“Pandemic Planning”

1. “Pandemic Planning” Oxfordshire Practice Manager Conference 21.1.09. (Paul Roblin 10:15am to 10:45am)

3. “Practice managers in particular should find it helpful” Launched 07 January 2009 57 pages

4. RCGP http://www.rcgp.org.uk/pdf/GP_Guidance.pdf BMA http://www.bma.org.uk/health_promotion_ethics/influenza/panfluguiddec08.jsp?page=1

5. More to come • Document will be updated regularly as ideas emerge. It is therefore important to visit the DOH website regularly: • www.dh.gov.uk/en/Publichealth/Flu/PandemicFlu/index.htm.

6. Buckman letter • Practices should identify Buddying Groups (clusters of practices which actively cooperate for pandemic work) • Pandemic Flu Contingency plan to be agreed between buddying group and PCT by March 31 2009.

7. Anna Hinton(PCT operational lead) “Please send all updated plans to into PCT by 1/3/09” • Tel: 01865 336858 • Fax: 01865 337094 • Mobile: 07900 212 454 • email:anna.hinton@oxfordshirepct.nhs.uk

8. The Government’s messages to the public will be: • Stay at home • Don’t spread it around • Phone the National Pandemic Flu Line Service not GP practices. • Arrange a ‘flu friend’

9. National Pandemic Flu Line • 24-hour telephone line for the general public. • Capable of activation from spring 2009. • For the public to access antiviral medication • Issue URN to collect antivirals from a local ‘collection point’. • GPs will receive referrals from the National Pandemic Flu Line Service call centre.

10. Flu Line Professional Service (No public access) • Doctor access to a patient’s National Pandemic Flu Line record • Bypasses National Pandemic Flu Line Service • Check previous antiviral authorisations. • Authorise an antiviral • Generate a URN

11. Uncertainties of Pandemic Planning • Prediction is inaccurate • Clinical attack rate could be 25% to 50%, (normal seasonal flu rate of 5% to 15%). • Adaptability will be needed. • Responses stepped up as appropriate.(Escalation)

13. Buddying-up system • A buddying-up system is proposed • Clusters of practices will actively cooperate for pandemic work, sharing resources and exchanging staff as necessary. • Templates at www.rcgp.org.uk • Tees Primary Care Services – Primary Care Continuity Agreement: • Caduceus Medical Practice Influenza Plan:

14. Role of LMCs • Organising buddying groups. • Ensuring no practice is left isolated • Involved in making decisions about stopping non-essential work.

16. Pandemic Spread • It seems likely that a flu pandemic will start outside the UK, but within two to four weeks of the start of the outbreak in the host country it will affect the UK. • It could spread around the UK in one to two weeks, with the peak incidence occurring only 50 days from the initial entry to the UK. • There may be single or multiple waves • It is likely that between a quarter and a half of the population will be affected.

17. Practice Funding • Financial protection of practices when they have to suspend some normal operations such as Quality and Outcomes Framework (QOF) work and enhanced services. • More details can be found in Appendix 1

18. GP workload • GPs will be looking after patients in the community who are more seriously ill than under normal circumstances • About one-third of symptomatic patients will require assessment and treatment by a GP • Other practice patients who get flu will be asked to self-care.

19. Peak Weeks • The duration of a pandemic is unknown • The peak is likely to occur within 50 days of the first cases of pandemic flu appearing in the UK. • 22% of cases likely to occur in the peak week. • For a typical practice of three GPs with a list of 6,000 patients, that works out at 186 extra cases in the peak week of the pandemic.

20. Bird Flu (A/H5N1 flu virus ) • The worry is flu with the virulence of bird flu and the transmissibility of human flu • A new strain of avian flu virus mixed with human flu virus is likely to transmit more easily to people

21. Ethics • At the peak of the pandemic it may be necessary to prioritise who will benefit most from treatment. • No one will like this but it will be done in an ethical and objective manner. • Scoring systems for hospital admissions are being validated at present • Modelling suggests that up to 2.5% of all flu victims may die.

22. Coronors • Likely relaxation of the legal requirement to have seen the dead patient in previous 14 days . • Possibly the period will increase from 14 days to 28 days.

23. Flexible Certification • Death Certificates: Doctors who have not attended the patient allowed. • The same doctor could also complete a streamlined Cremation Form B. • Need for a second cremation doctor will be suspended

24. WHO Phases and UK Alert Levels

26. UK Alert Levels • If a pandemic is declared, action will depend on whether cases have been identified in the UK and on the extent of spread. • Therefore, for UK purposes, four additional alert levels have been included within WHO Phase 6. • These UK alert levels are: 1. Virus/cases only outside the UK 2. Virus isolated in the UK 3. Outbreak(s) in the UK 4. Widespread activity across the UK

27. Clinical Aims and Philosophy • Minimise the spread of the flu virus: isolate flu patients wherever possible. • Limit the morbidity and mortality from influenza • Stay at home and self-care. • Only certain patients will be seen by a GP or other healthcare professional. • Only the most seriously ill should be sent to hospital (assessed as likely to benefit from specialist treatment) .

