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A summary of that document for LMCs has been prepared separately. This guidance document is for England only, and parallel guidance will be issued by the three devolved nations. However whilst there may be some difference in operational approach and organisational responsibilities, all four health departments are working closely to ensure a consistent approach wherever possible. The full text of this 102 page document can be found at the link below:  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080757" http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080757 Potential impact of an influenza pandemic on primary care (Chapter 2) Pandemic related consultations only With a 50% clinical attack rate and 25% complication rate and those under 3 years of age needing to see a GP or suitable healthcare professional – pandemic related GP consultations will increase to 14,250 per 100,000 over the course of a pandemic. If 22% of the cases occur in the peak week, there will be an additional 3,100 GP consultations per 100,000 population during that week. The above consultation rates assume that symptomatic older children and adults without complications will access antiviral medicines treatment via the National Flu Line service. Impact on workforce Up to 50% of the workforce may require time off at some stage over the entire period of the pandemic, with individuals likely to be absent for a period of seven to ten working days. At peak 2-3 weeks between 15% and 20% of staff from the workforce may be absent. Additional staff absences are likely to result from other illnesses, taking time off to provide care for dependents, family bereavement, other psychosocial impacts, fear of infection or practical difficulties in getting to work. Modelling suggests that small organisational units (with 5 to 15 staff members) or small teams within larger organisational units should allow for higher percentages of absenteeism – up to 30-35% over a two to three week peak period. Even higher rates are possible in very small organisations. A further 5-6% of staff could be absent as a result of school closures (should the decision be taken to close them), although this is based on an analysis of informal childcare being available for parents. PCTs AND LMCs/GPs NEED TO WORK TO THE SAME PLANNING PRINCIPLES Joint working and integrated planning between all key agencies - need to develop integrated local response plans that are resilient, proportionate, flexible and maintainable in responding to an influenza pandemic is essential Flexible planning – PCTs and primary care contractors need to prepare up to a ‘reasonable worst case’ scenario, with plans that describe the response to the less likely but more challenging clinical attack rates. Flexible thinking in bolstering local staff policy - plans need to be based on using local skills to the full, and working in novel ways e.g. moving staff between different parts of organisations or mobilising recently retired staff. Building on normal delivery models (as far as possible) – response arrangements that build upon normal delivery models have the advantages of familiarity, maintainability, reliability and local flexibility. Such arrangements may continue to prove adequate and sustainable during the early and latter phases. Advising and enabling symptomatic influenza patients to remain at home Rapid access to antiviral medicines - available evidence and experience in managing seasonal influenza and human cases of avian influenza suggests that antivirals could have a significant beneficial impact in lessening the severity of illness in infected people and thereby reduce the risk of complications that may lead to mortality. Reducing routine activity, but continuing to make essential care available – pre-planned measures to reduce or cease some routine services, and to deliver others via alternative means are important as are plans that demonstrate how essential services will be maintained to cope with additional demand and potential disruption. The GPC negotiators and NHSE are working on this premise in terms of ensuring GP practice pay protection when aspects of GP practice non-essential work may cease in order to meet the demands of the flu pandemic. Adopting measures that maintain public confidence and ‘feel fair’. Influenza pandemic coordination (Chapter 3) PCTs are responsible for ensuring local health plans and arrangements are in place in advance of a pandemic, and for managing the local health response during a pandemic PCTs should have a named Pandemic Influenza Coordinator who leads on the arrangements for providing an effective and sustainable community-based response during an influenza pandemic. Clear command and control arrangement will be critical in ensuring a robust response. Coordination arrangement will need to include the establishment of a PCT coordination centre to monitor and coordinate the overall health response. Roles and responsibilities of key PCT personnel PCT Chief Exec and board – should take overall control of preparing for an influenza pandemic. PCTs should have a named Pandemic Influenza Coordinator who leads on the arrangement for providing an effective and sustainable community-based response during an influenza pandemic. This would