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Preparing for pandemic influenza
Guidance for GP practices
Preparing for pandemic influenza
Guidance for GP practices
How to use this document
The timescale of an influenza pandemic
Preparing for an influenza pandemic
3.2 WHO international phases and UK alert levels Business continuity for GP practices: the role of GPs and their teams
4.12 Anxiety among public, patients and staff 4.14 Different ways of working in a pandemic Command and control
5.5 Social care, community hospitals and other key players 5.8 Example of a daily situation report to GP sites in a PCO area Caring for the general public
6.4 Direct contact with those patients who are symptomatic – means of transmission People who will be and could become vulnerable in a pandemic
and where GP involvement is more likely

Managing surge capacity and patient prioritisation
Prescribing issues
Death certification
Immunisation 46
11.3 How will the vaccine be supplied to practices? 11.4 Will healthcare workers receive pre-pandemic immunisation? Recovery phase
12.1 Rebuilding, restoring and rehabilitation List of acronyms
Appendix 1: GPs’ pay
Appendix 2: WHO international phases and UK alert levels
Appendix 3: Children’s dosage
Appendix 4: Communications
Appendix 5: Contents of the emergency box
Appendix 6: Command and control arrangements in an influenza
pandemic in England
How to use this document
This is the first issue of this guidance document. Some aspects of planning for andresponding to an influenza pandemic have not yet been decided or agreed. Thisdocument will be regularly reviewed to include decisions as they are agreed plus anyrelevant changes, which relate to general practice. In future issues this section of theguidance will be used to highlight what changes have been made to the guidance sothat practices can see at a glance what developments have occurred. The document sets out guidelines for business continuity planning within your practice.
It also introduces new systems and procedures, such as the National Pandemic Flu LineService, which will operate in an influenza pandemic.
Many aspects of planning for a flu pandemic are agreed and reflected in this guidance.
Where things are not yet agreed it has been clearly stated in the text. To help readersidentify them, these areas will be marked by the following words: To be agreed. This topic is currently under discussion at national level. Furtherguidance will follow.
The guidance has been prepared by the British Medical Association’s General
Practitioners Committee and the Royal College of General Practitioners with the support
of the Department of Health, England. Wherever possible it has been made applicable
to the UK as a whole. It has used as a model a predicted flu attack rate of between
25% and 50% in line with Pandemic flu: A national framework for responding to an
influenza pandemic
. Response to a pandemic must be proportionate. Should the flu
pandemic prove to be more or less severe than this attack rate, the response would
have to be adjusted accordingly, consistent with the National framework. It is expected
that very similar guidance will be issued in Scotland, Wales and Northern Ireland.

This guidance is for GPs and their staff in general practice. Practice Managers in
particular should find it helpful. It will also be of use to Primary Care Organisations
(PCOs) and is relevant to patients. It tells practices what they need to do now and in
the future in order to prepare for, and respond to, a pandemic influenza outbreak in
the UK. It explains why there is a need to take action and how this will help minimise
the spread of flu in a pandemic and make the best use of limited health resources.

We have worked with the Department of Health in England to produce this guidance,and where possible it should apply to the other countries of the UK. Not everything has been finalised, but we felt it was important to get information to GPs and theirteams as soon as possible. It is a living document, which will be updated regularly asideas emerge. It is therefore very important that you visit this website
In a flu pandemic general practice will be under enormous pressure. We will all beworking differently and, at the pandemic’s peak, we will have to suspend some normalservices in order to get through. An example of such adaptation is the work practicesunder the Quality and Outcomes Framework (QOF). Your practice resources will beprotected so that you will not be penalised for diverting your efforts to care for yourpatients during the pandemic. There will be clear command and control systems tomake sure we act together in a fair and ethical way. A flu pandemic will stretch the NHSto the limit – general practice in particular – requiring us all to act together in acoordinated way. GP practices will be asked to work together in groups – buddying-up – to makemaximum use of all the staff available. This guidance is meant to be practical and showyou how pandemic planning should be done. You will find action points, and checklists,which you can download and use to prepare your practice for a pandemic. Links aregiven to key information sources so that you can access them easily.
What is important is that no GP practice is left isolated and that we think about thepotential problems in advance, training up as necessary and putting systems in place sothat when a pandemic arrives we are as ready as we can be.
