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Monday 26 September 2016
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Action stations: is primary care ready for a flu pandemic?

Patient & Services

An outbreak of influenza on the scale of the 1918 "Spanish Flu" pandemic would kill tens of thousands of people and could paralyse society and healthcare.

GP practices could expect at least a quarter of their staff to be off sick or absent, there could be fuel crises and food and medicine shortages, hospitals would overflow and patients may become violent in a desperate bid to obtain scarce antiviral drugs.

This was the scenario of a 21st-century flu pandemic outlined at a recent conference in London, entitled "Pandemic flu – are we properly prepared?" and organised by Elsevier (publishers of the journal Hospital Doctor), which asked whether the UK was ready for such a health crisis.

The answer from most of the experts was "No". Doctors in particular are concerned. Four in 10 doctors who responded to a survey conducted by Hospital Doctor and medical pollster Medix believe the government is badly prepared for a flu pandemic, and only 20% think the country has made adequate preparations. Two-thirds said they did not feel the NHS could cope with a flu pandemic, the conference was told.

Fortune favours the prepared practice
Jim Hindle, a professional business manager with a large personal medical services (PMS) practice, who has a special interest in business continuity planning, said the reality was that most experts believed that it was not a question of whether there will be another flu pandemic, but when.

"We need to start planning now while we have time to plan, to reflect at leisure and take time to plan thoroughly," he said, adding that practice managers who had a grasp of how the practice operated from top to bottom were best placed to devise a pandemic flu plan for their practices.

The plan needed to identify the practice's critical functions and what resources would be needed; to determine the acceptable level of service that should be provided in a crisis; to allocate responsibilities; and to plan for staff absences.

Staff welfare should be an important part of the plan. Catering arrangements might be needed (the local Tesco may not be functioning fully because of a shortage of supplies); staff, who would be working longer than usual hours and under stress, would require rest facilities, counselling and support; and staff with domestic commitments may need to work flexible hours. It would be essential to ensure that there were daily briefings to inform staff of the progress of the pandemic.

Other issues to consider were whether the practice could cope with extra patients if a neighbouring practice had to close, and how staff would be affected if local schools shut or transport was disrupted because of fuel crises.

Putting a pandemic plan in place
The plan would need to be tested, audited and continually updated. Key staff should be involved in its development, and the whole team should be briefed on its contents.

If the practice did not draw up a detailed plan and failed to function effectively in the aftermath of a pandemic, it would find that staff were demoralised, the team dysfunctional, and that disaffected patients might leave the practice.

"Really, you need to start doing your planning for a flu pandemic now. Put it on the agenda this week, not next month," said Mr Hindle.

Graham Poulter, managing director of iQ Business Ltd, which provides specialist management software for the primary care sector, outlined details of the pandemic flu continuity planner that they have devised and which is currently being used by 3,000 practices.

He said his judgement, based on dozens of presentations made over the last year, was that many practices and primary care trusts (PCTs) were not prepared for a flu pandemic.

"There seems to be something of a Mexican standoff at the moment. When I present this product to GPs, the more enlightened ones are using it but many feel it is the responsibility of the PCT. But, unfortunately, many PCTs are under enormous financial pressure and are not prepared to pay for it and say it is the responsibility of the practice.

"I hope that this product will play a key role in what is going to be a very critical issue facing the whole country, not just from a health but also from an economic point of view. Planning is essential, and we need an accurate tool to do that."

UK preparations
Professor Lindsey Davies, national director of pandemic influenza preparedness at the Department of Health (DH), said that, compared with the flu pandemics of 1918 and 1958, the current population is healthier and stronger, and so are better prepared. She also said the fact that people were talking about the pandemic in advance was a good thing.

The whole population would be at risk, and there could be as many as 80,000 deaths in the UK and 10 million globally. Modelling showed that about 25% of the healthcare workforce might take 5–8 working days off. "This gives a sense of what we are preparing for," said Professor Davies.

She claimed the contingency planning the DH had already carried out made the UK probably the best-prepared country in the world. However, she admitted there was still a lot of work to do.

"We don't know the impact and whether it will spread very quickly," she said. The DH was considering stockpiling doses of H5N1 vaccine – this may provide some protection and could also be used for research to see how effective it was.

Professor Davies said she was concerned that the public would consider antiviral drugs to be a panacea: "What bothers me is that people think antiviral drugs will get them up and walking about again, but the important message we must get out there is that we don't know whether antiviral drugs will work against the new strain of flu. What we are hoping for is that it will reduce infectivity."

Good hygiene, such as handwashing and putting a hand in front of the mouth when coughing, would be the bedrock of their preventive practices, and GPs should start encouraging these practices now among the whole population. "People working in health and social care have a big responsibility as leaders, friends and role models to get health hygiene practices ingrained across the UK. This is something we should all be doing now," said Professor Davies.

