Implementation Support Pack

1. The objective of this pack is to provide a summary of key materials to support SHA Flu Leads, PCT Flu Co-ordinators and key contacts in Acute and Mental Health trusts with Pandemic Flu Preparedness work Note: Information is correct at the time of publishing. The programme will endeavour to update documentation regularly, however if you have any queries relating to the content of this document please email: pandemicflu@dh.gsi.gov.uk This document is not in the public domain. Please restrict circulation to those involved with flu planning. Implementation Support Pack 6th March 2008

2. An Introduction to Pandemic Flu • Influenza pandemics are natural phenomena that have occurred three times in the last century. • "Most experts believe that it is not a question of whether there will be another severe influenza pandemic but when” Chief Medical Officer 2002. • It is recognised that the likelihood of a high pathogenic human influenza virus, capable of causing a pandemic, evolving in the near term is real but unquantifiable. • This unquantifiable probability must be set against the possible huge impact of a pandemic. In the worst case a pandemic would have a massive impact, with many millions of people worldwide becoming ill and a proportion of these dying. In the UK this could mean up to half the population may become ill and up to 750,000 additional deaths. • A pandemic will impact on all aspects of UK society. In the worst case scenario, with no interventions taken, the possible cumulative costs of a pandemic to society have been estimated to be up to £1,242 billion. • The World Health Organization (WHO) currently advise that, out of six levels of alert, we are in the pandemic alert period at phase 3, where there are human infections with a new type of virus, but there is not efficient and sustained transmission from person to person. Phase 6 would be the start of a pandemic. • As a pandemic flu virus has yet to emerge, we do not know how infectious it will be, or the severity of the illness it will cause. We do know that it is likely to take only a few weeks between a pandemic virus emerging somewhere in the world and it reaching the UK, and that it will spread quickly to all parts of the UK. As it will be too late to secure stocks of countermeasures once the pandemic virus has emerged, we need to allow some time to procure stocks and to ensure a response strategy can be implemented in the NHS. Therefore, decisions need to be taken in the pandemic alert period, before a pandemic emerges. This is supported by the WHO state “in view of the immediacy of the threat, WHO recommends that all countries undertake urgent action to prepare for a pandemic”*. • *Responding to the avian influenza pandemic threat. Recommended strategic actions. WHO. Page 1

3. Useful reference documents • There are two useful reference documents that help build an understanding of the subject of pandemic flu. • Pandemic Flu Frequently Asked Questions • To open double click on the icon below • Pandemic Flu Key Facts • To open double click on the box below

4. The programme’s intervention strategy • The programme’s intervention strategy is based on the need for ‘defence in depth’. • This strategy aims to • Reduce amount of illness caused by pandemic flu • Reduce number of deaths which result from pandemic flu • Manage the increased pressure on the NHS and Social Care Services • The programme is building up capability in several areas to deliver to the above programme objectives • Clinical countermeasure stockpiles are being built up e.g. Antivirals, antibiotics, face masks etc • Infrastructure to deliver the pandemic response across the NHS and Social care is being built e.g. the national flu line service, surveillance mechanisms • Processes are being put in place to ensure the right information is available to inform management of a pandemic emergency situation, such as identifying key information required by Ministers • Public preparation and confidence is being built up through a public health and hygiene campaign • A programme of public engagement is testing how the public will respond to proposed policy • The programme is also helping the NHS and the Social Care field prepare • Health and social care service planning and preparation work is underway in the NHS • The programme is also liaising with the wider business continuity work being undertaken by the Department, in the Emergency Preparedness Division

5. Summary of outputs from the ProgrammeGuidancePosition on countermeasuresCommunications and training materialsContact details

6. Pandemic preparedness health guidance available To open the document double click on the box below

7. Pandemic preparedness infection control guidance available To open the document double click on the box below

8. Infection control training materials available To open the document double click on the box below For access to the infection control training video go to http://www.coionline.tv/singleVideo.php?vID=videos/flu.flv

9. Pandemic preparedness non health guidance available To open the document double click on the icon below For more information go to http://www.ukresilience.info/latest/human_pandemic.aspx

