ࡱ>  @ Nbjbj{{ 8FPPPPPPPd----\(.d6N.H00000040%M'M'M'M'M'M'M$"PRtRKMP78007878KMPP00`M!:!:!:78P0P0%M!:78%M!:!:AK|PPL0. PON-9K MMT6NKJS9|JS$LddPPPPJSPLP1(>3!:4<63111KMKMddhd: ddh Pandemic Flu (H1N1) Questions and Answers 22 June 2009 Current WHO status: Phase 6 UK Management Phase: CONTAINMENT The General Practitioners Committee has received a number of queries relating to pandemic flu from GP practices and LMCs, and we have provided the answers and our advice below. The answers to some questions may change in the light of experience or evidence. Note: There are many more questions in the system, which will be added to this Q&A as soon as we have concrete answers. Therefore, it is important to check this guidance regularly for updates. The Health Protection Agency (HPA) provides authoritative practical advice for investigating, managing and treating individuals with possible swine flu infection, which is updated regularly: England (and Northern Ireland) - HPA:  HYPERLINK "http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1242949541960?p=1242949541960" http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1242949541960?p=1242949541960 Scotland - Health Protection Scotland (HPS):  HYPERLINK "http://www.hps.scot.nhs.uk" www.hps.scot.nhs.uk Wales - National Public Health Services for Wales:  HYPERLINK "http://www.wales.nhs.uk/sites3/home.cfm?orgid=719" http://www.wales.nhs.uk/sites3/home.cfm?orgid=719 RCGP - The RCGP produces regular updates and educational guidance how to prepare for a pandemic flu:  HYPERLINK "http://www.rcgp.org.uk/clinical_and_research/pandemic_planning.aspx" http://www.rcgp.org.uk/clinical_and_research/pandemic_planning.aspx Department of Health (DH) - Regular updates and publications are also available on the DH website:  HYPERLINK "http://www.dh.gov.uk" www.dh.gov.uk The joint BMA/GPC/DH guidance for GP practices is available at:  HYPERLINK "http://www.bma.org.uk/health_promotion_ethics/influenza/panfluguiddec08.jsp" http://www.bma.org.uk/health_promotion_ethics/influenza/panfluguiddec08.jsp General Medical Council - For use when UK Level 3 of an influenza pandemic is announced, the GMC has produced 'Good Medical Practice: Responsibilities of doctors in a national pandemic' (PDF document)  HYPERLINK "http://www.gmc-uk.org/guidance/news_consultation/GMP_in_pandemic_draft_24_Feb_09.pdf" http://www.gmc-uk.org/guidance/news_consultation/GMP_in_pandemic_draft_24_Feb_09.pdf If members have any further queries relating to operational issues, please contact the GPC secretariat, either Catharina Ohman-Smith ( HYPERLINK "mailto:cohman-smith@bma.org.uk" cohman-smith@bma.org.uk) or Marianne Simmonds ( HYPERLINK "mailto:msimmonds@bma.org.uk" msimmonds@bma.org.uk). ANTIVIRALS Can a PCO insist on using a GP surgery as an antiviral distribution centre? All antiviral supplies will be held and issued through PCO distribution points which have to meet certain criteria. If the sole occupant of PCO-owned premises is a GP practice, it would be highly inappropriate for it to be used as an antiviral distribution centre. However, if the PCO-owned premises are multi purpose (e.g. large health centre), then it is unlikely that this should or could be prevented. We would advise practices to: Check tenancy agreement / lease Consult practice lawyer Speak to LMC (LMCs to contact GPC for further advice). Can patients get NHS or private prescriptions of Tamiflu? Antiviral medicines are no longer available on NHS prescription (via FP10 forms), or privately, as there are no antivirals in the retail or wholesale pharmaceutical chain in the UK. They can only be sourced from overseas and this is outwith UK government control. The quality of internet supplies cannot be vouched for. The importation of drugs also requires a licence. When Health