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Whilst many threats to service sustainability arise from local economic and environmental factors, increasing globalisation can have profound local effects. As the world saw with the spread of the severe acute respiratory syndrome – better known as SARS – rapid human transport systems meant that the disease spread to some 30 countries and areas worldwide with frightening speed.

Planning for a pandemic in NHS Lothian is at an advanced stage but intensive preparations are still required over the coming year. This article sets out recent progress at national and local level.

Pandemic ‘Flu

It is over 40 years since the last influenza pandemic. As the three pandemics which occurred in the last century did so at intervals of less than 38 years it is recognised that a pandemic is due. But we still do not know when it will occur. Pandemic influenza occurs when an influenza A virus sub-type emerges or re-emerges which is:

  • Markedly different from recently circulating strains;
  • Able to infect people;
  • Readily transmissible from person to person;
  • Capable of causing illness in a high proportion of those infected; and
  • Able to spread widely because few – if any – people have natural or acquired immunity to it.

It is impossible to forecast the precise characteristics, spread and impact of a new influenza virus strain. Modelling suggests that from the time it begins in the country of origin it may take as little as two to four weeks to build from a few to a thousand cases and could reach the UK within another two to four weeks.

Once in the UK, it is likely to spread to all major population centres within one or two weeks, with its peak around six to seven weeks from initial entry. The pandemic may occur in one wave or a series of waves, weeks to months apart. A fully effective vaccine is unlikely to be available until after the first wave.

The impact on the health service, as on all public services and the private sector, is likely to be on a scale not witnessed before by the current work force. The increase in patient demand will be coupled with a potential one third reduction in workforce as staff themselves are unable to work due to flu affecting them or their family members. Sustainability of health services therefore requires very significant planning.

The national context

In November 2007, the Scottish Government released ‘A Scottish framework for responding to an influenza pandemic’. This document set out the framework within which planning for a pandemic should take place and recommended planning for up to a ‘reasonable worst case scenario’ of 50% attack rate, 25% complication rate, medical assessment rate of 32%, hospitalisation rate of 4% and excess death rate of 2.5%.

The Government also announced strengthened counter- measures that saw :

  • Doubling the stock of antivirals to cover at least half the population;
  • 14.5 million (m) courses of antibiotics for at risk groups;
  • 34m disposable respirators and 350m surgical masks for frontline staff;
  • Stockpiling of 3.3m doses of H5N1 prepandemic vaccine; and
  • Advance supply agreements with vaccine firms to deliver vaccines for the entire population once the virus strain is known.

Pandemic ‘Flu in Lothian

Over the whole course of the pandemic, estimates based on Scottish Government projections suggest that some 400,000 people could be infected. This is nearly half the Lothian population. These infections are likely to lead to 128,000 additional GP consultations and 16,000 extra hospital admissions. Unfortunately we can also expect some 10,000 additional deaths.

We can expect the pandemic will peak around six weeks after the first cases have happened in Lothan. During that peak week, we can expect to have to deal with:

  • 88,000 new cases;
  • 30,000 GP consultations;
  • 3,500 hospital admissions; and
  • 2,240 additional deaths

Per GP practice within the peak, this equates to around 210 additional consultations, 30 hospital admissions and 20 deaths.

Planning in Lothian

Planning is ongoing at all levels throughout the NHS in Lothian. Our degree of preparedness was last assessed in November 2006. A summary of this self-assessment is contained in Box 1.

The co-ordinating group for the NHS Lothian response is the Avian Influenza and Pandemic Preparedness Group (AIPG). This group reports to the Lothian Emergency Planning Strategic Advisory Group. It works closely with the Business Continuity Planning Group and Divisional Emergency Planning Groups.

The AIPG is currently working to ensure that there are sustainable:

  • Primary care services;
  • Hospital and other secondary care services;
  • Supplies of medicines;
  • Means of controlling other communicable diseases;
  • Joint working arrangements between health and social care services;
  • Communication systems;
  • Human resources and staff management systems; and
  • Bereavement support for those who have suffered loss.

A Lothian multi-agency pandemic plan has been in place since October 2005 and is currently being updated to reflect the new national framework. The plan has been exercised on a number of occasions:

  • Exercise Fawkes – provision of primary care services (March 2006);
  • Exercise Long Shadow – overall NHS Lothian response (April 2006);
  • Exercise Big Chill – a joint NHS Health Protection Scotland exercise for South East Scotland (May 2006);
  • Exercise Mindful Peace – provision of hospital and secondary care services (June, 2006); and
  • Exercise Winter Willow - the UK national pandemic ‘flu exercise (January/February 2007).

The two key elements of work within 2006/07 were on operationalising the plan and business continuity planning. The initial focus of work has been at Lothian NHS Board and secondary care level. It is now appropriate to prioritise primary care issues in this area for 2008 and 2009.

It is also important for people and professionals to be aware of the risk associated with pandemic ‘flu and how the Government is planning its response. If you want to know more about pandemic ‘flu you can sign up for the Scottish Government’s e-newsletter at http://register.scotland.gov.uk/

You can also look at the following websites:

key points

  • A pandemic is inevitable and its impact will be immense. We can’t predict when it will happen but we can plan our response.
  • We already know that during the peak week of the pandemic we can expect that, on average, each GP practice in Lothian will have to deal with to around 210 additional consultations, 30 hospital admissions and 20 deaths.
  • The Scottish Government’s view of Lothian’s response to a national self assessment exercise concluded that ‘preparations for pandemic flu are advanced in NHS Lothian’.
  • Whilst NHS Lothian staff have achieved a great deal within the last year in pandemic influenza and business continuity planning, there is more that can and will be done.
Box 1: Case study; Lothian self assessment
  • In November 2006 NHS Boards were asked to complete a pandemic influenza preparedness self assessment tool Pandemic Influenza Preparedness: Standards for overall strategic, healthcare and health protection services for the Scottish Government.
  • The tool used a 4 level quality improvement scale 1 = consideration; 2 = development; 3 = implementation; and 4 = monitoring.
  • Twelve core areas were assessed in three areas: a. overall strategic preparedness; b.healthcare preparedness; and c.health protection preparedness.
  • Key aspects considered across the 12 areas were: i. accountability; ii. processes; and iii. audit and review.
  • The Lothian self-assessed position for most standards was 3. In some standards it was 2. The position of primary care services as assessed by NHS Lothian Primary Care Organisation was 1-2.
  • The Scottish Government response to Lothian concluded that ‘preparations for pandemic flu are advanced in NHS Lothian’.