10. Pandemic preparedness health guidance in progress This is information is correct as of February 2008 To review latest guidance published, see the DH website http://www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/index.htm

11. Summary of key sources • Guidance published by the Department can be found http://www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/index.htm • Guidance published by the Cabinet Office can be found http://www.ukresilience.info/latest/human_pandemic.aspx • Guidance published by HPA can be found http://www.hpa.org.uk/infections/topics_az/influenza/pandemic/default.htm • Guidance published by HSE can be foundhttp://www.hse.gov.uk/biosafety/diseases/pandemic.htm

12. The programme has devised an intervention strategy, for use in the event of a pandemic, based on the need for ‘Defence in Depth’. This strategy aims to Minimise illness and death Reduce the burden on the NHS Reduce economic impact of a pandemic There are four layers to the ‘Defence in Depth’ strategy, these are reflected the portfolio of countermeasures the programme proposes to procure. Figure 3 - Illustration of the Defence in Depth strategy Reduce the spread of the virus The first line of the ‘defence in depth’ model is to reduce the spread of the virus, this is achieved through good public hygiene habits, social distancing measures and the use of facemasks. Reduce the number of cases The next layer of defence aims to reduce the number of people who get the symptoms of flu. This is achieved through the use of vaccines and antiviral prophylaxis. Reduce length and severity of symptoms, reduce the risk of complications, hospitalisations and deaths The following layers aim to reduce the number of symptomatic people who get complications and reduce the number of people with complications who die or become chronically ill through use of antivirals and antibiotics. Summary of the programme’s countermeasures strategy

13. Summary of countermeasures to be procured by the programme

14. Template for Consumables • A framework of the consumable items that may be in short supply to trusts / health care providers during an influenza pandemic was drafted in Autumn 2007 and shared with SHA Flu Leads. • The Department of Health is not creating a complete, comprehensive list of items that all trusts / health care providers will need. However the below list is provided as a guide to stimulate local discussion with local experts as to what items are required and in what quantities. • Click the icon below to open up the consumables template

15. Scientific Evidence Papers To open the document double click on the box below

16. Campaign materials To open the document double click on the icon below For access to further materials including a screensaver go to - http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080839

17. National Director for Pandemic Influenza Preparedness Lindsey Davies Senior PA to National Director Tanya Nickols Pandemic Influenza Core Team Programme Director Karen Fitzgerald Programme Management Office Lloyd Thomas (Contractor), Kevyn Austyn Dan Oligive (Contractor), Anya Tahir Branch Head Bruce Taylor Branch Head Helen Shirley Quirke Science & Surveillance Science Manager Sandra Costigan Surveillance Manager Arlene Reynolds Surveillance Clinical Network Database Jane Leese Scientific Manager Colin Armstrong Surveillance/SAG/ Secretariat/ Support Noorie Beeharry Legal, International, Cross Government & Briefing International & Cross Government Lead Jo Newstead Legal, International, Briefing Neri Ineneji Cross-Govt, Ethics, UKNIP, Briefing Greg Hartwell Briefing/Secretariat Lorna Wilkinson Administrative Support Samuel Stewart Implementation Social care Simon Cole Ian Summerscales NHS Implementation Ruth Whitfield NHS Liaison John Pullin Healthcare Primary Care/Community Setting Manager Amy McCullough Antiviral Project Office Manager Vasanti Shirodkar Audit Tool SME Richard Puleston Distribution arrangements/ Audit Tool Tony McDermott Stock management Arrangements Umesh Kumar Mental Health/ Vulnerable Groups Manager Catherine Heffernan Pandemic Flu in Pregnancy Manager Chole Sellwood Clinical Advisor/ Engagement with the Professionals Barbara Bannister Healthcare Support Kola Okunola Clinical Countermeasures & Business Case Clinical Countermeasures Manager Damien Bishop Business Case Manager Mark Thomas Budget Manager Paul Winslow Budget Support Anita Sharma Communications & Stakeholder Management Communications & Stakeholder Relationship Manager Fiona Carr Internal Communications Bridget Le Good Respiratory and Hand Hygiene Campaigns Nicola Lewis Communications For Vulnerable & Hard To Reach Groups Alison Langridge Communications Support Sarah Wheller