Care Professionals (HCPs) start caring for those infected, how long will they be supplied with anti-virals? The current expectation is that during the mitigation phase HCPs get one treatment course, but this is subject to change according to evolving experience and scientific knowledge. If Tamiflu is at all effective why is it being used for mild cases and not keeping it for the possible more serious illness in the autumn/winter? Currently, during containment phase, it is only being issued to cases of and direct contacts of proven flu. IMMUNISATION /VACCINATION What is best practice for storing vaccines? It is proper practice to have a dedicated purpose designed medicines and vaccine refrigerator. Non clinical material should not be stored in such refrigerators. It is also good practice to keep a daily temperature logs and to have a maximum-minimum thermometer in the fridge. The actual storage environment for vaccine storage and utilisation depends upon the vaccine manufacturers instructions which must be followed. SWABS Who is the most appropriate healthcare professional to do the swabbing? Swabbing is a simple technical procedure. The FIRST principle is to minimise the number of contacts with a patient suspected of flu and therefore the health care professional who sees the patient should (if trained) take the swab. In practice in the early stages this is likely to mean the GP simply because the GP has already been exposed. Some OOH services have been operating swab teams consisting of appropriately trained healthcare assistant Is it an essential service to do swabs? Shouldnt the HPA be carrying out this work? Swabbing of suspected flu patients is deemed to be an essential service, as it is management of the acutely ill. Aiding the HPA in monitoring the extent of the spread of the flu is the professional responsibility of a medical practitioner. The GPC believes that the provision of specialist PPE (Personal Protective Equipment) for these procedures is a PCT responsibility. Once the UK moves to mitigation phase swabbing will cease. What swabs should be used? Use the proper HPA supplied kit only the HPA guidance advises to only use plastic swabs. The latest guidance is on their website. DIAGNOSIS/INVESTIGATION Do swabs need to be taken on patients with a temperature under 38C and with history of fever and any two symptoms on the list, or can they be excluded? There are other non flu conditions which could fulfil these criteria. If you do not believe that you are dealing with a case of flu then no, the swabs do not need to be taken. However should you believe that flu is a distinct possibility then follow the latest HPA guidance which was issued on 03 June version 6. Should practice staff work solely with infected or non-infected patients in order to minimise the risk of contracting the virus? Compared to the ordinary members of the public the increased risks of contracting an infection from a transmissible disease are recognised professional hazards of being a doctor or other health care professionals. It is as much a professional duty not to deny patients care simply because of the increased risk of infection as it is to minimise risks to oneself and ones colleagues by appropriate use of measures to minimise such increased risks. Operationally it will make sense in handling pandemic if one doctor/team in a practice deals solely with all suspected cases wherever possible in a dedicated segregated area. Later on in the pandemic in the absence of a vaccine it would make sense if the pandemic suspects team were to be comprised of those who had recovered from the pandemic MANAGING SURGE DEMAND Will pregnant women be assessed the same as everyone else or will they need to see their GP in the same way as children under 1yr