usually be the Director of Public Health. The PCT Pandemic Influenza Coordinator should chair a health Influenza Planning Committee or equivalent planning group, which should involve local health and social care partners, including representation from NHS Direct, the local authority, the NHS hospital trust and primary care contractors. In some areas these committees have been established as district-wide (regional) bodies, rather than being specific to individual PCTs, to facilitate multi-agency planning. The Influenza Planning Committee is responsible for overseeing and coordinating the local health preparedness arrangement and for ensuring that robust response arrangements are in place. Any gaps, areas of concern and actions identified through the planning process should be taken forward, with regular updates to the board. The Influenza Planning Committee should link with the Local Resilience Forum (LRF) the principle mechanism for the coordination of multi-agency (ie broader than health) planning at the local level. NB: The negotiators have stressed in discussions with the DH the need for LMCs to be involved within these structures. LMCs will want to engage with the Pandemic Influenza Coordinator and seek a place on the Influenza Planning Committee. It will be very important in the event of a pandemic that LMCs are involved in the operational functioning of the local health care community and they can bring their unique expertise and influence to the situation. Roles and responsibilities of PCTs PCTs will be responsible for managing the local healthcare response including providing 24-hour emergency management and clinical response. In order to manage and coordinate the local healthcare response, all PCTs will need to ensure they have a coordination centre or control room in place. The coordination centre should monitor and collect information on the provision of services and relevant medical supplies and coordinate care across all primary care services, social care and other agencies ensuring that the health service can supply and provide for patients as thoroughly as possible. PCTs should also have a command and control structure in place that allows appropriate linkages to and integration with external stakeholder command and control systems, in particular RCCCs (via the SHA) and local SCGs. Generic response arrangements at regional and local levels are set out in detail in Emergency response and recovery and are available at  HYPERLINK "http://www.ukresilience.info/ccact/errpdfs/emergresponse.pdf" www.ukresilience.info/ccact/errpdfs/emergresponse.pdf Further guidance on command and control arrangements are also sited on the DH Health Emergency Planning web page. Primary care contractors All primary care contractors and their staff have a critical role in ensuring an effective response, minimising disruption and maintaining essential services. General practice and community pharmacy will, in particular, represent ‘pinch points’ in the delivery of services and in the management of demand. All practices and pharmacies will need to develop robust response plans and should engage with their PCT from an early stage to ensure that plans are coordinated and consistent with the approach taken across the PCT area. Plans should be regularly tested for their resilience. Primary care contractors will also need to liaise with partner agencies such as local authorities to identify and coordinate support for vulnerable patients. Interventions to support the delivery of healthcare in a community setting (Chapter 4) Supporting self care Key ways of supporting members of the public to self care will be through national and local information, educational materials and tools, and support networks. Specific self care support for those with long-term conditions, vulnerable groups, and for those people at the end of their lives (and who may die) and their families or informal carers is also important. Antiviral medicines Each UK country has established a stockpile of oseltamivir (Tamiflu) antiviral medicine that allows for the treatment of all symptomatic patients at clinical attack rates of up to 25%. Arrangements to make it rapidly available, without symptomatic patients having to visit a healthcare facility (where they risk infecting others), are an important part of the health response. Pre-pandemic vaccine Pre-first-wave immunisation with an influenza vaccine that is related but not specific to the pandemic strain – a pre-pandemic vaccine – might offer some limited, but nonetheless useful, protection. Currently, the UK has very limited stocks of an A/H5N1 vaccine purchased specifically for the protection of healthcare workers. Pandemic-specific vaccine It is not possible to develop a matching vaccine – a pandemic-specific vaccine – until the emerging influenza strain has been identified. The Government has awarded contracts to Baxter and GlaxoSmithKline to secure production capacity for the manufacture of pandemic-specific vaccine for the UK population. However it may take four to six months before an effective vaccine is available and evaluated for safety, and considerably longer before it can be manufactured in sufficient quantities for the entire population. Therefore it could be an effective intervention during the latter stages of the first wave and/or