It will not be easy. There will be things such as prioritisation of services at the peak ofthe pandemic, which no one will like. However, by thinking things out now, before thepandemic, we can try to ensure that we limit the extent of sickness and death from flu,and will be able to care for non-flu patients as well. Foreword
If general practice is ready it could make the difference between ‘getting through’ andsaving extra lives. Previous experience has shown us that there is a danger that non-flupatients with serious health problems could suffer in a pandemic unless general practicesare on the alert to meet their needs.
A flu pandemic will place huge demands on general practice, but with the help of thisguidance you will place yourselves – and therefore your patients – in the best possibleposition to cope. Dr Laurence Buckman
Professor Steve Field
Chairman of the British Medical Association’s Introduction
Summary: This introduction and chapter 2 give a general overview of what a pandemic
entails. The following chapters provide detail of how general practice can respond.
1.1.1 A pandemic occurs when a new influenza virus to which people have no immunity emerges and starts spreading as easily as normal seasonal flu.
1.1.2 No one knows when a flu pandemic will occur, but modelling suggests that once in the UK, it could spread to all major population centres in one to two weeks,with the peak incidence occurring only 50 days from the initial entry to the UK.
1.1.3 It is likely that between a quarter and a half of the population will be affected. If half get symptoms, over the course of the pandemic 30 million people will beill with flu. This might be over a number of waves or could be in a single wave.
Most people will be asked to stay at home and self-care, ie look after themselvesat home (if they are able to), but inevitably about a third – including children under1 year old – may also need to be assessed and treated by a GP or other healthprofessional. Some of these will require hospital admission if beds are available.
1.1.4 While it may be possible to maintain normal general practice in the early stages of a pandemic flu wave, it will not be possible to carry on as normal at the peakof the pandemic, nor for some time afterwards during the recovery phase.
Arrangements are in place to identify when non-essential services have to becurtailed or dropped, and primary care organisations (PCOs) will tell practiceswhen this point is reached, based upon advice from the regional directors ofpublic health.
1.1.5 The arrangements cover protection of general medical services (GMS) practice income so that practices are not penalised when they have to suspend somenormal operations such as Quality and Outcomes Framework (QOF) work andenhanced services. More details can be found in appendix 1. The agreementincludes recommendations to apply the same principles to primary medicalservices contracts and other services.
A graded response to increasing threat, with specific ‘trigger points’, will be used so that everyone understands at what stages of the pandemic certainfunctions will stop and/or start. The decisions on when specific milestones are reached will be made at regional or national level, and GP practices will beinformed. At the peak of a pandemic, all parts of the NHS will need to worktogether in different ways in partnership with social services, the voluntary sectorand other bodies.
A great deal of pre-pandemic planning is taking place across all sectors inaddition to health, for example in the areas of power and food supplies. This document, however, is specifically for general practice guidance.
2 The timescale of an influenza pandemic
Summary: This chapter gives the history of pandemics, speed of development,
predicted attack rates and effects of the virus.
2.1 History
2.1.1 Influenza pandemics have occurred three times in the last century, in 1918, 1957 and 1968. It is highly likely that another worldwide pandemic will occur at sometime, but its timing cannot be predicted. It seems likely that a flu pandemic willstart outside the UK, but within two to four weeks of the start of the outbreakin the host country it will affect the UK. It could then take just one or two moreweeks to spread to all major population centres here.
2.1.2 General practice will be one of the critical ‘pinch points’ in responding to a pandemic. By planning now, a lot can be done to contain the impact of apandemic. The NHS will clearly be placed under enormous pressures, and newways of working will be introduced to create extra capacity (surge capacity) tomeet demand. With hospital beds at a premium, general practice, and GPs inparticular, will be providing more community-based critical care than normal tonon-flu as well as flu patients. Experience shows that the ability of generalpractice to care for these critically ill patients outside hospital should make thedifference between simply ‘getting through’ a pandemic and avoiding asignificantly increased number of deaths among non-flu patients as well as those who are victims of the pandemic itself.
2.1.3 In previous pandemics, the overall clinical attack rate was of the order of 25% to 35%, compared to the normal seasonal flu rate of 5% to 15%. However, it isnot possible to predict with any certainty the epidemiology of a new influenzapandemic virus and its clinical behaviour. This will only become apparent asperson-to-person transmission develops, so plans have to be flexible enough to cope with a range of possible attack rates, with responses stepped up asappropriate. The National framework recognises the possibility of an attack rateof 50% in a single-wave pandemic. Plans should consider this, and will have tobe adjusted as new information becomes available.