old? They will need to be seen by GP in same way as under-1s. See also DH doc Pandemic flu: managing demand and capacity in health care organisations (surge) guidance:  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098769" http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098769 Does the agreement on income protection, if practices make themselves available and assist with the PCO response to pandemic flu, include any implied participation in out of hours (OOH) arrangements? It will not be compulsory to work OOH per se, but it may make sense to alter practice opening hours depending on the situation at the time. Part of the financial arrangements for practices is the acceptance of direction of labour and therefore a practice/GP may be asked NOT to work during a given day at the practice. They may instead be asked to work on the OOH service at some point in the 24 hour cycle. How will the collapse of OOH services due to overwhelming demand for their services and staff shortages be prevented? PCOs will employ all available locum GPs during a pandemic period (section 4.10.4 of Preparing for pandemic influenza - Guidance for GP practices). It will not be the responsibility of GP practices to directly employ locums (section 4.14.4). The PCO will collect and act upon data collected from practices and buddying-up groups in order to allocate locum doctors as necessary throughout the PCO area (section 5.7.4). It is intended that this will also overcome issues associated with the potential collapse of OOH organisations. To enable round-the-clock medical services, buddying-up clusters of GP practices may be asked to bolster OOH services (section 8.1.8). It is likely that normal surgery times will differ during a pandemic - for example, a set number of hours of work per week may be imposed for in- and out-of hours staff. Such alteration will be subject to discussion between the buddying-up group, PCO and LMC. PLANNING, IMPLEMENTATION AND COMMUNICATION Do you have examples of Flu Pandemic Planning LES? Yes please contact  HYPERLINK "mailto:msimmonds@bma.org.uk" msimmonds@bma.org.uk or  HYPERLINK "mailto:info.gpc@bma.org.uk" info.gpc@bma.org.uk. The GPC keeps a database of LESs which have been shared with it. If you have a LES for pandemic flu planning, and would be prepared to share it with GPC, please send it to Marianne Simmonds, at the above email address. What is the situation of income guarantee with respect to LESs? The principle of the agreement is that there should be no loss of income. Given the multitude of local variations of LESs, it would be impractical to negotiate a national agreement encompassing LES income protection. LMCs should enter into discussions with PCOs locally to decide how to use LESs funding to resource practice work related to pandemic flu. Where can ethical guidance pertaining to dealing with a pandemic be obtained? The DH has issued a guidance document, Responding to pandemic influenza: The ethical framework for policy and planning, available to download at:  HYPERLINK "http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_080751" http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_080751 The BMA Ethics department has not issued separate guidance, but worked with the DH in developing the above document which is now cross government guidance. What happens if my practice does not enter in to a buddying-up agreement with other practices? Although practices are free to chose not enter in to buddying-up arrangements with other local practices, it is strongly recommended that they do so. Failure to buddy-up with other practices is likely to be viewed as a failure comply with the terms of the Costing methodology for GMS practice payments during an influenza pandemic agreement between the BMA and