for subsequent waves should they occur. Antibiotics Antibiotics are the most effective means of treating the secondary bacterial complications of influenza, but should be prescribed appropriately. It will be necessary to: -determine the organisms most likely to cause complications (advice on this will come from the HPA) -determine and ensure available stocks of antibiotics The DH is reviewing available stock levels and options for enhancing. Managing demand surge Primary care services will not have the resources to conduct all their usual activities during a pandemic and will need to focus upon delivering care to those individuals in greatest need. It is important to identify what essential work or activity must continue and to make local decisions on what could be reduced, stopped or delivered by alternative means. As well as prioritising services, some reconfiguration will be required to enable primary care services to support influenza patients at home. This may include practices ‘buddying up’ to enhance their ability to provide a domiciliary-based service to influenza patients, for example. It may also involve establishing multi-disciplinary visiting ‘teams’ so that the range of healthcare professionals and their skills are fully utilised (ie nurses, healthcare assistants, allied healthcare professionals etc). Both influenza and non-influenza patients will need to be managed as part of the day-to-day response. Although influenza will represent a large part of the primary care services’ workload, people will continue to have non-influenza healthcare needs that require assessment, care and treatment. Plans must therefore ensure that there are robust arrangements in place for the maintenance of both influenza and non-influenza essential services. As far as possible, non-influenza ill people should access and receive care in the same way as in ‘normal’ circumstances. Practices should, for example, continue to provide essential practice-based care to those who are not symptomatic with the influenza virus. During the negotiations on safe-guarding practice based income the GPC and NHSE negotiators came to the conclusion that they could not draw up a definitive list of what aspects of general practice could be stopped and what should continue during a pandemic. It was recognised that this would be affected by the severity of the disease and the clinical details that patients presented with. For instance, there may well be some types of drug monitoring that could easily be left to lapse with only the smallest risk of clinical harm however there may be other types of drugs where to stop monitoring them could lead to significant harm to a patient. As a result GPs and PCTs will have to work flexibly and proportionately on this issue. Supporting self-care – Chapter 5 More details on what PCTs need to do to encourage/support population self-care. Access to medicines – Chapter 6 Antivirals On the basis of the current stockpile (based on a 25% attack rate) scientific advice confirms that it is best used for: - Treatment rather than prophylaxis and - Treating all symptomatic patients who have an acute influenza-like illness and a fever (+38 degrees C) and have been symptomatic for no more than 48 hours (unless contraindicated) at a clinical attack rate of 25% or less. If the attack rate was greater than 25% or there were high levels of wastage, prioritisation of treatment will be necessary. As a key planning principle is to encourage symptomatic patients to remain at home (and slow and limit the general spread of infection) and GP practices would be overwhelmed if patients turned up for face to face consultations – it is important to enable patients to access care from their home as far as possible. As this could not be achieved via home visits alone, creating capacity to assess patients over the telephone, and other non-face-to-face interfaces where these are appropriate, will therefore be key in managing demand and enabling rapid access to antiviral medicines. As general practice will be under immense pressure during an influenza pandemic, it will also be important to have a system in place that enables practices to focus upon delivering care to those individuals in greatest need of their services and who cannot be managed by alternative means. Although some additional capacity may be available from ceasing non-essential activities, pressure on individual practices will be heavy, additional demand for home visiting significant and smaller practices disproportionately affected by the absence of key stuff. A model for accessing antiviral medicines that is based upon primary care augmented with a telephone service has the benefits of enabling prompt assessment and rapid access to antiviral medicines from the home. The National Flu Line service. From WHO Phase 6, UK alert level 2, the National Flu Line service will assess patients to determine their eligibility for antiviral treatment (ie if they are symptomatic and can take the first dose within 48 hours of onset of symptoms) authorise antiviral treatment if appropriate refer eligible patients (in practice a family member, friend or carer of the patient) to an antiviral collection point to collect their antiviral medicines OR another part of the health and social care system where the patients have