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4. Context and what to expect

4.1 Context

The impact on the UK healthcare system of previous pandemics has been variable. In his annual report for 1957, the then Chief Medical Officer commented that there was 'considerable pressure on hospitals for the admission of patients with acute chest infections'. ²

In the report for 1969, the Chief Medical Officer commented: 'the intensity of the demand may well have been masked by the availability of a large number of beds normally empty at Christmas'. ³

Could the NHS in 2008 cope to a similar degree? There are a number of differences between the situation today and that in 1957/58 and 1968/69:

• Over the last 35 years, there have been considerable changes to the way health services are delivered: there have been clinical innovations, changes to practice and the development of community services. The excess bed capacity that was previously in the system to accommodate large numbers of inpatients now no longer exists.
• There have been changes to the way in which primary care services are delivered, with a greater emphasis on chronic disease management and health promotion and the development of out-of-hours services. The increasing complexity of the organisation of primary care services presents challenges in gearing the system to respond to a pandemic.
• Since the last pandemic, the UK general population has grown by 8% (from 55.9 million in 1971 to 60.6 million in 2006). The number of people over 65 years of age - the group usually hardest hit by influenza and traditionally high users of healthcare resources - has increased by 31% (from 7.4 million to 9.7 million). ⁴
• The health service in 2008 is already working at or near capacity. For example, in 2005/06 the NHS in England had an average, overall, staffed bed occupancy of 85% ⁵ leaving little scope to accommodate sudden increases in demand for inpatient healthcare.
• Treatment modalities have changed and critical care has developed and become more widely used than was the case in 1957 and 1968. It is likely that, in a pandemic, the demand for critical care will be high and the current 3,450 adult critical care beds ⁶ and 320 paediatric critical care beds in England could be rapidly overwhelmed. ⁷

4.2 What to expect

Over the entire period of a pandemic, up to 50% of the population may show clinical symptoms of influenza. This could result in the total healthcare contacts for influenza-like illness increasing from around 1 million during a 'normal' season up to 30 million; it will not be possible to refine estimates until a pandemic occurs and person-to-person transmission begins.

Of those developing symptoms, up to 28.5% (including all affected children under three) will require assessment and treatment by a GP or other health professional, and up to 4% may require hospital admission if sufficient capacity is available. Average length of stay for those with complications may be six days (ten days if in intensive care). Of those who become symptomatic, up to 2.5% may die.

Table 1 illustrates the potential impact of a pandemic based on a population of 100,000.

Table 1: Expected healthcare demand over the course of a pandemic

Hospitalisations and deaths are likely to be greatest if the highest attack rates are in elderly people. The lowest burden on healthcare might be associated with higher attack rates in adults aged 15-64.

A temporal profile of a pandemic wave, based on the three pandemics from the last century and current models of disease transmission, has been developed and is illustrated in Figure 1.

Figure 1: Pandemic wave national profile showing proportion of new clinical cases by week

The profile attempts to show the fastest overall national progression of a pandemic from the time it becomes the dominant form of influenza-like disease, when the number of cases rises above the background of such diseases. Local epidemics might be over more quickly (six to eight weeks), with a proportionately higher peak lasting two to three weeks.

Given a 50% clinical attack rate in a pandemic wave, up to 22% of the total number of influenza cases will occur during the 'peak week', resulting in 11,000 new healthcare contacts per 100,000 population (including people accessing the National Flu Line service, which offers antiviral medication) (Table 2). At the peak of the pandemic, there could potentially be up to 440 new cases per 100,000 population requiring hospitalisation each week, 110 of whom could require access to critical care facilities. This is the reasonable worst-case scenario that local health planners should plan for.

Table 2: Expected healthcare demand during the peak week of a pandemic*

*A week-by-week analysis is available in the National framework.

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