Effects of the seasonal flu virus
2.2.1 There are three broad types of influenza virus: ‘A’, ‘B’ and ‘C’. ‘A’ viruses cause most winter epidemics (and pandemics) and can affect a wide range of animalsas well as humans. ‘B’ flu viruses can only infect people, and circulate mostwinters. ‘C’ viruses are among the many causes of the common cold.
Pandemic influenza: Guidance for GP practices
2.2.2 Around half of those who become infected with the seasonal flu virus have no symptoms and are not even aware of the infection.
2.2.3 For most of the others, while seasonal flu is unpleasant, it is self-limiting and not life threatening to the majority of people. All GPs will be aware of their patientswho are in the high-risk group for whom, without intervention, flu would causeserious illness. An estimated 12,000 – mainly older – people die each year inEngland and Wales from seasonal flu.
Flu pandemic patterns
2.3.1 More recently, the A/H5N1 flu virus has caused concerns. While a number of people have contracted flu after contact with infected birds, worldwide there has been only limited evidence of person-to-person transmission so far, and thistransmission has not been sustained. Whether derived from A/H5N1 or anothervirus, the fear is the emergence of an adapted or new virus capable of spreadingeasily between humans and causing a pandemic. A new strain is likely to transmitmore easily to people if it contains genetic material from a human influenza virus –that is, if a strain of avian flu mixes with a human flu virus and evolves.
2.3.2 A pandemic can occur in one wave or a series of waves, weeks to months apart.
Initially, a flu pandemic in the UK may last for three to five months dependingon the time of year in which it starts. There may be subsequent waves, whichmay be more severe than the first wave.
2.3.3 The three pandemics in the last century were: This pandemic caused 20–40 million deathsworldwide.
The 1957 and 1968 pandemics were less severe than Spanish flu, but caused an estimated 1-4 million deaths between them.
2.3.4 There are many uncertainties about a future flu pandemic. Response plans should allow for a clinical attack rate of up to half the population. Up to 4% ofthose with symptoms may require hospital admission.
3 Preparing for an influenza pandemic
Summary: This chapter explains the need to prepare for a flu pandemic, where to
find guidance and why a command and control system must operate. Many of the
preparations made for a flu pandemic should also prove relevant and useful for
other emergencies and for general service continuity planning.
Overview of preparations
3.1.1 Most health and social care will be delivered in the community setting, with acute hospital capacity reserved for those most in clinical need. Even so, at thepeak of the pandemic it may be necessary to prioritise who will benefit mostfrom treatment. This will be done in an ethical and objective manner. Scoringsystems for hospital admissions are being validated at present and further work is in progress to develop outcome tools.
3.1.2 Clear command and control arrangements are essential. This guidance explains how these will work and why practices must follow the guidance to provide a
uniform response to the pandemic. This will boost capacity and ensure fairness
to patients and staff.
3.1.3 The General Practitioners Committee (GPC) of the British Medical Association (BMA) and the Royal College of General Practitioners (RCGP) have prepared thisguidance jointly, supported by the Department of Health.
3.1.4 A flu pandemic will put primary care and the NHS in general under unprecedented pressure. General practice has a critical role to play. Practices are
asked to acknowledge that unless everyone follows the principles of the ‘five
Cs’ – command, control, communicate, coordinate and cooperate – there will
be chaos
. To minimise risk, guidance documents are being published so that
everyone knows what is expected of them, can take part in the planning to
ensure that we are as prepared as possible and has well-understood action
plans in place.
The five Cs:
Pandemic influenza: Guidance for GP practices
3.1.5 Practices must work with their local primary care organisation when planning for and during a flu pandemic. There is published guidance for primary careorganisations on their duties and roles.
3.1.6 You can find guidance documents at.
Country-specific guidance:
Scotland –
Wales –
Northern Ireland –
Professional bodies:
WHO international phases and UK alert levels
3.2.1 The World Health Organization (WHO) has defined phases in the evolution of a flu pandemic. These allow us to plan so that we can respond in steps accordingto the level of threat. WHO identifies six phases, where Phase 1 is the lowestlevel of risk and Phase 6 indicates a pandemic period, with pandemic alertphases in between.