further higher level needs. In this way, the National Flu Line service will be a first port of call (only) for the assessment and triage of influenza patients. It is intended to triage routine cases to the antiviral collection points with minimum or no impact upon practices, whilst allowing those with higher-level needs to be referred on to a GP or other health or social care professional for further care and treatment. Access for children Adult treatment courses of antiviral medicines are stored as pre-packed capsules, but children aged 7 years and under (weighing about 23 kg and under) will be given an age-related dose of oseltamivir. The Government has purchased the active ingredient powder for reconstitution into a solution during a pandemic. Children within the normal weight range for their age who have high fever and cough or influenza like symptoms should, if: - Aged under 1 year or at high risk of complications (due to severe co-morbid disease) – be seen and assessed by a GP or hospital emergency department - Aged 1 or 2 years (ie up to 3 years) – be seen and assessed by a GP or suitably qualified and experienced (in the care of children) healthcare professional - Aged 3 years or over – can be assessed by the National Flu Line service staff using a clinically based paediatric triage protocol and referred to antivirals and/or to a medical practitioner if indicated (eg those at risk of suffering complications of influenza). Antiviral collection points In general GP practices will not be antiviral collection points EXCEPT where they are dispensing practices and then it is possible they will become one of many antiviral collection points which could also include community pharmacies, NHS and partner agency facilities etc. Access to other essential and over-the-counter medicines Demand for essential medicines and over-the-counter remedies is likely to be high in a pandemic, and re-supply may be uncertain. In order to ensure, as far as possible, that people have ready access to the medicines they need, it is proposed that once an influenza pandemic is declared by WHO, amendments to medicines and related legislation will be brought into force for its duration. These changes are outlined in Proposals to amend medicines and associated legislation during an influenza pandemic document, and if agreed to would include: Protocols for the mass supply of key influenza-related medicines New powers of emergency medicines supply for pharmacists Powers for dispensers to repeat ongoing prescriptions without recourse to a doctor Access to over-the-counter medicines and healthcare products, through schemes developed by PCTs, that would authorise supply of a limited list of medicines on the NHS, without a doctor’s prescription and free of charge. These schemes would be for the group of people who are exempt from prescription charges and would otherwise have made an appointment with a GP to obtain a prescription. Delivery of pandemic-specific vaccine population-wide – Chapter 7 This chapter deals in detail with the delivery of a pandemic specific vaccine which is only likely to be available in part during a second wave of a pandemic. Vaccine production is finite so it will take many months for the whole population to receive it. For a typical GP with a patient list size of 1,860 patients on average 85 patients will need to be immunised per week over the course of a specific pandemic vaccine immunisation campaign. Section 7.5 deals with Organising vaccination clinics in primary care where is gives suggestions to practices on how vaccination clinics may best be delivered e.g.: The arrangements should build as much as possible on current arrangements for seasonal influenza vaccination There needs to be a lead within each practice (such as the practice manager) to coordinate arrangements Where the overall lead is not a clinical member of staff, a clinical lead (usually a practice nurse) will also be needed to work closely with the overall lead. Administrative support is important, including notifying patients of clinics, and the identified lead will have to liaise closely with practice administrative staff Careful preparation, particularly for the first clinics, is essential, ranging from ensuring that enough fully trained staff and adequate rooms are available, to checking that sufficient consumables have been ordered In vaccination clinics, it is most efficient if as much of the overall process as possible is delegated to supporting administrative staff, aided possibly by local volunteers, leaving the vaccinators as free as possible to focus on the specific task of vaccination. If vaccination occurs between pandemic waves, clinics could take place at any time and within the main surgery area. However, as vaccination could occur in part during a pandemic wave, it is important that there are plans for vaccination clinics to be physically separate from ordinary surgeries if necessary. Delivery of pre-pandemic vaccines in healthcare workers – Chapter 8 The UK has limited stocks of an A/H5N1 vaccine purchased specifically for the protection of healthcare workers. Currently this is considered to be for staff employed by NHS trusts and general practices. Immunisation of healthcare workers employed by primary care contractors It is common for general practices to provide