Masks would help reduce infectivity but would not keep out the small particles of infection, only prevent the transfer of larger droplets. They could be used by infected people and healthcare workers but would not be necessary for people going about their everyday business.

National and local responses
The government may consider imposing travel restrictions if the infection became a pandemic, but Professor Davies said she thought it highly unlikely there would be any mandatory travel restrictions imposed during a flu pandemic in the UK.

Another option in the plan would be to set up a telephone advice line to give advice nationally to help relieve pressure on GPs. Antivirals could be provided without patients having to contact the GP directly.

The national framework plan, which is currently being revised, would be flexible enough to enable local areas to respond differently in different circumstances.

There would be difficult questions about the allocation of resources, which would have to be used to best effect and provided on clinical need. There would be no hard-and-fast answers to these dilemmas. "We need everyone to do their bit and to understand what their particular bit is. We will need to work together and remain constantly alert," said Professor Davies.

Vaccine supplies – and demands
Professor John Oxford, professor of virology at Barts and the London Trust, said that ideally antivirals should be given to the families of anyone diagnosed with pandemic flu, but currently there was only enough for 25% of the population, meaning this would be impossible. "This is a dilemma," he said.

Andrew Lansley, shadow secretary of state for health, raised several political question marks over the government's planning. These included why 3.5 million doses of an H5N1 vaccine had been bought, why there was not a strategic stockpile of facemasks, and when a contract for pandemic flu vaccine would be placed. He demanded to know when there would be a full-scale exercise that would answer the "hard questions".

Frontline risk
Dr Hilary Pickles, director of public health at Hillingdon Primary Care Trust, warned primary care teams that one of the lessons learned from any disaster was that "first responders" often rushed in with selfless heroism and put themselves at risk repeatedly and often unnecessarily.

Frontline staff would need to be protected from fear of litigation and violence and to be supported in difficult decisions.
 
"Keep good records, since avoidable mistakes will be made, and it may be necessary to be able to explain why," said Dr Pickles.

She went on: "What those of us doing the planning have to accept is that less than perfect care and rationing will be completely inevitable, and it would help if somebody 'up there' started saying it – not just the DH, but professional bodies such as the Royal College of Nursing and the British Medical Association."

Dr Simon Stockley, a full-time GP principal at the Eaglescliffe Medical Practice in Stockton-on Tees, who has a special interest in emergency work and planning, said each practice would face different problems. Remote rural practices would be doing everything for everybody, while urban areas would have large numbers of patients to deal with – their own patients, in addition to those who fell sick while they were in the locality.

"Sophie's choice" danger?
In addition to dealing with the flu crisis, practice staff would continue to need to treat other medical illnesses and look after very sick patients in the community, and would have to continue managing patients with chronic illness to prevent them deteriorating.

During a pandemic, GPs would be busy assessing flu patients, managing the worried well, issuing death and cremation certificates, and immunising patients. Routine work, such as the Quality and Outcomes Framework (QOF), would have to be ditched.

There were several contentious issues that could arise during a pandemic. When hospitals were full to overflowing, which patients should receive inpatient treatment? Many patients needing hospital care would have to be sent home, where they may have no support. "The question is: under what circumstances can suboptimal treatment be accepted
by the profession and the public?" asked Dr Stockley.

Doctors may also have to decide whether to give special care and consideration to key workers, such as fellow healthcare workers or public sector workers. The practice would have to decide how to deal with special needs groups, such as the elderly frail, very poor or ethnic groups, who were likely to have problems accessing services.

Community care
Another issue was whether GPs should visit more patients at home to help contain the spread of the disease. However, it was felt that this would be time-consuming and would reduce doctors' time and capacity to deliver oseltamivir to patients within 12 hours, which could also reduce the spread of infection.

Telephone triage may have a role in reducing visits and patient mixing. Other support that could be provided by the DH or the local PCT may include leadership from the centre (command and control), central call-handling, telephone assessment of antivirals and flu assessment centres.

Dr Stockley said 56% of his GP colleagues did not have any planning in place for pandemic flu, although most were aware of the disease, the implications for their practices and how they would work during a crisis. Many were starting to think about issues such as whether infectious patients should be allowed to sit together in the same waiting room, whether they came through the main entrance or were seen at home.

During a flu pandemic, GPs would be the best people to reassure and lead their communities. "Historically, GPs have always managed," said Dr Stockley. "It has involved a lot of sacrifices and a lot of hard work. This time there will much higher expectations of us and the possibility that we will be required to intervene to stem the progress of the pandemic."

He concluded: "Today there is less cohesion of family groups and more reliance on technology. This will make our task harder. So we will have to plan for that eventuality; otherwise we will have chaos."