workforce could be absent at some stage over the period of a pandemic.
6.10 As a minimum, organisations should ensure their plans anticipate this possibility and are capable of responding to staff absence rates of 15% to 20% over the two to three-week peak of a pandemic (up to 30% for smaller organisations). Absences are likely to be for seven to ten working days.
6.11 An increased number will be absent for family care responsibilities, bereavement and other impacts including practical difficulties in getting to work or organising childcare. Planning to maximise available staff levels should be a key focus for influenza pandemic preparedness. One approach could be to develop and maintain a register for staff and skill mix, and as covered before, to identify staff with skills and experience in physical healthcare. Mental health services could develop a risk assessment tool, to show the likelihood of event occurrence against the degree of impact. This could cover scenarios with different staff levels, timings for closing or reducing areas/services and for deploying staff. These scenarios should be tested in advance of a pandemic.
6.12 It is recommended that a register of reserve staff be developed prior to a pandemic, covering:
- those performing tasks considered pandemic essential (clinical and non-clinical);
- those performing tasks considered pandemic non-essential (clinical and non-clinical);
- managerial;
- voluntary;
- external contractors; and
- Other reserve staff pools (retired, etc).
6.13 Key elements to consider for these staff groups are:
- normal operational staffing levels;
- minimal staffing levels required to maintain a satisfactory level of care;
- mapping of directly employed staff ( as is currently done in non pandemic situations;
- mapping of reserve staff, including agency workers and volunteers;
- skills audit (to establish the pool of clinical and non-clinical skills);
- current management of sick leave and other staff absences;
- Ethical and professional obligations of staff;
- Contracted hours and the European Working Time Directive;
- Occupational Health;
- Health and Safety;
- restriction of deployment of potentially infected staff, reserve staff and volunteers;
- Regulatory issues;
- Indemnity;
- Certification; and
- Disclosure Scotland screening of staff, reserve staff and volunteers.
6.14 NHS Boards and mental health services may also need to draw on a range of sources to supplement current staff. As suggested in the lists above, recently retired staff is one such resource, local students or trainees in the sector is another. Further options include local voluntary or faith groups and (again as previously covered) deploying staff from non-essential services.
6.15 Disclosure Scotland issues are mentioned above and there may indeed be issues regarding security and other clearances. It should be remembered that Disclosure Scotland and all other employers and services will be similarly impacted by the pandemic. Where there are delays in clearance, uncleared staff (e.g. recently retired staff or volunteers) may initially have to be deployed for work that does not involve patient contact (e.g. cleaning or administration). In addition reserve staff could be deployed as a second staff member to avoid lone working and the risks associated with this.
6.16 Fear of flu will be an issue. Staff should be encouraged to continue to work (if not ill). Staff can be reassured through specific guidelines, for example helping them to have confidence in the preventative measures in place at their place of work. The aforementioned awareness raising initiatives on how flu is transmitted and on preventative measures will help. Staff at high personal risk of influenza complications, including those who have pre-existing respiratory disease, pregnant women etc., may need to be reallocated to work and areas where they may be at less risk of exposure.
6.17 NHS Boards and mental health services should consider the steps needed to ensure that employees who are ill or think they are ill with influenza are positively encouraged not to come into work. This may require reviewing current personnel policies. Systems will be needed for identifying staff who have influenza-like symptoms before they arrive at work. Arrangements will also be needed for handling staff who become ill with influenza-like symptoms whilst at work. Once staff are recovered from pandemic influenza, it may be appropriate to use these staff to look after patients with pandemic influenza, provided that health and safety needs of such staff are taken into account.
6.18 Local planning should involve human resource staff and trade unions in relation to changes to duties.
6.19 The voluntary and independent sectors may be able to help support the response to pandemic influenza at a local level. NHS Boards and mental health services along with local authorities and other partners will need to consider how to involve voluntary organisations in their area with which they do not usually have formal working arrangements, for example the Salvation Army, St John's Ambulance, local self-help groups and faith based community groups or charities.
6.20 Contributions could include:
- communicating key messages, information and advice both before and during and after a pandemic;
- providing a closer personal link to vulnerable or isolated individuals;
- supporting vulnerable or isolated individuals by facilitating collection of antivirals on their behalf; and
- putting in place initiatives for 'good neighbour' schemes.
6.21 Both voluntary and independent sectors should be involved as appropriate in planning and coordination of roles, particularly where the organisation provides services or care relied on by mental health services users or contracted for by NHS Scotland and partners. This interest should be identified in advance.
6.22 Helplines run by voluntary sector organisations and others will be an important communicator of advice and reassurance and it is important that messages are consistent with those contained within the national communications campaign.
6.23 Access to core equipment and requirements should be examined and assured as part of the planning process. Provision of supplies and services by private or independent organisations will be affected during an influenza pandemic and this eventuality needs to be taken into consideration. Supplies of consumables and utility supplies (such as catering and cleaning of linen in secure units) are likely to be disrupted.
6.24 For the medium secure and secure facilities there could be issues regarding access to domestic and auxiliary services. Possible fuel shortages may impede staff attendance and the delivery of supplies. While the continuation of supplies is being examined nationally, NHS Boards and mental health services should consider which of their supplies are considered vital and local plans should be made for how these can be maintained during a crisis. It may be necessary to discuss with suppliers whether they in turn have robust contingency plans and also investigate the need to stockpile essential items. NHS Boards and mental health services will combine with others in this consideration.
Recovery Plans
6.25 A single wave pandemic profile with a sharp peak provides the most prudent basis for planning. However, second or subsequent waves have occurred in some previous pandemics, weeks or months after the first wave. While the first priority at the end of the first wave will be to develop recovery plans and restore mental health services to their original capacity, plans must assume that some regrouping may be necessary in anticipation of a future wave. Ongoing constraints on supplies and services may also continue to place pressure on mental health services.
6.26 As the threat subsides, services will move into the recovery phase. Although the objective is to return to pre-pandemic levels of functioning as soon as possible, the pace of recovery will depend on a number of factors including demands for services, backlogs, staff and organisational fatigue and supply difficulties. Therefore, a gradual return to normality should be anticipated and expectations shaped accordingly.
6.27 Restoration of normal working will include:
- assessment of the clinical and non-clinical workforce available to return to work and over what period;
- phased resumption of normal services;
- provision of psychological support to staff;
- recruitment in a post pandemic competitive environment; and
- ensuring that buildings are adequately cleaned, sanitised and otherwise made ready for resumption of full services.
6.28 Mental health services are likely to experience persistent secondary effects for some time. There may be increased demand for continuing care from:
- people whose existing illnesses have been exacerbated by influenza;
- people who suffer potential medium or long-term health complications; and
- a backlog burden resulting from the postponement of treatments.
6.29 The reintroduction of performance targets and normal care standards should recognise the impacts of the pandemic and its aftermath.
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