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Is primary care prepared for a bird flu pandemic?

An outbreak of influenza on the scale of the 1918 "Spanish Flu" pandemic would kill tens of thousands of people and could paralyse society and healthcare.
GP practices could expect at least a quarter of their staff to go off sick or absent, there could be fuel crises and food and medicine shortages, hospitals would overflow, and patients may become violent in a desperate bid to obtain rationed antiviral drugs.
This was the possible scenario of a 21st century flu pandemic outlined at a recent conference in London, arranged by Elsevier, which asked whether the UK was ready for such a health crisis.
The answer from most experts was no. Doctors in particular are concerned. Four in 10 doctors who responded to a survey believe the government is badly prepared for a flu pandemic, and only 20% think the country has made adequate preparations. Two-thirds said they did not feel the NHS could cope with a flu pandemic, the conference was told.

Forewarned is forearmed: preparing the practice
Jim Hindle, a professional business manager with a large PMS practice with a special interest in business continuity planning, said that most experts believed that it was not a question of whether there will be another flu pandemic, but when.
GP practices should already be drawing up contingency plans and involving their nurses, who would be key workers in a crisis. "We need to start planning now while we have time to plan, to reflect at leisure and take time to plan thoroughly," he said.
The plan needed to identify the practice's critical functions, what resources would be needed, determine the acceptable level of service that should be provided in a crisis, allocate responsibilities and plan for staff absences.
Staff welfare should be an important part of the plan - catering arrangements might be needed (the local Tesco may not be functioning fully because of a shortage of supplies), staff may have to work longer than usual hours under considerable stress, and rest facilities may need to be available, as well as counselling and support, while staff with domestic commitments may need to work flexible hours. Daily briefings would be essential to inform staff of the progress of the pandemic.
Other issues to consider were whether the practice could cope with extra patients if a neighbouring practice had to close, and how staff would be affected if local schools shut or transport was disrupted because of fuel crises.
Mr Hindle warned that if practices did not draw up a detailed plan and failed to function effectively during a flu pandemic, they could find in the aftermath that staff were demoralised, the team dysfunctional and disaffected patients were leaving.
"Really you need to start doing your planning for a flu pandemic now, put it on the agenda this week, not next month," said Mr Hindle.

The nurse's role
One of the biggest dilemmas for practice nurses during a flu pandemic will be whether to turn up for work if their children are ill or if local schools have closed.  They may also be reluctant to put themselves at risk of infection in the practice if patients are dying.
Dr Hilary Pickles, director of public health at Hillingdon Primary Care Trust, said in a pandemic it would be possible that everyone would be exposed to infection, even if only 50% had clinical symptoms. The greatest risk for nurses and other healthcare workers would actually be from their own children and other relatives.
She warned nurses of the lessons learned in previous health crises, such as the ebola crisis in West Africa, not, as "first responders", to rush in with selfless heroism and put themselves at unnecessary risk.
She said nurses should also consider that they might face angry confrontation with patients wanting antiviral drugs, which would probably be in short supply. They may not have protection from violent patients.
"What we need to do is to keep reminding ourselves that we are currently planning for an experiment in mass therapy - there will not be enough antivirals for everybody," she explained. "Those of us doing the planning have to accept that less than perfect care and rationing will be completely inevitable and it would help if somebody 'up there' started saying it, not just the Department of Health, but professional bodies such as the Royal College of Nursing and the British Medical Association."
Because of pressure on hospitals and rationing of drugs some patients may have to receive suboptimal care and nurses could be at risk of litigation. "Keep good records, make sure if things go wrong you have thought through the situation, you will make avoidable mistakes, that's the way it goes," advised Dr Pickles.
Prof John Oxford, professor of virology at Barts and The London NHS Trust, said that antivirals should be given to the families of anyone diagnosed with pandemic flu. However, currently there is only enough for 25% of the population, a situation he described as impossible and a "dilemma".