28. Infectivity • The incubation period: 1-4 days • Most infectious soon after symptoms develop. • Droplet spread and Hand-to-face contact

29. Virus Survival on Surfaces • Hard non-porous surfaces • Flu viruses can survive >24h on • Soft materials(nightclothes, magazines and tissues)Up to 2h (15 mins mainly)

30. Surfaces and Hands • Remove soft furnishings and toys during a pandemic. • Flu viruses are easily deactivated by • washing with soap and water or alcohol handrub • cleaning surfaces with normal household detergents and cleaners. • Good hand hygiene is essential • Home visitors should carry personal packs of alcohol hand rub.

31. Personal protective equipment (PPE) • Fluid-repellent face masks should be worn by any healthcare worker who will have close contact (within one metre) of people with flu. • Government to stockpile face masks • These will be held centrally until a change in WHO flu phase status triggers dispatch to PCTs. • The point at which the face mask supplies are distributed to GP practices will be for PCTs to determine. • The masks will be supplied to practices free of charge. • Storage in practices?

32. Using Surgical Masks • Surgical masks should: • be worn once only and then discarded to an appropriate bin as clinical waste; hands should then be washed/cleansed after disposing of the mask. • cover nose and mouth • not be allowed to dangle round the neck after or between each use • not be touched until disposed • be changed when moist • GroupsIf there is a surgery for flu patients, or a GP/nurse is visiting patients in a nursing home, it may be more pragmatic to wear a single mask for the whole time or until it becomes moist and needs replacing.

33. Staff absence levels • Primary care staff will get flu, or stay at home caring for children or other dependants. • Up to half the workforce may require time off at some stage over the pandemic period (up to two weeks). • At the peak of the pandemic up to a fifth of the workforce may be absent. • Single-handed practices will be hit even harder and may become non-viable without support from ‘buddy practices’.

34. Staff Illness and Safety • Any GP or member of staff who shows flu symptoms must be sent home immediately. • Practice staff who have recovered from pandemic flu and feel well enough to work should have immunity and should be able to treat flu patients.

35. Staff Contracts and Pay • Alter staff contracts now • Flexibility clause. • to cover possible redeployment and/or altered hours of work. • Additional overtime taken by staff during the pandemic must also be funded by the primary care PCT.

36. Practice Continuity Plans • All practices must have a service continuity plan. For advice on how to do this and what to include read the joint guidance produced by the RCGP and the GPC at: • www.bma.org.uk/ap.nsf/Content/flupanprep?OpenDocument&Highlight=2,business,continuity • www.rcgp.org.uk/default.aspx?page=3908.

37. Photo ID • Each practice should develop an electronic library of staff photographs • Photo ID during a pandemic • Fuel supply for their vehicles.

38. Emergency Box Advised • Suggested Contents • Torch • spare batteries • standard phone for use with emergency line • e-charging adaptor for mobile phone • space blanket • up-to-date copy of this document • copies of the service continuity plan and the practice’s pandemic flu plan • prepared signs for surgery • photocopied patient encounter forms (in case computers are down) • a ream of A4 paper and writing materials for logging decisions and recording clinical treatments.

39. Retired Doctors • Retired doctors will be allowed to certify death • The BMA is working with the DOH to help identify retired doctors willing to help in a flu pandemic. • Legislation is proposed which would permit the GMC, under new emergency powers, to grant a doctor registration subject to conditions. • PCTs would pay the costs of GMC registration for this purpose.

40. Locum GPs • Locums/freelance GPs must be included in • preparation and training programmes, • information cascades • Photo databases • PCTs will employ all available freelance locum GPs • Arrangements being discussed at national level. • Performers List checking now

41. GP Registrars • Training and teaching will stop • Length of training period may well be affected. • Training rotational post changes will be suspended during a pandemic(inside and outside hospital.)

42. Litigation Risk • Special edition of Good Medical Practice will cover what will be expected of doctors in a flu pandemic • Doctors acting in good faith unlikely to be disciplined (The GMC and Defence Societies)

43. Practice Actions now • Staff contractsmaking voluntary changes. • Staff telephone numberdatabase(including mobile numbers) • Emergency Boxes • Buddy Up • Protocols “parachuted in” staff (Practice systems and IT use) • Plan patient separation

44. Daily “Sit” Reports • Regular reports to a PCT data collection point • Standard national template of content • Permits assessment of staffing levels at each site. • Precursor to transfer from one site to another.

45. Antiviral medicines • Not on FP10s • Most via National Pandemic Flu Line Service • Unique Reference Number (URN), needed to obtain antivirals from a local ‘collection point’.

46. Collecting Antivirals • Flu FriendsA nationwide campaign • Collect antiviral drugs from PCT collection point centres • Security measures will be in place • no unauthorised or duplicate access to antivirals.

47. Rebuilding, restoring and rehabilitation • Gradual Return to normality over months • Exhausted GPs and staff surprised at feeling unwell at this point. • Recuperation time • Mass vaccination campaign, could put added pressure on primary care

48. Questions?