Scottish Government

8 THE HEALTH AND COMMUNITY CARE RESPONSE

Saving lives is at the heart of the UK and Scottish Executive's response strategy. There will be increased and sustained pressure on health and community care services during a pandemic. An effective well planned health and community care response is central to our planning and can help to save lives and reduce illness.

8.1 Aims

The health and community care aims are to reduce mortality and morbidity by:

• maintaining surveillance to detect the emergence of a novel virus strain or any illness attributable to it, monitor its spread and health impact, describe the illness and inform response
• providing prompt access to rapid and reliable diagnostic tests
• providing data to monitor the impact and effectiveness of interventions, adjusting our response to reflect emerging data
• reducing disease transmission and rates of illness by applying infection control measures and by encouraging the public and other sectors to do the same
• developing surge capacity to meet expected demand and making effective use of potentially scarce medical skills and resources
• reducing or ceasing non essential activity as demand increases but maintaining essential care
• assessing and treating all symptomatic patients promptly
• providing effective treatment for those suffering complications
• providing vaccination if and when suitable vaccines become available
• providing public advice, education and information

8.2 Key Principles underlying planning and response

Health and community care organisations should apply the following general principles to their planning and response:

• the overriding priority is to reduce illness and save lives
• where possible and practical arrangements should be based on strengthening and supplementing normal delivery mechanisms
• interventions will be applied to maximise health benefit, but may also be required to maintain essential services
• plans should be developed on an integrated multi-agency basis with risk pooling and cross cover between all organisations - seeking to mobilise the capacity and skills of all public and private sector health and care staff (including those who are retired), contractors and volunteers
• primary care plans should be based on taking care to the patient wherever possible
• initial telephone based assessment is likely to be necessary to meet demand at the peak
• primary care response strategies should focus the capacity and clinical skills available on assessing patients in groups at particular risk and treating those suffering complications or requiring other essential clinical care
• antiviral medicines should be available to patients who have been symptomatic for <48 hours within 12-24 hours of reporting symptoms
• response measures should maintain public confidence and 'feel fair'
• treatment and admission criteria should be transparent and applied in a consistent and equitable way that maximises available capacity
• plans should recognise the need to respond to psychosocial issues and for sympathetic arrangements to manage illnesses and deaths

8.3 Key planning assumptions for health and community care planning

To allow sufficient time to finalise and implement operational response arrangements, SEHD will advise on the reduction of non-essential and elective NHS services and will suspend some performance targets at UK alert level 2. Organisations should use the following planning assumptions to ensure that response arrangements are resilient and robust, but must be prepared to modify plans should emerging information vary.

Severity of illness

• Up to 50% of the population may show clinical symptoms of influenza (clinical cases) over the entire period of a pandemic (planning range 25% to 50%)
• up to 25% may develop complications (planning range 10% to 25% of cases)
• Up to 2.5% of those who become symptomatic may die (planning range 0.4 to 2.5% of cases).
• Up to 22% of influenza cases can be expected during the 'peak week' of a pandemic wave.
• Up to 32% of symptomatic patients (including all symptomatic children under seven) will require assessment and treatment by a general medical practitioner or other health professional. (planning range 16% - 32% of cases)
• Up to 4% of those who are symptomatic may require hospital admission depending on available capacity (planning range 0.55% to 4.0% of cases). Average length of stay for those with complications may be 6 days (10 if in intensive care).

Health and community care demand

• A short epidemic would put greater strains on services than a lower level but more sustained one.
• Hospitalisations and deaths will depend upon the age profile affected, virulence and specific complications associated with the pandemic virus, but demand is likely to be greatest in children and the elderly.
• Total healthcare contacts for influenza-like illness could increase from around 90,000 during a 'normal' season to 2.7 million during a pandemic (at a 50% attack rate). Refined estimates of demand will depend upon early and continued surveillance data.
• New healthcare contacts for influenza-like illness can be expected to exceed 10,000 per 100,000 population per week at the peak period (at a 50% attack rate). Peak consultations during seasonal influenza periods in recent years have been 400-900 per 100,000 per week.
• Peak demand could be sustained for one to two weeks with local epidemic waves for 6-8 weeks.
• At present children of <23kg (<7 years of age) need assessment by a GP or suitable health professional as weight related antiviral medication must be prescribed, although alternative formulations are being investigated.
• Assuming a complication rate of 25%, an attack rate of 50% and under 7s needing to see a health professional, general practices can expect to see 3500 influenza patients per 100,000 population per week at the peak.
• 2000 per 100,000 population may require hospital admission - an increase of at least 50% on normal demand
• Demand for hospital admission can be expected to increase up to 440 new cases per 100,000 per week at the peak and is unlikely to be met from available acute hospital capacity
• Demand for critical care beds could rise to 110 per 100,000 per week at the peak and would exceed available capacity.
• An increase in the numbers suffering from influenza and its direct complications may be accompanied by other demand caused by anxiety and bereavement and service provision challenges exacerbated by depletion of the workforce and logistical difficulties.
• The following tables estimate anticipated cases, healthcare contacts, GP consultations, Emergency Department visits, hospital admissions and deaths based on a uniform attack rate across all age groups.