NHS Employers. This agreement offers income protection to GP practices in the event of a flu pandemic. Below are the relevant clauses: 8. To be eligible for the income protection offered to practices under this agreement they must be: a. Actively participating in the national and PCO response to the pandemic, or have made their resources available to the PCO. b. Actively supporting their staff in line with any recommendations for good practice within general practice which may be agreed at a national level. The full document can be found here:  HYPERLINK "http://www.bma.org.uk/images/Pandemicflu_methodology_May2008_tcm41-173416.pdf" http://www.bma.org.uk/images/Pandemicflu_methodology_May2008_tcm41-173416.pdf NHS INCOME Will NHS income be guaranteed in the event the Pandemic moves to Phase 6 and mitigation? Yes, NHS income will be guaranteed, (but not private income), both during the pandemic and recovery phase. In light of the costing methodology agreement between NHSE and GPC (FLU_058_9), if a pandemic is deemed to end on 30th March, is there no income protection? The agreement between NHSE and GPC is that in the event of a pandemic GP funding will be maintained at the same level as the same month in the previous year plus any DDRB rises during the pandemic phase and the recovery phase. If a pandemic has lasted several months and routine work has been suspended for a significant time, how are we expected to catch up? The costing methodology agreement between NHSE and GPC (FLU_058_9) gives guidance on the issue of a pandemic, covering the end of one QOF year and the beginning of another - particularly where changes to QOF were to be introduced in the new year - practices will continue to get funding based on the previous year irrespective of planned changes to QOF. It is expected that the recovery phase after the end of a pandemic will last many months and during that phase practices will have time to catch up Is there an agreement to compensate for overtime worked by practice employed staff/salaried GP? There is agreement that extra expenses will be met. GP principal time over 52.5 hours/week is expected to be remunerated at the average OOH hourly rate. (Note that it is for practices to sort out rates for part time principals). Will dispensing income be protected in the case of a pandemic? Not explicitly but we cannot envisage a situation where protection will be required. OTHER COSTS Will private income (e.g. that earned from completing insurance reports) be protected during the pandemic? No. Only NHS income will be protected. IT Should PCOs be arranging for HCPs to be able to log on at any practice in their cluster? Yes, and this will also require practices to make relevant preparation as part of Business Continuity Management. INDEMNITY Has the issue of indemnity for GPs during a pandemic been developed? The vast majority of GPs have insured or discretionary indemnity through a medical defence organisation, and their normal indemnity entitlements will be available during a pandemic while they are carrying out their ordinary duties as GPs. GPs who have any questions about indemnity during a pandemic should contact their MDO. It would be up to the individual GP's clinical judgement to determine how best to provide their professional services in unusual or difficult conditions and their indemnity would not be affected. All other benefits of membership of an MDO would also be available in the usual way if any other medico-legal problems arose e.g. advice and assistance with GMC complaints, disciplinary investigations etc. It is envisaged that PCOs will act as the employer for all available freelance locum GPs during a flu pandemic. This will preserve their indemnity at a time when they will be working at maximum flexibility, possibly