seasonal influenza vaccine to their own practice staff, although such staff may also have access to a local NHS occupational health service. Local consideration will need to be given to suitable arrangements in a pandemic, particularly given the need for detailed recording of vaccine usage (in order to measure vaccine coverage and effectiveness, but also to allow robust stock control). Practical considerations, such as proximity to trust premises, may guide plans for the provision of vaccination to staff employed by general practices, but such provision must be clearly coordinated, and the gathering of coverage data robust. Managing demand surge: key roles and services – Chapter 9 In order to manage demand surge, prioritisation of services will be required. A graded approach to configuring services (ie that states which non-essential activity can be reduced, ceased and/or transferred to other trained workers earlier than others) will be appropriate, so that the response is proportionate to the severity of the pandemic in a particular locality. Integrated plans and a whole-systems approach to managing surge demand is critical to ensure patient pathways are maintained and all partners understand what will and will not be delivered by whom. Arrangements for admission and discharge are also critical in managing demand surge and need to be comprehensive and transparent to all health and social care professionals. Managing demand surge In a pandemic, more people will require care and treatment within primary care, some of whom would ‘normally’ be cared for in a hospital setting. This will be due to illness from the pandemic itself and because secondary care services are likely to become overwhelmed. In order to manage this surge in demand, primary care services will need to focus upon delivering care to those individuals in greatest need of their services and who cannot be managed with alternative means. This will require a focus on delivering essential services and on mobilising staff within a locality (including those who are recently retired) to bolster frontline resources Specific guidance for managing demand surge across the whole of the health and social care system is being developed by the Scottish Government, in partnership with the Department of Health, devolved administrations and key stakeholders. This will include national admission criteria to aid the management of demand across the primary and secondary care interface. In the interim, the Department of Health (in partnership with the devolved administrations) has developed provisional guidance on the management of additional capacity and prioritisation of services. Feedback on this document will be used to inform the work of the Scottish Government. See Pandemic influenza: Surge capacity and prioritisation in health services.  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080744" http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080744 Integrated configuration of services Integrated plans and a whole-systems approach to managing surge demand are critical to ensure that patient pathways are maintained and all partners understand what will and will not be delivered by whom. If, for example, it is agreed that general practices plan to suspend some more routine work to enable them to focus on caring for and treating those with more acute or urgent needs, it will be important to maintain pharmacy services such as medicines management for those with long-term conditions and repeat dispensing schemes (where they are established). In order to promote integrated response plans, PCTs should seek to fully involve practices, regional and head office teams (for pharmacy multiples), local medical, pharmaceutical and (where appropriate) dental and ophthalmic committees, and acute and mental health trusts in the development and testing of plans. Framework for local decision-making on service priorities during a pandemic It will be important for PCTs and all independent contractors to maintain normal services for as long as possible and appropriate, and then activate a proportionate response to the pandemic. During WHO Phase 6, UK alert level 2 it is anticipated that there will be central delegation of decision-making powers concerning key responsibilities to SHAs. At this point, the SHAs will need to use their responsibility for managing health services under special/exceptional circumstances and lead the strategic response across the health economy. This will include decisions (in line with national guidance) about which services receive priority and which targets and standards can be explicitly suspended whilst maintaining internal NHS bodies’ governance arrangements. In making these decisions, SHAs will need to liaise with PCTs (who should also liaise with their Local Medical Committees and Local Pharmaceutical Committee) in their region to determine if and when resources are stretched to the point at which services should focus on delivering essential work, and in effect reduce or cease (some) non-essential activity. The targets and standards that SHAs may need to consider include National Standards, National Targets (including ambulance and mental health) and the Quality and Outcomes Framework. A graded approach to configuring services (ie that states which non-essential actitivies