Expected healthcare demand over the course of a pandemic, for 25%, 35% and 50% clinical attack rates and the upper end of the range for all other planning assumptions

Expected healthcare demand during the peak of a pandemic, for 25%, 35% and 50% clinical attack rates and the upper end of the range for all other planning assumptions

Assumptions:

• All complications (@ 25% cases) and symptomatic children under the age of 7 (7% of the population) are consulted by a GP.
• Hospital admissions @ 4.0% of cases.
• Deaths @ 2.5% of cases.

8.4 Infection control

Specific guidance is available for hospitals, primary care and other settings but limiting the transmission of pandemic influenza requires the application of tried, tested and proportionate basic infection control measures such as:

• ensuring that the public and staff are well informed about and adhere to procedures for the prevention and transmission of influenza
• local risk assessments to inform decisions on control and protective measures as required by the Control of Substances Hazardous to Health Regulations 2002
• documenting proportionate procedures, operational protocols and checklists
• timely recognition of symptomatic patients
• segregating (isolating) any symptomatic patient and limiting external contact by voluntary quarantining measures if necessary
• clustering symptomatic patients in specific wards/areas
• providing personal protective equipment ( PPE) if occupational risk assessments indicate that to be necessary and ensuring that staff are trained in its correct wear, limitations and use
• implementing enhanced cleaning routines to minimise the risk from contact with hard surfaces.

Further guidance on infection control measures for hospitals and primary care settings is available fromhttp://www.scotland.gov.uk/Resource/Doc/924/0040727.pdf

Face masks/respirators in care settings

Various types of face masks are available offering different levels of protection and meeting agreed European and/or international normative standards. WHO recommends the use of the equivalent of the European FFP2 standard disposable respirators (high protection face masks) and surgical masks by healthcare workers in a pandemic. In addition that symptomatic patients should themselves wear surgical masks to protect others if circumstances make it absolutely necessary for them to leave home. Standard UK Health and Safety Executive ( HSE) guidance calls for higher specification FFP3 respirators for healthcare workers whenever respiratory protection is indicated, while recognising that this may not be sustainable in the special circumstances of pandemic. The current UK Pandemic Influenza Infection Control Guidance recommends:

• wearing FFP3 standard disposable respirators should be worn when carrying out clinical procedures likely to generate aerosols of respiratory secretions from infected patients ( e.g. dental drilling, intubation, aspiration) although they should avoid such procedures as far as that is possible
• use of fluid repellent surgical masks by carers who may be in close or frequent contact (within 1m) with symptomatic patients.

Other protective equipment

If close contact with a symptomatic patient is inevitable or highly likely, health and other carers should adopt sensible barrier precautions in addition to face masks. Disposable protective equipment such as aprons and gloves, provide a physical barrier and help avoid spreading contamination. The ocular inoculation is not regarded as a major transmission route but is biologically plausible and eye protection (preferably disposable) may be necessary when carrying out aerosol-generating procedures or if risk assessment indicates that this is necessary.

Further guidance for employers is available on the HSE websitewww.hse.gov.uk/biosafety/diseases/influenza.htm

Clinical Guidance

The British Thoracic Society, British Infection Society and Health Protection Agency have produced joint provisional guidelines for the clinical management of patients with an influenza-like illness during a pandemic. They describe the clinical features, assessment and treatment of adults and children in hospital and community settings. The guidelines are regularly reviewed and updated and may need to be varied to reflect capacity, shortages or constraints as the pandemic develops.