moving frequently between practices. You can read statements on indemnity in the event of a pandemic from the Medical Defence Organisations via the links below: Medical Protection Society (MDS)  HYPERLINK "http://www.medicalprotection.org/uk/response-documents/Policy-position-on-pandemic-flu-and-indemnity" http://www.medicalprotection.org/uk/response-documents/Policy-position-on-pandemic-flu-and-indemnity Medical Defence Union (MDU)  HYPERLINK "http://www.the-mdu.com/section_GPs_and_primary_care_professionals/topnav_Advice_centre_1/hidden_Article.asp?articleID=1995&contentType=Advice%20article&articleTitle=Pandemic+flu+and+indemnity" http://www.the-mdu.com/section_GPs_and_primary_care_professionals/topnav_Advice_centre_1/hidden_Article.asp?articleID=1995&contentType=Advice%20article&articleTitle=Pandemic+flu+and+indemnity+ Medical & Dental Defence Union of Scotland (MDDUS)  HYPERLINK "http://www.mddus.com/mddus/news-and-events/news/june-2009/gp-indemnity-in-flu-pandemic.aspx" http://www.mddus.com/mddus/news-and-events/news/june-2009/gp-indemnity-in-flu-pandemic.aspx What are the GMC registration and indemnity arrangements for retired doctors who volunteer to work during a pandemic? Under current regulations, retired doctors who are still on the GMC register, i.e. have not taken voluntary erasure themselves or been erased, are able to practise as a fully registered medical practitioner. Retired doctors not registered with the GMC may, subject to them meeting the provisions of the legislation, be registered with the GMC for the duration of the pandemic. Legislation with a sunset clause will be laid before parliament immediately as such an emergency is declared and will be triggered by that declaration. Such registration may be subject to conditions relevant to the emergency. Temporary registration in an emergency will not attract a fee. It is understood that indemnity will be provided by the PCO with whom the retired doctor will have an honorary contract. Any negligence claims made against retired doctors working under an honorary contract to a PCT will be defended by the PCO, insofar as the doctor was acting in the course of their honorary employment. Retired doctors should let the medical defence organisations of which they were previously a member know what they are doing. The BMA website provides information on the deployment of retired doctors during a flu pandemic:  HYPERLINK "http://www.bma.org.uk/health_promotion_ethics/influenza/pandemicinfluenzadatabase.jsp" http://www.bma.org.uk/health_promotion_ethics/influenza/pandemicinfluenzadatabase.jsp ,.0;<=OXYZ]{}~ A C G e o }  ) * սս竤wpbwYwpph?h^-0Jjh?h^-U h?h^-jh?h^-U h^-5h?ih^-5h^-B*phh\}h^-5B*ph h\4@h^-h^-h^-5B*CJaJphh$gh^-5CJaJhp 4h^-5CJaJh^-5CJaJhB5CJaJhCh^-5>*CJaJh^-5>*CJaJ".<={} A B C  jGC$Eƀfgd^-GC$EƀLFgd^-gd^- N  ) e f g    I$Eƀfa$gd^-$a$gd^-gd^- $ % M N O b c   w x vwGIJKžųɪtkh2nrh^-0Jj=h^-U hLh^-h2|h^-5jh?h^-Ujh?h^-Uh|h^-0Jjh^-U h2h^-h^-jh^-Uh?h^-0Jjh?h^-U h?h^-jh?h^-U h^-5*bco,./0DEHITU}vqjbjhAh^-5 hAh^- h^-5 hh^-Ujv h>h^-Ujh>h^-U h>h^-h>h^-5h8_>h^-5h@Bh^-0J5B*ph h^-0J5h@Bh^-0J5h@Bh^-5B*phhx\h^-5 h^-5huHh^-5h^--+------RI^gd^-R & F Eƀf `gd^-gd^-KC$Eƀ2f^gd^- 7$8$H$gd^--c/d/// 1 1NEƀf^`gd^-^gd^- & F ^`gd^- ^`gd^-///// 1 1 1Z11111a2c2d2e222l335555)6+6666 7 7o7p7|7׮ˡאuhhuhuXujh^-0J5B*Uphhxh^-0JB*phh^-0J5B*phh@Bh^-0J5B*ph h@Bh^-5B*mH phsH h4Wh^-0JmH sH #j h4Wh^-UmH sH h>h^-mH sH jh^-UmH sH h^-mH sH hx\h^-5h^-hx3h^-6 hx3h^- h^-5" 1Y1Z122k3l33355)6ylcc 7$8$H$gd^- 7$8$H$^gd^- $ & Fa$gd^- $^a$gd^- $^a$gd^-$^`a$gd^-^gd^-I & FEƀfgd^- )66 7G7H788)8*8gd^-N$C$Eƀ5f^a$gd^- $7$8$H$a$gd^- 7$8$H$gd^-7$8$H$^`gd^-|7777788888)8*8889999q:r:t::::0;1;2;[<\<<<<O=P=Q=S====8>¹񮦢xqj h)h^- hh^- h*h^- hJ'h^- hN<h^- h^-5hJ'h^-5h*h^-5h^-h,dh^-5h>h^-mH sH hC`Oh^-0Jjh^-0J5B*Uph$j1hC`Oh^-B*Uphh^-0J5B*phh@Bh^-0J5B*ph'*88888]T`gd^-JEƀf`gd^-gd^-R & F Eƀf `gd^-899s:t:::;V & F Eƀf ^`gd^- ^`gd^-^gd^-V & F Eƀf ^`gd^-:<<Q=R=8>9>x>y>>>>>H?I?q?