can be reduced, ceased and/or transferred to other trained workers earlier than others) may be appropriate, so that the response is proportionate to the severity of the pandemic in a particular locality. PCTs will need to ensure that their response plans include how services will be enhanced, scaled back and/or stopped as the pandemic threat increases. General practices: key roles and services Role of general practice General practice will play a pivotal role in providing and coordinating community-based health services in a pandemic, and in managing the flow of patients to secondary care services, care homes and other residential settings. As general practice will be subject to a very high level of demand, at a time when the practice workforce will be under considerable stress, it is not expected that practices will have the resources to conduct all of their usual activities during a pandemic. In addition to this, once available hospital capacity has been exceeded, there will be more patients with acute and urgent healthcare needs who will require care in the community. It is anticipated that GPs in particular, therefore, will need to focus on providing medical care and treatment to both influenza and non-influenza patients with acute clinical illness. This will require ceasing services which are not immediately relevant to patient care, such as continuing professional development and some administrative work, and ceasing or reducing some more routine work such as elective procedures. In some instances, the care normally provided to someone who does not have an immediately life-threatening condition may be deferred. It is important in the pre pandemic period to use the national guidance to agree, across a local health economy, a phased approach to the types of patients and treatments that will be deferred or prioritised. It must be clear to patients that such decisions are made consistently and equitably, and are not a caprice of the individual practitioner. Good communication throughout the pandemic will be essential to ensure equitable use of scarce healthcare resources and to reflect the varying levels of capacity and demand. As symptomatic (influenza) patients will be advised to remain at home, where influenza patients do require face-to-face care by a healthcare professional, care should be taken to the patient as far as this is possible. This will require configuring services to ensure the continuation of practice-based care for those who have non-influenza needs, and a combination of telephone assessment and home-based care (as far as this is practical and possible) for influenza patients. As there is a high workload associated with widespread home visiting, arrangements that may support practices in delivering care to the patient are as follows: Make early ‘buddying up’ arrangements or consolidate general practice services, particularly where small practices are involved. This will help to ensure service continuity and a wider pool of staff and skills to draw upon. Mobilise and utilise the skills of the whole healthcare team. Nursing staff, practitioners with a special interest, and non-medical prescribers could support specific groups of patients, which would free up GPs’ time, enabling them to focus on other patients. If possible, rotate staff who care for influenza patients so that not all of the staffing pool are in increased direct contact with symptomatic patients over the same period. Provide initial assessment and triage over the phone to minimise unnecessary home visits. Signpost patients to other services where appropriate, including services that have been established to reduce routine information requests on general practice (eg the National Flu Line service). Link practices to care homes and residential settings to avoid requests for a number of GPs (from different practices) to visit patients in the same care home or setting. Liaise with out-of-hours services and other practices to learn from their experiences of providing care through a combination of access arrangements, including telephone assessment/advice and home visits. General practice will also play an essential role in governing the flow of patients to secondary care services, care homes and other residential settings. Practices will need to work closely with their PCT to ensure that arrangements for admission and discharge are comprehensive and transparent to all health and social care professionals. Arrangements will also need to ensure regular contact and reporting between practices and PCTs, so that practices are up to date with local hospital service availability. The work taking place in conjunction with the Scottish Government will consider how localities can be supported to manage demand across the primary and secondary care interface. This will also consider what will need to be maintained by secondary care services to ensure that primary care capacity is not compromised. See also the UK provisional guidance on managing surge capacity: Pandemic influenza: Surge capacity and prioritisation in health services. Key general practice services in the event of a pandemic In the event of a pandemic, general practices will need to manage additional demand by focusing their resources on maintaining essential influenza and non-influenza services to the