Swine flu pandemic: from containment to treatment - guidance for the NHS

From containment to treatment: the rationale

Swine Flu and its treatment

2. As you aware, a new strain of Influenza A (H1N1), also known as Swine Flu, has now spread to over 100 countries around the world and it was confirmed in the UK in April.

3. When the Swine Flu pandemic started in Mexico, it appeared to be more severe than it has proved to be in the UK or elsewhere. Although symptoms are generally mild, a small number of patients will develop more serious illness. Many of these people have other underlying health conditions, such as diabetes, heart or chronic respiratory disease. that put them at increased risk.

The approach to date

4. As little was known about the new flu virus, the strategy to date has been to try to work to slow its spread while we learned more about it. To do this the NHS and HPA have been:

• testing patients suspected of having Swine Flu to confirm the infection;
• offering antivirals to all patients suspected or confirmed as having Swine Flu;
• collecting detailed information about these patients to learn more about how the virus affects people;
• closing schools where medical advice deemed it appropriate; and
• tracing people that patients have had close contact with and giving them prophylactic antivirals to try to prevent further spread.

5. The response from NHS organisations, Health Protection Agency staff and, in particular, GPs to date has been commendable. During the containment phase, we have had precious time to understand the characteristics of the new virus, to build up medical supplies and to make significant progress towards developing a vaccine.

The move from containment to treatment

6. Ministers in all four UK nations (England, Scotland, Wales and Northern Ireland) have always been clear that, at some point, there would be a need to take the decision to move from containment to treatment when community transmission became widespread across many parts of the country. This will mean establishing national systems to deal with high numbers of Swine Flu cases.

7. Ministers have drawn on advice from leading scientists and health experts to inform this decision, and on 2 July, all four UK administrations confirmed the decision to move to the treatment phase.

8. In practical terms, this will mean that across the country:

• GPs will be able to diagnose Swine Flu on the basis of symptoms rather than waiting for laboratory testing;
• all contact tracing will now cease, and we will stop giving antiviral drugs to people who may have been exposed to the virus;
• all those who have contracted the illness will continue to be offered antivirals. However, it will remain a matter of clinical discretion as to whether antivirals should be prescribed in individual cases.

9. Primary care trusts will also now begin to establish antiviral collection points (ACPs). These could be at a designated pharmacy or a community centre, depending on local need and arrangements.

10. The HPA will continue to provide expert health protection advice and operational support to the NHS during the transition to the treatment phase

The groups of people at greatest risk from Swine Flu 11. Some groups of people are more at risk of serious illness if they become infected with Swine Flu, and will need to start taking antivirals as soon as possible after they present with the illness.

12. We are still learning more about the risk profile of the virus, but based on what we know about seasonal flu and the current pandemic virus, the following groups of people have been identified as likely to be at greater risk of serious illness. People with:

• Chronic respiratory disease
• Chronic heart disease
• Chronic kidney disease
• Chronic liver disease
• Chronic neurological disease
• Immunosuppression (whether caused by disease or treatment)
• Diabetes mellitus
• patients who have had drug treatment for asthma within the
• past three years
• pregnant women
• people aged 65 years and older
• young children under five years old

13. It is vital that people in these higher risk groups get antivirals and start using them as soon as possible - within 48 hours of the onset of symptoms.

Expectations of the NHS

14. During national emergency preparedness situations, like pandemic Swine Flu, the DH can implement national coordinating arrangements.

These arrangements are intended to support SHAs to manage and oversee the NHS response, ensuring wider NHS resources are made available and cross-government assistance is accessed as required.

15. Monitor, as the independent regulator of NHS foundation trusts, agrees with the importance of a system-wide response on this issue and supports the need for NHS foundation trusts to play a full part in these arrangements.

16. As we move into the treatment phase of managing the Swine Flu pandemic, the NHS response will need to move quickly from working to slow its spread while we learned more about the new virus to establishing clear governance and accountability arrangements to ensure people affected by the virus receive the correct advice, assessment and treatment.

17. These ‘command and control’ arrangements will operate via the NHS Flu Resilience Directorate (working with the Emergency Planning Directorate (EPD)) in the Department of Health, through to SHAs as system managers and down to PCTs (and through them GPs and pharmacies) and to NHS trusts and NHS foundation trusts locally.