18. Key programme contacts

19. SHA Flu Teams X-DH Reference Groups UKNIP, SAG, EPCLAG Extended Programme Structure The structure is designed to provide both strategic and operational direction to the programme. The complexity of the programme means that multiple stakeholders are involved in delivery. The governance process integrates these groups. MISC 32provides cross-government strategic direction / issue resolution and ensures strategy is aligned DMB responds to escalated decisions & issues which affect stated ministerial & departmental positions MISC 32 (meets quarterly) DMB Programme Representation (reviews quarterly) Flu Working Group  Programme Sponsor Programme Board provides leadership, oversees the implementation of strategy and interacts with key stakeholders Programme Board(meets six weekly)  SRO Operational Management Board actively coordinates and manages day to day risks, issues, conflicts and priorities of the PIG workstreams. PIG / Project Chairs are represented at formal meetings (together with DA, Finance and HPA representatives). PIG Leads participate in informal meetings. NHS Implementation Board(meets every 4 weeks) Operational Management Board(meets fortnightly on informal basis and formally once every six weeks)  Programme Director NHSIBprovides a bridge between the programme & regional operations & is responsible for the local implementation of the preparedness plan.  Programme Manager Pandemic Influenza Groups (PIGS) /Project Boardstake place regularly to discuss progress / risks and resolve issues on the day to day running of the workstream (eg: Health Care, Clinical Counter Measures, National Flu Line, Business Case etc). Workstreams • Business Case • Communications • Countermeasures • Healthcare • Pharmacy • Research • Surveillance • Social Care • X-Cutting

20. SHA Flu Leads contact details

21. Healthcare PIG members contact details

22. Dentistry PIG contact details

23. Summary of planning support materials Implementation timingsPlanning assumptionsExercise feedback

24. A summary of key dates for NHS preparedness planning 2008 *Indicative timings will be confirmed as soon as possible Jan Mar May Jul Sept Nov Jan Feb Apr Jun Aug Oct Dec • Current timings • Audit tools for • Acute • Community • Ambulance 05/12 SHA confirm results 31/10 Implementation deadline 14/11 Re-audit completed 10/04 Actions plans reviewed 31/01 Audits complete 20/03 SHA confirm results 30/04 Action plans complete 06/08 Implementation check point • Proposed audit tool timing for • SHA • Mental health • Social care 21/03 SHA audit launched 04/04 Audit completed 06/05 SHA confirm results Indicative timings* 15/05 mental health audit launched 30/05 audit completed 10/06 SHA confirm results 04/07 Action plans complete Indicative timings* 10/06 SC Audit launched 26/09 Audit completed 31/10 Action plans complete Indicative timings* Programme work • Agree the measure and target for an acceptable level of preparedness by end 2007 • Update to NHS Man. Board on audit results • Programme delivers support to NHS Implementation • Programme offers independent review of plans/flu squad challenge sessions • Agree forward look of programme of exercises required • Update to NHS Man. Board on audit results Key meetings 23/06 NHS National Workshop 23/04 NHS Management Board update tbc/10 NHS Management Board update tbc/01 NHS Management Board update Key tbc = to be confirmed. These will be confirmed as soon as possible. Draft = Milestone = Programme activity = Meeting Restricted: Policy

25. Pandemic preparedness planning principles • The National Framework articulates the planning principles upon which the health and social care response to a pandemic should be planned • Response arrangements should be based on strengthening and supplementing normal delivery mechanisms as far as is practicable • Plans should be developed on an integrated multi-agency basis with risk sharing and cross-cover between all organisations • Plans should encourage pan-organisational working, seeking to mobilise capacity and skills of all public and private sector healthcare staff, contractors and volunteers • Response measures should maintain public confidence and ‘feel fair’ Source: National Framework, p94,95

