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Executive summary
Since the influenza pandemic in 1968/69, changes to health service delivery and the growth of the UK population, particularly in the older age groups, have meant that the excess capacity to accommodate sudden influxes of patients which historically existed in the healthcare system no longer exists. It is estimated that, given a 50% clinical attack rate, a locality with 100,000 people could expect 11,000 clinical cases of influenza-like illness in the peak week of a pandemic, with 440 of these people requiring hospitalisation. With these projected numbers, it is likely that health services will be overwhelmed rapidly, unless steps to preserve the provision of essential care are taken, as well as measures to control access to such care.
This document provides guidance on managing the surge capacity - the ability of the health service to expand beyond normal capacity to meet an increased demand for clinical care - needed to respond to this volume of patients.
Chapters 1 and 2 provide context for the guidance. Chapter 3 outlines the ethical principles underpinning the development of the guidance with projections of the expected healthcare demand in chapter 4.
Guiding principles for health service planning are listed in chapter 5, and a conceptual model of the response is described. It is recognised that most ill people will have to be cared for outside of hospital, and the presumption must be that they will remain at home with such support as relatives/neighbours/friends/volunteers and health and social care can give.
In chapter 6 a concept of operations, consistent with Pandemic flu: A national framework for responding to an influenza pandemic, covers the timing and organisation of the healthcare response at a local level. Three suggested stages to the local health service response are described (increasing capacity, prioritising services, and prioritising patients and treatments), along with examples of the types of activity that might take place at each stage.
Chapter 7 deals with service prioritisation in more detail. The identification in the pre-pandemic period of priority services is critical. To facilitate the prioritisation process, a Service Priority Assessment Tool and guidance on its usage has been developed. Service strategies and actions based on local triggers are outlined. Checklists have been provided which address some of the broad issues relating to surge preparation that may be faced locally in healthcare facilities.
Chapter 8 introduces a model of stepped levels of care, and emphasises the need to understand and mitigate any potential adverse effects of proposed service alterations. In chapter 9 admission and discharge from services is discussed. A system for prioritising patients is proposed, which includes a process for assessing their continuing need for secondary care in the context of the ethical framework for policy and planning in a pandemic.
In chapter 10 a framework for implementation of phased response patterns and triage for the care of critically ill patients is presented.
The remaining chapters of the guidance cover the provision of paediatric care, non-invasive ventilatory support, palliative care, communications and security.
Key challenges in implementing guidance for managing the surge include:
- public and professional understanding of the need for, and involvement in, the prioritisation of services, treatments and patients at the peak of the pandemic
- ensuring that an appropriate legal framework is in place to support clinical decisions on prioritisation made during a pandemic
- developing the infrastructure in local communities to encourage self-care, to avoid admission of those patients for whom only symptomatic or palliative care is deemed appropriate and to support the early discharge of patients from hospital
- defining the geographical and health service footprint of a locality for the purposes of activating surge responses, for example health board/primary care trust groupings.
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