18. This includes a requirement for each NHS organisation to ensure that:

• each NHS Board appoints a full time director level lead dedicated to flu preparedness and resilience with immediate effect. This can be a single individual or shared between directors but must provide visible, full-time, senior leadership and ensure a well-resourced team on this issue through the months ahead;
• pandemic preparedness plans are stress tested to ensure that the provision of high quality care to flu and non-flu patients now and during a potential second, sustained wave of up to five months can be sustained;
• each NHS Board is requested to take reports on progress towards their readiness assessment against the Department’s HR and Surge guidance to their July and August meetings;
• they understand and test capacity constraints that may be caused through increased demand and workforce sickness absence. This includes but is not limited to those clinical ares that are likely to face most flu-related pressures.

Recent ‘Pandemic Flu: Managing Demand and Capacity in Health Care Organisations (surge)’ guidance and the NHS Employers/ Department of Health document ‘Pandemic Influenza Human Resources Guidance for the NHS’ will help with this work;

• their organisation takes part in the September nationally devised and SHA and HPA-organised resilience testing and exercise programmes to validate Pandemic Flu Plans and Winter Readiness Plans. Board level attendance, including from NHS CEs, is expected at these events.

19. These arrangements will ensure that across the NHS:

• PCTs deliver robust and effective communications locally to the public, GPs, Community Pharmacies (CPs), PCTs and NHS trusts and NHS foundation trusts, local partners and frontline NHS staff;
• PCTs, GPs, CPs and hospitals ensure that all those people with suspected Swine Flu in the higher risk groups get antivirals and start using them as soon as possible - within 48 hours of the onset of symptoms;
• PCTs are strongly supporting GP and community staff with advice, guidance and practical support (e.g. around telephony, temporary staffing etc.) to cope with the level of demand locally until the National Pandemic Flu Service’s online and dedicate call centre assessment and authorisation service is introduced;
• PCT plans for antiviral collection points (ACPs) are effectively stood up, with at least one ACP in each PCT cluster area to be operational by the beginning of next week, with more where the current level of Swine Flu in the community warrants it. PCTs will be added to DH’s Wholesaler Dealer Licence for medicines as the DH’s agents for the distribution of antiviral medicines;
• local plans are in place in each PCT area for the Introduction of the National Pandemic Flu Service, including establishing a network of ACPs to meet the needs of local communities.

Preparations are at an advanced stage and we expect that the service will be ready to be stood up, if needed, by the middle of July;

• all NHS organisations have tested by September the resilience of organisational and local health and care system Flu Pandemic Plans against the national HR and Surge guidance and a potentially more severe attack over the autumn or winter.

20. The specific roles, responsibilities and expectations of SHAs, PCTs, NHS trusts (including NHS foundation trusts) and of GPs and pharmacists are described in Appendix A and should be read alongside this document.

Support to NHS Staff

21. The response of NHS staff and, in particular GPs, to the flu pandemic has been first rate, helping the HPA and the Department of Health to better understand the virus and to collect surveillance information during the containment phase to inform future strategy and the clinical management of pandemic swine flu.

22. It is important that all NHS employers respond positively to the professionalism of NHS staff shown since April in managing the pandemic. This should include:

• ensuring that appropriate HR policies and procedures are in place to support staff and maintain their wellbeing in line with the national Pandemic Flu HR guidance;
• delivering staff training as required to support service provision and high quality patient care;
• effective communications and consultation with staff and their representatives on the support needed;
• ensuring that staff have access to timely and accurate information about the progress of the pandemic and the practical steps they can take to protect themselves, including clear advice about the importance of infection control procedures and routine respiratory and hand hygiene practices
• one of the very best ways people can protect themselves,
• their families and their patients from the virus;
• ensuring that staff in close and regular contact with patients with pandemic Swine Flu have access to appropriate personal protective equipment, such as face masks;
• ensuring that the case is being made to NHS staff and their Representatives for the importance of getting vaccinated against seasonal flu and Swine Flu as the vaccines become available to protect staff, their families and patients;

Further information

23. Further information about this guidance can be obtained from:

• for PCTs, from SHA Flu Lead Directors and SHA Flu Leads;
• for other NHS organisations, GPs and pharmacists, from their local PCT.

2nd July 2009