WHO number and phase
Overarching public health goals
Inter-pandemic period
preparedness at global, regional, national and sub-national levels humans; detect and report such transmission rapidly if it occurs Pandemic alert period
notification and response to additional cases 4. Small cluster(s) with limited person-to- Contain new virus or delay its spread to person transmission but spread is highly localised, suggesting that the virus is not 5. Large cluster(s) but person-to-person spread still localised, suggesting the virus spread, to possibly avert a pandemic and Pandemic period
UK alert levels:
As of December 2008, the WHO phase is Phase 3.
A version of the above table can also be found at appendix 2 for practices to print out and keep to hand.
Pandemic influenza: Guidance for GP practices
3.2.3 If a pandemic is declared, action will depend on whether cases have been identified in the UK and on the extent of spread. Therefore, for UK purposes,four additional alert levels have been included within WHO Phase 6.
These UK alert levels are:
3.3 Clinical
3.3.1 The clinical aim is to limit the morbidity and mortality from influenza and minimise the spread of the flu virus by isolating flu patients wherever possible.
This means asking patients to stay at home and self-care. Most patients will not
need to see a GP or other healthcare professional. Only certain patients, such as
those with the greatest clinical need, will be seen by a GP or other healthcare
professional. Only the most seriously ill who have been assessed as likely to
benefit from specialist treatment should be sent to hospital.
3.3.2 A more detailed explanation of how this will work can be found in chapter 8 and in the surge capacity guidance published by the Department of Health. You can find this at
4 Business continuity for GP practices:
the role of GPs and their teams
Summary: This chapter sets out the predicted workload for GP practices in terms of
patient numbers, highlights the importance of staff contracts, explains what practices
can do to cope, predicts staff absence levels, provides a step-by-step guide to setting
up buddying-up groups, suggests emergency boxes, describes how freelance GPs will
work and describes the impact on GP trainees and infection control procedures.
Impact on general practice
4.1.1 Given the number of influenza patients in a pandemic, it will not be possible or necessary to provide rapid face to face consultations with everyone. Flu patientswill be asked not to come to their GP surgery. If they do so, they should beadvised to contact the National Pandemic Flu Line Service. This service will bemade available in the event of a pandemic and will be the national system bywhich the general public will access antiviral medication. The National PandemicFlu Line Service system is explained further in chapter 6. Inevitably, somepatients who attend for other reasons may have flu and not realise it. Practicesshould have plans to minimise further exposure to staff and patients. This willinvolve increasing the awareness of reception staff of this issue and, wherepossible, keeping flu and non-flu patients apart. GPs should plan now for howthis could be done, for example by using separate waiting rooms and consultingrooms for non-flu patients where practicable.
4.1.2 Patients will need to access care in their homes as far as possible to help reduce and limit the spread of infection. The majority of people will rely on self-care,
contacting the National Pandemic Flu Line Service (please see chapter 6 for
more details), taking antiviral medicine and treating symptoms with over-the-
counter medicines
The Government’s messages to the public will be: phone the National Pandemic Flu Line Service.
Communications will play a huge role in coping with a flu pandemic. TheGovernment has firm plans for a mass communication programme to let thepublic know what will be involved in a pandemic and how they can help makethe best use of services. You can read more about the communications plannedin appendix 4.
Pandemic influenza: Guidance for GP practices
4.1.5 Modelling suggests that about one-third of symptomatic patients, including all children under 1 year old, will require assessment and treatment by a GP orother healthcare professional. Patients who may be at risk of complications dueto their age, some other medical condition, or the severity of flu symptoms may,in addition to being authorised to receive antivirals by the National Pandemic Flu Line Service, be advised to seek further medical support from primary care services. The National Pandemic Flu Line Service will advise the publicwhether they would need to see a GP. GPs should be aware that they will thenreceive referrals from the National Pandemic Flu Line Service call centre.
4.1.6 This means that if we have a 50% attack rate and a complication rate of 25% (plus all children under 1) demand for pandemic-related GP consultations can beexpected to increase to 14,250 per 100,000 population over the course of thepandemic. 4.1.7 For an average GP practice with three full-time doctors and a list of 6,000 patients, that equates to around 750 consultations over the course of thepandemic. The other practice patients who get flu will be asked to self-care.