Guidance on the clinical management of patients with influenza-like symptoms during a pandemic is available from:

British Thoracic Society-

http://www.brit-thoracic.org.uk/PandemicFlu.html

SE Health Department -

http://www.scotland.gov.uk/Topics/Health/health/AvianInfluenza/PandemicFlu

Health Protection Scotland -http://www.hps.scot.nhs.uk/resp/index.aspx

8.5 Prioritisation of Services

National planning assumptions for healthcare demand and staff absence rates during a pandemic indicate that high demand for services and high levels of staff absence will converge over an extended period of time. In these circumstances it is unrealistic to expect the NHS to maintain current levels of service over the course of an outbreak.

The capacity to deliver continuity of essential and emergency flu and non-flu services throughout an outbreak must be protected and preserved. To achieve this, the scaling-back, limiting or temporary cessation of other services in both primary and acute settings must be considered inevitable. The extent to which other services will be affected will only be determined when the actual characteristics of the emergent virus are known.

A strategy for service prioritisation is being developed by a Service Prioritisation work group. It is intended that the work of this group will lead to the development of a common understanding across services of what the priorities are and to assist a nationally consistent approach to the application and removal of service restrictions. Further guidance in this area will be published in due course.

8.6 NHS Performance Targets

Consistent with and subject to the work described above to be carried out by the Service Prioritisation work group, it is necessary to take a view on the status of NHS performance targets (and especially access targets relating to maximum waiting times for elective treatment) during a pandemic.

The existing range of key objectives for the NHS covers Health Improvement, Efficiency, Access and Treatment ( HEAT). Within these key ministerial objectives, key targets exist across a number of areas in the acute sector e.g.

• Waiting times for elective outpatient appointments, diagnosis and treatment
• Cancer and coronary care treatment
• Hip fracture surgery
• A&E waiting times

We propose to take the following approach:

• All elective targets and the A&E target should be suspended during a pandemic flu outbreak. The Department would continue to monitor Boards' performance to help identify "hot spots" in the care system and to ensure that the local, regional and national response to the pandemic was delivering appropriate care to patients.
• The following Scottish Executive HEAT targets will remain in place through a flu pandemic:

However, Boards' performance against these targets would be interpreted in a pragmatic way in accordance with the circumstances faced by Boards and the priority attached to patients by the clinicians responsible for their care.

• A sensitive approach to the reinstatement of targets should be taken - over a suitable period of time to be discussed according to the circumstances immediately following the pandemic.
• These proposals are subject to the work to be carried out by the Association of Medical Directors on prioritising services and may be revised.

Trigger for suspension of targets

We propose that targets would be suspended at Phase 6 Alert level 2 - the point at which the pandemic reaches the UK - as spread would be expected to be rapid to all areas of the UK at that point. Board Chief Executives would be notified by the Department that the targets specified were being temporarily suspended when this point was reached.

Further Work

Further guidance will be issued in due course on a wider range of targets. This may cover primary care, community care, NHS 24 and the Scottish Ambulance Service.

8.7 Workforce arrangements and personnel policies

Considerable pressure will be experienced by NHS and local authority staff during a pandemic. Part of this pressure will be caused by the likelihood that staff will be pushed hard by the demands of a pandemic and, at the same time, the availability of those staff will decline due to the spread of the virus and staff becoming ill.

Planning needs to take place both locally and nationally to deal with the consequences of this pressure.

A strategy is being developed centrally by a Workforce group and a full report will be available from that group in due course. The work undertaken centrally will aim to ensure that local policies can be fully and legally implemented and that any national legislative and policy barriers to local actions have been removed.

National action will encompass the following:

• Relevant legislative and contractual barriers to redeployment and the use of students and retired staff
• Professional constraints
• Working hours and pay and rewards
• Updating staff absence policies
• Altering arrangements for certification of sick leave (at UK level)
• Disclosure requirements
• Training for redeployment

This will facilitate local strategies which should focus on the following:

• Redeployment of staff and making use of skills in a flexible way to cover for absences
• Redeployment of staff from areas where work has been cancelled to priority areas
• Management of the flow of staff between the NHS and community care settings
• Considering the use locally of medical students and available retired staff and retaining registers of those available
• Considering the use of allied professions and non medical staff to perform medical duties
• Removing local contractual barriers
• Communicating the messages to staff in advance about redeployment
• Provision of local training

Further guidance will be published in due course.

