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									   “Pandemic Planning”

Oxfordshire Practice Manager Conference
   (Paul Roblin 10:15am to 10:45am)
    Launched 07 January 2009
           57 pages

     “Practice managers in
particular should find it helpful”

            More to come
 Document will be updated regularly as
  ideas emerge. It is therefore important to
  visit the DOH website regularly:
           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.
                 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

  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‟
     National Pandemic Flu Line
 24-hour telephone line for the general
   Capable of activation from spring 2009.
   For the public to access antiviral
   Issue URN to collect antivirals from a local
    „collection point‟.
   GPs will receive referrals from the National
    Pandemic Flu Line Service call centre.
Flu Line Professional Service
               (No public access)

 Doctor access to a patient‟s National
  Pandemic Flu Line record
 Bypasses National Pandemic Flu Line
   Check previous antiviral authorisations.
   Authorise an antiviral
   Generate a URN
     Uncertainties of Pandemic

 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.
Overall case      Range of possible excess deaths in the UK
fatality rate (%)
                 25% clinical     35% clinical      50% clinical
                 attack rate      attack rate       attack rate

0.4              55,500           77,700            111,000

1.0              15,000           210,000           300,000

1.5              225,000          315,000           450,000

2.5              375,000          525,000           750,000
        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
    Tees Primary Care Services – Primary Care
     Continuity Agreement:
    Caduceus Medical Practice Influenza Plan:
             Role of LMCs

 Organising buddying groups.
 Ensuring no practice is left isolated
 Involved in making decisions about
  stopping non-essential work.
1918/19   „Spanish flu‟   20-40 million deaths

1957      Asian flu‟      1-4 million deaths

1968      „Hong Kong      1-4 million deaths
            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.
          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
            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.
                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.
    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
 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.

 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.
        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
WHO Phases and UK
   Alert Levels
1. No new influenza virus subtypes detected in humans
2. Animal influenza virus subtype proposes substantial risk humans
                           Pandemic alert period
3. Human infection(s) with a new subtype, but no (or rare) person-to-person
spread to a close contact
4. Small cluster(s) with limited person-to-person transmission but spread is
highly localised, suggesting that the virus is not well adapted to humans
5. Large cluster(s) but person-to-person spread still localised, suggesting
the virus is becoming increasingly better adapted to humans
                              Pandemic period
6. Increased and sustained transmission in general population
UK alert levels come into play
UK alert levels (x4):
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
             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
    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
    (assessed as likely to benefit from specialist

 The incubation period: 1-4 days
 Most infectious soon after symptoms
 Droplet spread and Hand-to-face contact
  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)
        Surfaces and Hands
 Remove soft furnishings and toys during a

 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.
    Personal protective equipment

 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?
           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
    not be touched until disposed
    be changed when moist
 Groups
  If 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.
         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‟.
      Staff Illness and Safety
 Any GP or member of staff who shows flu
  symptoms must be sent home
 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.
      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.
     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:
                 Photo ID

 Each practice should develop an
  electronic library of staff photographs

 Photo ID during a pandemic

 Fuel supply for their vehicles.
       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
   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.
             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
 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.
                Locum GPs
 Locums/freelance GPs must be included in
   preparation and training programmes,
   information cascades
   Photo databases

 PCTs will employ all available freelance locum
 Arrangements being discussed at national level.
 Performers List checking now
            GP Registrars

 Training and teaching will stop
 Length of training period may well be
 Training rotational post changes will be
  suspended during a pandemic
  (inside and outside hospital.)
             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
  (The GMC and Defence Societies)
          Practice Actions now
 Staff contracts
    making voluntary changes.
   Staff telephone number database
    (including mobile numbers)
   Emergency Boxes
   Buddy Up
   Protocols
    “parachuted in” staff (Practice systems and IT
   Plan patient separation
         Daily “Sit” Reports
 Regular reports to a PCT data collection
 Standard national template of content
 Permits assessment of staffing levels at
  each site.
 Precursor to transfer from one site to
         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‟.
         Collecting Antivirals
 Flu Friends
  A nationwide campaign
 Collect antiviral drugs from PCT collection
  point centres
 Security measures will be in place
   no unauthorised or duplicate access to
    Rebuilding, restoring and
 Gradual Return to normality over
 Exhausted GPs and staff surprised at
  feeling unwell at this point.
 Recuperation time
 Mass vaccination campaign, could put
  added pressure on primary care

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