4.1.8 The above figures are likely to be an underestimate of workload as they don’t take account of any second consultations, complications of flu, or patients whocontact their practice because they have concerns or needs that the NationalPandemic Flu Line Service cannot address. 4.1.9 The duration of a pandemic will be unknown and it may be spread over several waves that are months apart. There will be times of peak activity and the peak is likely to occur within 50 days of the first cases of pandemic flu appearing inthe UK.
4.1.10 Experience and modelling suggest that 22% of cases will occur in the peak week. This means that for every 100,000 people there will be an additional3,100 GP consultations in the peak week. Again, these figures are likely to be anunderestimate of the work involved for the reasons given above.
4.1.11 For a typical practice of three GPs with a list of 6,000 patients, that works out at 186 cases in the peak week of the pandemic. These are for pandemic-relatedconsultations only and assume that older children and adults with symptomswithout complications will get their antiviral medicines through the NationalPandemic Flu Line Service.
4.1.12 For every 100 patients with flu symptoms up to four of them may require hospital admission, if there are beds available. Up to a quarter of these patientsare expected to require critical care. The average length of stay in hospital islikely to be up to six days (ten for patients in intensive care). Modelling suggeststhat up to 2.5% of all flu victims may die. Special arrangements are being drawn Business continuity for GP practices: the role of GPs and their teams up for the issuing of death certificates during a pandemic, possibly using aworkforce of retired doctors. The British Medical Association (BMA) is workingwith the Department of Health to help identify retired doctors willing to help ina flu pandemic.
4.1.13 Clearly, with this overall level of demand, general practice will be stretched beyond its current limits. Added to this are the complications arising fromprimary care staff themselves getting flu, or being away from work because theyhave to care for children or other dependants.
4.2 Staff
4.2.1 GP practices and their staff will be key to the delivery of primary care services during an influenza pandemic. Flexible working, both in terms of time andlocation, will be needed from all practice staff and GPs alike to ensure themaximum level of service capacity, and to maintain practice income under thegeneral medical services (GMS) practice payments agreements made with theDepartment of Health and NHS Employers.
4.2.2 Practices must consider workforce issues that will arise during a pandemic. They need to develop guidance and policy through discussion with individualsand local staff-side organisations where appropriate on changes such as hours of work, and potential redeployment outside of the practice due to traveldisruption and to manage local staffing arrangements.
4.2.3 Employers should also acknowledge the level of anxiety that an influenza pandemic is likely to generate, and work closely with their staff to address theseanxieties within the context of early planning. It will be vital for practices tohave provisions and agreements in place in advance, and consideration mayneed to be given to other issues that may arise following school closures andtransport disruption.
4.2.4 Funding for additional practice staff travel to and from an alternative place of work has been agreed with the Department of Health in England. Additionalovertime taken by staff during the pandemic must also be funded by theprimary care organisation (PCO). 4.2.5 Staff contract terms and conditions should be maintained as normal during a pandemic. However, practices should consider the potential benefits of insertinga flexibility clause into their staff employment contracts to allow for servicecontinuity in the event of a flu pandemic or other emergency, to cover possibleredeployment and/or altered hours of work.
Pandemic influenza: Guidance for GP practices
What GP practices can do to cope
4.3.1 All practices must have a service continuity plan. For advice on how to do this and what to include read the joint guidance produced by the Royal College ofGeneral Practitioners (RCGP) and the General Practitioners Committee (GPC) of the BMA found at,business,continuity and
Staff absence levels
4.4.1 Up to half the workforce may require time off at some stage over the pandemic period. People with flu are likely to be away from work for up to two weeks. At the peak of the pandemic up to a fifth of the workforce may be absent.
However, many GP practices come into the category of small organisationalunits with five to 15 staff. Practices of this size should allow for a higherpercentage of staff to be away from work – up to 35% at the height of thepandemic. Single-handed practices will be hit even harder and may becomenon-viable without support from ‘buddy practices’.
Deploying practice staff safely
4.5.1 Any GP or member of staff who shows flu symptoms must be sent home
immediately. Practice staff who have recovered from pandemic flu and feel well
enough to work should have immunity and should be able to treat flu patients.