8.8 Access to Care

Normal patient pathways and service delivery arrangements will need to be adapted in a pandemic as additional demand saturates or threatens to overwhelm available capacity, staffing or other resources. Alternative arrangements and strategies need to be developed to cope with likely numbers and implemented as demand increases:

• the introduction of a telephone-based initial assessment sift of all symptomatic flu patients and authorisation for antiviral collection or referral to general practice assessment by trained lay-operators following clinically approved algorithms
• the provision of a wider range of treatments by health professionals ( e.g. nurses, paramedics, pharmacists, dentists) following agreed guidelines and using 'prescription only' medicines under agreed authorisations
• care in the community by GPs and community-based health teams of patients who under normal circumstances would be admitted to hospital
• treatment of 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 health facilities not normally used for acute medical care by medical and nursing teams who do not normally manage such patients

Delivering Care in a Community Setting

Most sufferers are likely to experience typical influenza symptoms that can be appropriately managed at home.

It is therefore vital to the health and community care response to ensure that there are effective arrangements, based on taking care to the patient, for a sustainable community based response that provides for:

• patient assessment,
• access to antiviral and other medicines,
• treatment of complications and access to hospital care if necessary

There is a recognised need to develop a common approach to the organisation and co-ordination of community based services across Scotland during a pandemic. SEHD has commissioned a multi-discipline group, led by the Royal College of General Practitioners Scotland to develop a framework and guidance for the delivery of an integrated community based response. It is intended that this guidance will be published in the final draft of this document.

Acute Care

Adults and children with uncomplicated influenza infection do not usually require hospital treatment, but those with worsening pre-existing medical conditions or suffering influenza-related complications may need referral.

The interface between acute and primary care is crucial and joint review of agreed appropriate protocols are needed in the planning and clinical phases. Symptomatic patients will be advised to stay at home, seek help by telephone and not to attend surgeries or health facilities unless by prior arrangement. Contingency arrangements should recognise, however, that self-referral is inevitable. The level of self-referral is likely to be significantly higher for certain patient groups e.g. infants, children and patients with chronic conditions. Breakdowns, loss of confidence or access difficulties in community provision will exacerbate this.

Existing hospital capacity may only meet 20% to 25% of the expected demand at the peak. Normally there are some 28,296 beds (including day beds) in use in Scotland, of which 17,523 are acute beds and 467 are for patients requiring HDU or ITU care. It may be possible to release almost 33% of the total acute bed capacity within 5-10 days of ceasing elective work.

Even with additional capacity, and the implementation of measures to improve utilisation and supplement availability, the level of additional demand, combined with increased staff absences and possible increases in length of stay, will make hospital overcrowding inevitable and capacity a major limiting factor. Other limiting factors such as shortages of medical supplies, limited availability of diagnostic support services, and potential disruption to the supply of blood/blood products are also likely to have an impact.

Proportionate admission thresholds based on clinical management guidelines will need to be agreed and progressively applied. Consistency and equity in their application is important in gaining public understanding and maintaining confidence. Common understanding and interpretation of those guidelines by health professionals at the primary, secondary and community care interfaces are particularly important.

Plans should focus on ways of supplementing and making the most effective use of the staffing and beds, with particular attention to factors that facilitate rapid discharge or step-down arrangements. Plans should also address establishing alternative care sites; utilising private hospital/clinic facilities; staffing; and other options for increasing capacity. Up to 25% of symptomatic patients who would warrant hospital admission (if sufficient capacity were available) may require high dependency or intensive care ( HDU/ ICU). Most will have influenza-related pneumonia or a severe exacerbation of underlying co-morbid illness. The indications for such transfer are no different when compared to non-influenza patients.

Acute sector plans should detail:

• staff protection (physical and mental health and personal safety aspects), infection control and security aspects for supplies and entry/exit controls.
• the core services and areas of operation which will continue during the pandemic
• arrangements for progressively winding down elective and non-essential activity before and during the pandemic phase
• for the clinical management and, if required, isolation and cohorting, for: i) non-pandemic flu emergencies

ii) suspected or proven pandemic flu patients

iii) patients at special risk e.g. immunocompromised patients and those with chronic diseases

i) Emergency Medicine departments

ii) Acute Medical and Admission Units

iii) HDU/ ITU Units

iv) Care of the Elderly

• arrangements for discharge from hospital or to 'step-down' units
• the identification and training of redeployed staff
• arrangements to inform staff of clinical guidelines for patient management and to monitor and review the effectiveness of these arrangements.

Community Care

Effective arrangements developed jointly by health and community care agencies are critical to the relief of suffering and to achieving the wider public health aims of keeping symptomatic patients at home, caring for them in a community setting and reducing the demand on healthcare facilities. More than 110,000 people rely to varying extents on community care support provided by or through local authorities. Those services cover a wide range of needs such as care in residential/nursing homes, day centre provision, meals on wheels, home helps and personal assistant schemes. The 2001 census also indicated that over 60,000 people care for a relative or friend for between 20-49 hours per week - and almost 116,000 people for over 50 hours a week - in Scotland. Many of these 'informal' carers will be affected over the pandemic period and alternative care arrangements may be required.