public. GPs will wish to focus on those patients with more urgent or complex healthcare needs, whilst other practice staff and staff available within the locality will need to be mobilised to ensure the continuation of some other key services, for example to patients with chronic disease needs or the administration of a pandemic-specific vaccine. Key service areas that will need to be maintained to some level include: _ acute clinical disease management _ screening _ procedures _ monitoring (ie of certain therapies such as anticoagulation therapy) _ childhood immunisations _ child protection. Practices will also wish to consider how out-of-hours care can be maintained (where this service is already provided) or if there are opportunities to supplement the work of providers of out-of-hours and unscheduled care within their locality. Core skills that will be required to care for influenza patients are diagnostic, management and prescribing skills, whilst these and a broader knowledge base will be required for non-influenza patients. The Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) have issued joint guidance on service continuity, which those working in primary care will wish to refer to. The guidance suggests that some functions and activities could be ceased, reduced or delivered by alternative means to enable practices to focus on delivering essential work: _ cancellation of outside activities (meetings, teaching etc) _ defining minimum safe staffing levels _ suspension of (some) chronic disease management _ suspension of (some) new routine referrals _ suspension of minor surgery _ having emergency-only open surgeries _ team working with neighbouring practices _ identifying recently retired or non-practising colleagues who might be utilised. (Source: RCGP/GPC, Service continuity planning framework, January 2006.) After the pandemic, it is likely that there will be a backlog of work relating to chronic disease complications, ‘non-urgent’ presentations, simple elective procedure cases, and the psychological effect of a pandemic on the general population. Practices will wish to consider arrangements for the re-provision of services and which are a priority to provide first. Because of the higher levels of sickness and death in a pandemic, it is likely that new powers will come into force (subject to consultation and Parliamentary approval) on sickness and death certification, which will aim to ease pressure on GP surgeries and other services. (See Pandemic influenza: Guidance on the management of death certification and cremation certification.) The Department of Health is currently working with the Department of Work and Pensions and other key stakeholders to develop guidance on sickness certification. Financial payment for general practices The Department of Health recognises that GPs may be concerned about how the significant increase in the more acute aspects of their workload, which could accompany pandemic influenza, could impact adversely on the finances of their practices. The Department of Health does not intend any general practice to be disadvantaged financially by its participation in responding to an influenza pandemic. Details are being negotiated in the usual way via NHS Employers for GMS contractors. The Department of Health expects that PCTs would apply comparable arrangements to their other contractors. Community pharmacy – there are several pages of the guidance that outline the role of community pharmacy and the extensions that role may take which could include the 28 day emergency supply of all medicines. The role of community hospitals Community hospital capacity, like acute services, will be extremely limited and it will be important to ensure that there are clear admission and discharge criteria that are transparent to all health and social care professionals. Bed management and communication of available capacity during a pandemic will also be key. Whilst most community hospitals are unlikely to have the breadth of skills or equipment necessary to provide care to those who are ill enough to require admission to an acute hospital, they will be an important ‘step facility’. They will, for example, be critical in facilitating earlier discharge following the acute phase or an intermediate/respite/hospice facility for those who are too ill or vulnerable to be managed at home but would not benefit from acute intervention. This will require pre-planning to ensure that the equipment and staffing needs are in place or can be rapidly assembled in the event of a pandemic. It is likely that, from a clinical perspective, the key skills required for handling influenza pandemic cases in a community hospital setting will include (although this list is not exhaustive): Emergency care Basic nursing care Medicine management Infection control Venous access Basic respiratory care/monitoring Care of older people Basic imaging Basic diagnostic lab tests Pharmacy Counselling Out-of-hours services and unscheduled care arrangements Out-of-hours services and unscheduled care providers are key to the pandemic influenza response. PCTs should work closely with their out-of-hours services and unscheduled care providers, to ensure that response plans are robust and that arrangements for a pandemic are in place. As out-of-hours services are likely to be under intense pressure during a pandemic, PCTs will wish to utilise opportunities for bolstering their service with additional resource where this is possible. Other public health measures – Chapter 10 This chapter deals with infection control, health and safety and risk mitigation, dealing with a large number of deaths, surveillance reporting and data collection. Business continuity arrangements – Chapter 11 This chapter stresses the need for all relevant organisations to have a business continuity plan. One for general practice is on the BMA website and was developed with the RCGP.  