4.5.2 In a flu pandemic practices should assign GPs, nurses and other staff to see either flu patients or non-flu patients on a daily basis. GPs will need to workwith their buddying-up partner practices to ensure that they can functioneffectively while minimising the risk of the spread of infection. certification
4.6.1 GPs would be overwhelmed if they were expected to continue with the normal process for issuing patients with sick notes during a pandemic. Plans are in handto ease this workload. It is planned to change arrangements for self-certificationso that in a pandemic self-certification will be extended from seven to 14 days.
4.7 Buddying-up
4.7.1 Practices must work together in a pandemic. A buddying-up system is proposed in which clusters of practices will actively cooperate for pandemic work, sharingresources and exchanging staff as necessary.
Business continuity for GP practices: the role of GPs and their teams 4.7.2 Some practices have already drafted plans of how the buddying-up would work for them locally. You can see an example from Teesside at the web link below.
This guidance uses the Teeside model as the basis for buddying-up information.
The model involves 15–20 doctors working in a buddying-up group covering25,000 patients. The Teesside documents can now be accessed on the RCGP’swebsite. For the College’s Pandemic and Flu Planning page go
Then within this page, under the title Further Examples of Pandemic PlanningDocuments, the following two documents can be accessed: Tees Primary Care Services – Primary Care Continuity
Caduceus Medical Practice Influenza
4.7.3 Buddying-up groups can be based on naturally occurring groups such as those in a discrete locality. However, no practice must be left isolated. Primary careorganisations (PCOs) together with the Local Medical Committee (LMC) will, if necessary, step in to ensure that all practices are members of a localbuddying-up group.
4.7.4 LMCs have a role to play in helping with the formation of buddying-up groups.
The process will generally follow the steps outlined in the box below: Step one: Identify neighbouring practices to form a buddying-up group and
notify the PCO and LMCs.
Step two: Form a working group within the cluster of buddy practices.
All practices in the cluster should be represented. Agree how often the group
will meet on a regular basis, both before the pandemic and during it.
Step three: The working group should draw up a combined pandemic flu
plan. This will build on individual practices’ service continuity plans.
It should identify the existing capacity, responsibilities and constraints thateach practice has in providing services during a pandemic so that resourcescan be pooled.
Step four: Buddy practices may have to combine temporarily during the flu
pandemic. Because of this, it is necessary to identify which IT systems are
used in the buddying-up group and discuss compatibility and how practice
staff could work together and operate the different systems.
Pandemic influenza: Guidance for GP practices
4.7.5 Any gaps in service provision will be identified and, if the cluster cannot fill them, outstanding issues should be shared with the local PCO.
4.7.6 PCOs will be able to add to practice resources by relocating other healthcare workers into practices as necessary. Practices should be aware that the numberof extra staff available will be limited as all sectors will be affected by thepandemic. Health professionals from the private sector may also augment theNHS workforce along with recently retired staff and senior trainees. 4.7.7 Within each buddying-up cluster practices retain contractual responsibility for their listed patients but responsibility for clinical decision-making will belong tothe treating clinician (and/or their employed staff seeing the patient) irrespectiveof which practice within the cluster the patient belongs to.
4.8 Photo
4.8.1 Experience in the past fuel crisis shows that photographic ID of doctors and staff will be essential in a pandemic. For example, clinicians will need access to a fuelsupply for their vehicles in order to do home visits. Each practice should developan electronic library of staff photographs as part of a staff contact database sothat no time is wasted should these be needed by PCOs producing photo ID ina pandemic.
4.8.2 When produced the ID card will need to confirm identity and contain a photograph and job role.
4.9 Emergency
4.9.1 Every practice should have an emergency box for use if main services such as electricity fail and all staff should know where this is kept. The contents shouldbe decided by the practice but would include things such as torches with sparebatteries. It is possible that computers could be down so paper forms will beneeded. All appropriate staff should know how to access this box and open it.
See appendix 5 for more information on suggested contents. Prescription padsare regarded as restricted stationery and must be locked up with restricted access,but designated people should know how to access them quickly and easily.
4.10 Locum
4.10.1 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 timewhen they will be working at maximum flexibility, possibly moving frequentlybetween practices.
Business continuity for GP practices: the role of GPs and their teams 4.10.2 Like all GPs, locum doctors need to be on a performers’ list relevant to the country in which they plan to work. As part of the preparation for a flupandemic, PCOs must check their databases ensuring that they are robust andthat data on them are correct, including contact details and email addresses.