Community care providers are in regular contact with individuals in the community who might be more vulnerable to, or more affected by, pandemic influenza. In addition to maintaining services for those who will continue to rely upon them, community care providers must also anticipate additional short-term and short notice demand from those unable to cope independently or whose normal care arrangements have been disrupted. Voluntary, private or independent sector organisations provide many of the services on contract and all forms of community care provision need intergration into local contingency plans. Key challenges include:

• sustaining services that provide essential lifelines, e.g. meals on wheels, provision of community equipment, community alarm services
• meeting the additional pressures on already overstretched local community care services and intermediate care services due to the additional pressures on acute hospital beds
• ensuring that the lines of communication exist to relay essential national, regional and local messages to the diverse range of community care services (statutory, voluntary, independent and private)
• additional pressures on caring time to support care home residents and people cared for at home
• sustaining people with complex disabilities who are currently supported with intensive care packages in the community
• providing emergency respite care for vulnerable people looked after at home by informal carers while their carer is ill
• maintaining a balance between appropriate safety and infection control measures and ensuring that the quality of life of vulnerable adults is maintained as far as possible.
• dealing with workforce and resource implications. This would include dealing with staff absenses and redeployment to ensure adequate level of care services.

Role of NHS 24

NHS 24 will continue to play their important role in providing health advice and information through their normal telephone number, and via the NHS 24 Online website ( http://www.nhs24.com).

Demand on NHS24 is likely to increase moderately in a pandemic. The primary focus of service continuity plans is the maintenance of core services in the face of high levels of staff absence.

It is also anticipated that there may be a further role for NHS24 in the development and support of local delivery arrangements for a UK national flu helpline. It is intended that further clarification of the role of NHS24 will be published in the final draft of this document.

Role of Scottish Ambulance Service

Demand on the Scottish Ambulance Service ( SAS) is likely to increase significantly in a pandemic. The primary focus of service continuity plans is the maintenance of capacity to answer all emergency and urgent calls, although some prioritisation and changes in normal performance standards may become unavoidable. Plans should recognise the need to facilitate rapid discharge or transfer arrangements and explore opportunities to utilise any organisational and communication capacity available from the curtailment of non-essential activities to support the delivery of home care to influenza sufferers.

Pandemic specific pre-hospital patient assessment and treatment protocols should recognise that hospital capacity will be extremely limited; emphasising treatment at home and ensuring that only patients with life-threatening conditions are actually conveyed to emergency departments. Local response plans should also consider the extent to which the field assessment and treatment skills of ambulance staff could be utilised to support the wider delivery of home care.

Dentistry

Current infection control advice suggests that health professionals should avoid aerosol generating procedures on symptomatic patients as far as possible during a pandemic and must wear respirators and suitable protective equipment where that is not possible. Many dental procedures have the potential to generate aerosols and risk assessments will therefore be necessary. Local plans should ensure that emergency care remains available throughout a pandemic, but dental practitioners may find normal demand reduced because of limits on the procedures they are able to carry out on those with respiratory symptoms and patients themselves deferring treatment or facing travel difficulties. Opportunities to use the assessment and treatment skills of dental practitioners or other health professionals to support the wider delivery of health care in a pandemic should be explored in local planning.

8.9 Coping with stress and bereavement

In the lead up to a pandemic, many people are likely to feel anxious, apprehensive, and to have an understandably subjective perception of the degree of risk. As the pandemic develops, many people may feel fear for their own health and that of their family and friends, grief for loss of relatives or friends, a sense of social isolation or other potential causes of psychological distress. Whilst many are likely to be resilient enough to cope with little or no professional or specialist intervention, some people may need or may welcome additional support.

Local plans should consider how to provide that additional support. For example, Health Boards and community care services should consider how they can offer support both to their own staff and to patients and their families. This could include a range of measures such as:

Support should be made available both during and for some time following a pandemic.

8.10 Vaccination

A small group which is led by occupational health physicians is considering the best strategy to be followed locally to ensure that we are prepared for the provision of vaccination both pre pandemic and during a pandemic.

A flexible model will be developed which can be adapted to suit whatever situation we are facing and can be adjusted to deliver vaccines to priority groups, where these have been identified.

Further guidance will be published in due course.