26. Plans should account for the following assumptions on how healthcare will be delivered during a pandemic • The National Framework explains that the NHS should plan on the basis that normal patient pathways and service delivery arrangements will need to be adapted. It suggests that plans should assume use of the following • From WHO Phase 6, UK Alert Level 2 a National Flu Line Service is activated to enable symptomatic patients rapid access to a assessment, advice and, if appropriate, antiviral medicine treatment and onward referral. This includes triage to another healthcare professional where further advice and care is required. The Flu Line Service is intended to help preserve primary healthcare capacity for seeing those people that most need their services, as well as facilitating rapid access to antiviral treatment • Provision of a wider range of treatments by health professionals other than GPs e.g. nurses following agreed guidelines • Care of patients, who under normal circumstances would be admitted to hospital, in their own home/residential settings • Treatment of severely ill patients in areas of a hospital not normally used for providing acute medical care by medical and nursing teams who do not normally manage such patients • Treatment of patients in private healthcare facilities not normally used for acute medical care by healthcare teams that do not normally manage such patients • Managing surge demand during the pandemic will require a focus on delivering essential services • Note: • DH is currently consulting on necessary changes to medicines or other legislation that may be required to implement these alternative operational arrangements Source: National Framework, p97

27. Plans must take account of the following surge management assumptions Introduction At WHO Phase 6,Alert Level 2 respective health departments will need to make decisions to reduce or change NHS services and, where appropriate, to modify or suspend some normal performance targets. Health and social care organisations need to ensure their plans include provision for enhancing, scaling down, or ceasing some services at the pandemic threat increases. Their planning should be based on the following surge assumptions Severity of illness assumptions* Health and social care demand assumptions* • Up to 50% of the population may show clinical symptoms, up to 25% of those may develop complications • Up to 2.5% of those who become symptomatic may die • Up to 22% of cases can be expected in the ‘peak week’ of a pandemic wave • Up to 28.5% of symptomatic patients will require assessment and treatment by a general medical practitioner or experience nurse • Up to 4% of those symptomatic may require hospital admission, average length of stay for those with complications may be 6 days (10 if in intensive care) • A short epidemic would be greater strain on services than a lower-level but more sustained one • Hospitalisations and deaths are likely to be greatest if the highest attack rates are in older people, lowest burden if highest attack rates are in adults aged 15-64 • Total healthcare contacts for influenza –like illness could be up to 30 million • Peak demand could last for 1-2 weeks, local epidemic waves 6-8 weeks • Most patients will be treated at home with antiviral medicines initially Further information can be found in the Primary care guidance and managing surge guidance Source: National Framework, p95, 96 * All statistics are based on national planning assumption attack rate of 50%

28. Planners are asked to plan on the basis of a clinical attack rate of up to 50% Planning will assume a clinical attack rate of up to 50%, the table below shows the surge in demand healthcare providers must plan for. Source: National Framework, p96, 97 * All statistics are based on national planning assumption attack rate of 50%. This is assumed to be a worst case attack rate/

29. The following assumptions should underpin Primary Care planning Source: National Framework, p107-113 * All statistics are based on national planning assumption attack rate of 50%. This is assumed to be a worst case attack rate/

30. The following assumptions should underpin Primary Care planning Source: National Framework, p107-113

31. The following assumptions should underpin PCT planning Source: National Framework, p107-113

32. The following assumptions should underpin planning for acute care Source: National Framework, p107-113

33. The following assumptions should underpin Ambulance, Mental health and Social care planning Source: National Framework, p107-113

34. Planners may want to review feedback from the following exercises To open the document double click on the icon below

35. Disclaimer • In carrying out our work and preparing our report, we have worked solely on the instructions of Department of Health and for Department of Health’s purposes. It should not be provided to any third party without prior written consent. Our report may not have considered issues relevant to any third parties, any use such third parties may choose to make of our report is entirely at their own risk and we shall have no responsibility whatsoever in relation to any such use. • The information in this pack is intended to provide only a general outline of the subjects covered. It should not be regarded as comprehensive or sufficient for making decisions, nor should it be used in place of professional advice. Accordingly, Assurance Strategy and Audit accepts no responsibility for loss arising from any action taken or not taken by anyone using this pack. • The information in this presentation pack will have been supplemented by matters arising from any oral presentation by us, and should be considered in light of this additional information.