^gd^- & Fgd^-^gd^-R & F Eƀf`gd^-gd^-^gd^-8>9>x>>J?q?r?s?u?y??E@G@P@Q@R@@@@@AAAAA'C-CbCwCxCCCtDuDϼ粨zozozgozozo[[hBB*KH^Jphh B*phhBhBB*phhBB*phhB5B*phh@BhBB*KH^Jphh@BhB5B*phh^-5B*phh 5B*phhd69h^-B*phh*h^-5h^-h,dh^-5 h)h^- h^-5h@Bh^-5B*phh@Bh^-B*ph!q?s?x?y???E@F@R@S@@@{s & FgdB `gdB `gd^-^gd^-R & F Eƀf`gd^-gd^-^gd^- @AAwCxCuDvDDDEEEEFFGGGGH$7$8$H$^a$gd $7$8$H$^a$gdB `gdB ^`gdBuDvDDEEE#EEEEEEEEEFFFFFFFFGGGGGGGGGAHCHDHEHHHHHžžpž,j\h4h B*KHU^Jph,jh4h B*KHU^Jphh4h 0JKH^J,jh4h B*KHU^Jph jh B*KHU^Jph h h 5B*KH^Jphh h B*KH^Jphh B*KH^Jph'HHIIKKwMxMM||l$7$8$H$`a$gd^-$7$8$H$^a$gd^- $7$8$H$a$gd^-$ & F 7$8$H$^`a$gd^-JEƀf^gd^-HHIMMM>N?N@NNNNNNөӥhhqh^-/jAhoPh^->*B*KHU^Jph#jh^->*B*KHU^Jphh^->*B*KH^Jphh^-KH^Jh^-5KH\^Jh@Bh^-B*ph MNNNgd^-Q$7$8$EƀfH$^a$gdCZ6&P 1h:p^-. A!S"S#n$S% DyK ]http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1242949541960?p=1242949541960yK http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1242949541960?p=1242949541960DyK www.hps.scot.nhs.ukyK 8http://www.hps.scot.nhs.uk/=DyK 2http://www.wales.nhs.uk/sites3/home.cfm?orgid=719yK dhttp://www.wales.nhs.uk/sites3/home.cfm?orgid=719DyK Dhttp://www.rcgp.org.uk/clinical_and_research/pandemic_planning.aspxyK http://www.rcgp.org.uk/clinical_and_research/pandemic_planning.aspxDyK www.dh.gov.ukyK ,http://www.dh.gov.uk/DyK Lhttp://www.bma.org.uk/health_promotion_ethics/influenza/panfluguiddec08.jspyK http://www.bma.org.uk/health_promotion_ethics/influenza/panfluguiddec08.jspDyK Uhttp://www.gmc-uk.org/guidance/news_consultation/GMP_in_pandemic_draft_24_Feb_09.pdfyK http://www.gmc-uk.org/guidance/news_consultation/GMP_in_pandemic_draft_24_Feb_09.pdfDyK cohman-smith@bma.org.ukyK >mailto:cohman-smith@bma.org.ukDyK msimmonds@bma.org.ukyK 8mailto:msimmonds@bma.org.ukDyK ghttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098769yK http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098769DyK msimmonds@bma.org.ukyK 8mailto:msimmonds@bma.org.ukDyK info.gpc@bma.org.ukyK 6mailto:info.gpc@bma.org.ukDyK ghttp://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_080751yK http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_080751DyK Nhttp://www.bma.org.uk/images/Pandemicflu_methodology_May2008_tcm41-173416.pdfyK http://www.bma.org.uk/images/Pandemicflu_methodology_May2008_tcm41-173416.pdf DyK ehttp://www.medicalprotection.org/uk/response-documents/Policy-position-on-pandemic-flu-and-indemnityyK http://www.medicalprotection.org/uk/response-documents/Policy-position-on-pandemic-flu-and-indemnityuDyK http://www.the-mdu.com/section_GPs_and_primary_care_professionals/topnav_Advice_centre_1/hidden_Article.asp?articleID=1995&contentType=Advice%20article&articleTitle=Pandemic+flu+and+indemnityyK http://www.the-mdu.com/section_GPs_and_primary_care_professionals/topnav_Advice_centre_1/hidden_Article.asp?articleID=1995&contentType=Advice%20article&articleTitle=Pandemic+flu+and+indemnityDyK \http://www.mddus.com/mddus/news-and-events/news/june-2009/gp-indemnity-in-flu-pandemic.aspxyK http://www.mddus.com/mddus/news-and-events/news/june-2009/gp-indemnity-in-flu-pandemic.aspxDyK yK http://www.bma.org.uk/health_promotion_ethics/influenza/pandemicinfluenzadatabase.jspT@T ^-Normal$a$%B*KHOJQJ_HmH phsH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No ListzOz ^-List Paragraph$d^a$m$%B*CJKHOJPJQJaJphtH B'B ^-Comment ReferenceCJaJ4@4 ^- Comment Text6U@!6 ^- Hyperlink >*B*phNO2N ^-MinutesContent7d^7aJ rOAr ^-MinutesContent Char Char)B*KHOJQJ_HaJ mH phsH tH 2OQ2 ^- BoldContent5PObP ^- LetterContent$da$ B*KHphHrH ^- Balloon TextCJOJQJ^JaJFV@F CZFollowedHyperlink >*B* phF.<={}ABC)efg  H I T U : ; 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