HYPERLINK "http://www.bma.org.uk/ap.nsf/Content/flupanprep" http://www.bma.org.uk/ap.nsf/Content/flupanprep A business continuity plan cannot be considered reliable until it has been exercised and has been found to be robust. False confidence may be placed in the plan if there has not been rigorous testing. Exercising should involve plan validation, key staff role rehearsal and systems testing where systems are relied on to deliver resilience (eg uninterrupted power supply). Testing of response arrangements and plans should involve those partners who are key to the response, including primary care contractors. Partnership working and integrated planning Planning should be undertaken in conjunction with local partners, particularly primary care contractors (and their field or head office teams where applicable), local medical and pharmaceutical committees, and social care providers. All partners should be involved from an early stage to ensure the development of integrated response plans and arrangements. Supplies and consumables An influenza pandemic will result in increased demand for supplies at a time when the ability of suppliers to maintain deliveries will be compromised. Most healthcare organisations do not hold large amounts of stock, instead relying on timely deliveries. PCTs should consider what the vital supply requirements for their locality are (both in terms of specific and influenza-related use and general use) and ensure that they have systems in place that are capable of receiving, storing and distributing any share of national stockpiles they may be allocated. Mutual aid and ‘buddying up’ arrangements An influenza pandemic is likely to affect many areas simultaneously, and so the ability to provide and receive mutual aid from other providers will be limited. PCTs should establish dialogue with the SHA and other local or regional healthcare providers (NHS and independent sector) about providing mutual aid and support. Elements of mutual aid provision that should be considered include sharing staff (especially those with specific expertise), allocation of reserve staff, material resource sharing (clinical and non-clinical), pharmaceutical, beds (where appropriate) and transport. Single-handed general practices with low numbers of staff are likely to face the biggest challenges during a pandemic. As well as needing to develop local (practice-level) response plans, there will be a need for local coordination across a locality to consider how practices can best work with and/or cover for other practices to cope with demand and to maintain access to care. (In areas such as London this coordination may need to be organised above the level of the PCT area.) Practices will need clear guidance from the PCT as to whom they contact to report sudden changes in their workforce capacity, and there needs to be clear contingency plans for coping with such reports. These issues will require planning at both practice and PCT level in advance of a pandemic. HR guidance is out in draft format for comment – the guidance addresses the full range of workforce issues, including those around professional registration, and liability and indemnity issues associated with using staff outside their normal role and using volunteers or recently retired staff. The DH is currently reviewing specific indemnity issues for primary care contractor staff, and further advice will follow. The draft guidance can be found at the following link:  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080742" http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080742 Staffing and optimising available resources Response plans should contain a strategy for coping with widespread staff shortages. As a minimum, organisations should ensure that plans are in place for handling staff absence rates of up to 15% to 20% over the two-to-three week peak of a pandemic (and up to 30% for smaller organisations). Recovery phase: returning to normality Chapter 12 As the impact of the pandemic wave subsides and it is considered that there is no threat of further waves occurring, the UK will move into the recovery phase. Although the objective is to return to inter-pandemic levels of functioning as soon as possible, the pace of recovery will depend on the residual impact of the pandemic, ongoing demands, backlogs, staff and organisational fatigue, and continuing supply difficulties. Therefore a gradual return to normality should be anticipated and expectations shaped accordingly. Plans at all levels should recognise the potential need to prioritise the restoration of services and to phase the return to normality in a managed and sustainable way. 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