Each practice will face different problems
Dr Simon Stockley, a GP principal at the Eaglescliffe Medical Practice in Stockton-on-Tees, who has a special interest in emergency work and planning, spoke about the different problems faced by each practice. Remote rural practices would be doing everything for everybody, while those in urban areas would have large numbers of patients to deal with - their own patients in addition to those who fell sick while they were in the locality.
In addition to dealing with the flu crisis, practice staff would continue to have to treat other medical illnesses, and look after very sick patients in the community, and would have to continue managing patients with chronic illness to prevent them deteriorating.
During a pandemic, GPs and practice nurses would be busy assessing flu patients, managing the worried well, issuing death and cremation certificates and immunising patients. Routine work, such as the Quality and Outcomes Framework, would have to be ditched.
There are several contentious issues that could arise during a pandemic. When hospitals are full to overflowing, which patients should receive inpatient treatment? Many patients who need hospital care would have to be sent home, where they may have no support. "The question is, under what circumstances can suboptimal treatment be accepted by the profession and the public?", commented Dr Stockley.
Doctors may also have to decide whether to give special care and consideration to key people, such as fellow healthcare workers or public sector workers. The practice would have to decide how to deal with special needs groups, such as the elderly frail, very poor or ethnic groups who were likely to have problems accessing services.
Another issue was whether GPs and nurses should visit patients at home to help contain the spread of the disease. This would be time-consuming, and doctors might run out of time and capacity to deliver antiviral drugs to patients within 12 hours, which could also reduce the spread of infection. Telephone triage may have a role in reducing visits and patient mixing.
Other support that could be provided by the Department of Health or the local primary care trust may include leadership from the centre (command and control), central call handling, telephone assessment for prescription of antivirals and flu assessment centres.
Dr Stockley said 56% of his GP colleagues did not have any planning in place for pandemic flu, although most were aware of the disease, the implications for their practices and how they would work during a crisis. Many were starting to think about issues, such as whether you allowed infectious patients to sit in the same waiting room, whether they came through the main entrance or were seen at home. 
As for most GPs, his main concern would be to protect his family and his staff. But GPs should consider adopting a key role as they are ideally placed to reassure and lead the community in a health crisis. GPs, he said, would have to be prepared to lead and in turn be led.
"Historically GPs have always managed. It has involved a lot of sacrifices and a lot of hard work. This time there will be much higher expectations of us and the possibility that we will be required to intervene to stem the progress of the pandemic. Because today there is less cohesion of family groups and more reliance on technology this will make our task harder. We will have to plan for that eventuality otherwise we will have chaos," he said.

The government's flu plans
Andrew Lansley, shadow health secretary, was critical of the government's existing flu plans. He questioned why three and a half million doses of the H5N1 vaccine had been bought, and why there was not a strategic stockpile of facemasks, and he asked when a contract for pandemic flu vaccine would be placed. He demanded to know when there would be a full-scale exercise, which would answer the "hard questions".
Prof Lindsey Davies, national director of pandemic influenza preparedness at the Department of Health, said that compared with the flu pandemics of 1918 and 1958 the population was healthier and stronger and therefore better prepared, and the fact that people were talking about it in advance was a good thing.
The whole population would be at risk, and there could be as many as 80,000 deaths in the UK and 10 million globally. Modelling showed that about 25% of the healthcare workforce might take five to eight working days off. "This gives a sense of what we are preparing for," she said.
The contingency planning that had already been carried out made the UK probably the best-prepared country in the world, Prof Davies claimed, but she admitted there was still a lot of work to do.
"We don't know the impact, whether it will spread very quickly," she said. They were considering stockpiling doses of H5N1 vaccine - this may provide some protection, and the drugs could also be used for research to see how effective they were.
She said she was concerned that the public would see antivirals as a wonder drug that would cure their symptoms. In fact they were not a panacea. "What bothers me is that people think antiviral drugs will get them up and walking about again, but the important message we must get out there is that we don't know whether antiviral drugs will work against the new strain of flu. What we are hoping for is that it will reduce infectivity," said Prof Davies.

Preventive practices
Good hygiene, such as handwashing and putting a hand in front of the mouth when coughing, would be the bedrock of preventive practices, and practice nurses should already be promoting these ideas among their patients. "People working in health and social care have a big responsibility as leaders, friends and role models to get health hygiene practices ingrained across the UK, and it is something we should all be doing now," said Prof Davies.
Masks would help reduce infectivity, but they would not keep out the small particles of infection, only prevent the transfer of larger droplets. They could be used by infected people and nurses and other healthcare workers but would not be necessary for people going about their everyday business.
The government may consider imposing travel restrictions if the infection became a pandemic, but Prof Davies said she thought it was highly unlikely there would be any mandatory travel restrictions imposed during a flu pandemic in the UK. 
Another option would be to set up a telephone advice line to give advice nationally to help relieve pressure on primary care. Antivirals could be provided without patients having to contact their GP directly.
The national framework plan, which is currently being revised, would be flexible enough to enable local areas to respond differently in different circumstances, said Prof Davies.
Practice nurses along with all other healthcare workers would be required to "do their bit" in a crisis. "We will all need to work together and remain constantly alert," she said.