4.10.3 Locums/freelance GPs must be included in any preparation and training programmes, including information cascades, and be issued with any necessaryphoto ID cards as provided to other frontline doctors.
4.10.4 It is envisaged that PCOs will contract to employ ALL available locum GPs for the duration of the pandemic so that they have indemnity protection anddeath-in-service benefits. The rate of pay and details of the employmentarrangements are the subject of ongoing discussions at national level.
To be agreed. This topic is currently under discussion at national level.
Further guidance will follow.
4.11.1 A flu pandemic will affect the training of GP trainees. Not least, their trainers and educators will be needed to deliver clinical care and will not have the timeto also do their educational job. The knowledge and skills of the GP trainees willbe needed to cope with the pandemic and the length of their training periodmay well be affected. It is envisaged that all training rotational post changes willbe suspended during a pandemic both inside and outside hospital.
4.12 Anxiety among public, patients and staff
4.12.1 Everyone will naturally be anxious during a pandemic. Healthcare workers will not only have to cope with their own concerns but will also have to deal withanxiety among their patients. This anxiety could take the form of aggression insome patients.
4.12.2 GPs should ensure that they and their staff are briefed to deal with difficult situations. There will be a large-scale public information campaign before andduring a flu pandemic explaining what services are available and why healthcareservices will be different from normal. Adopting an open and planned approachshould help to avert confrontation, but inevitably GPs and their staff will comeface to face with it and need to be prepared.
Pandemic influenza: Guidance for GP practices
4.13 Infection control precautions
4.13.1 Flu viruses can survive for more than a day on hard non-porous surfaces such as stainless steel. Experiments have shown that flu viruses can be transferred fromthese contaminated surfaces onto hands up to 24 hours later. With soft materialssuch as nightclothes, magazines and tissues, the virus can be passed onto thehands for up to two hours, although only in low quantities after the first 15 minutes.
4.13.2 Because the virus survives for a long time on frequently touched hard surfaces (eg doorknobs) frequent cleaning is essential to control the spread of infection.
Non-essential soft furnishings and toys, which are not easily cleanable, shouldbe removed from surgeries during a pandemic.
4.13.3 The good news is that flu viruses are easily deactivated by washing with soap and water or alcohol handrub and by cleaning surfaces with normal householddetergents and cleaners. Practices should ensure that they have an adequatesupply of these basic cleaning materials.
4.13.4 Hand washing is the single most important practice needed to reduce the transmission of infection in a healthcare setting. Good hand hygiene among staffand patients is vital for the protection of everyone.
4.13.5 Paper towels should be used to dry the hands thoroughly and be disposed of in a waste bin. Lined waste bins with foot-operated lids should be used wheneverpossible.
4.13.6 Doctors and staff doing home visits should carry personal packs of alcohol 4.14 Different ways of working in a pandemic
4.14.1 During a flu pandemic GP practices will work in different ways. The balance between proactive and reactive medicine will change significantly to cope withdemand. Practice staff may be asked to take on different duties, within theirprofessional capability, and to work in different locations. 4.14.2 In a buddying-up cluster of practices, for example, a nurse or doctor from one practice may be asked to work at a nearby practice that is particularly short-staffed.
4.14.3 PCOs may assign additional staff to struggling practices including community nurses, locum GPs, or perhaps local dentists. Community clinicians too may havea role to play. Community hospitals and walk-in centres could take on a differentrole during a flu pandemic. The majority of flu patients will stay in their ownhomes with self-care and antivirals.
Business continuity for GP practices: the role of GPs and their teams 4.14.4 It is envisaged that GPs available for sessional work will be employed by PCOs during a pandemic at a pay rate to be agreed in ongoing national discussions.
Practices will not directly employ locum GPs.
To be agreed. This topic is currently under discussion at national level.
Further guidance will follow.
4.14.5 When staff are working under such pressure, perhaps in unfamiliar surroundings, mistakes may be more common. The General Medical Council (GMC) hasindicated that provided doctors act in good faith within their skills andcompetence, it would not usually anticipate that a disciplinary issue will emerge.
Action points
GP practices must take action now to look at their staff contracts witha view to planning for a flu pandemic. Any change made to a contractwould be voluntary and with the agreement of the staff member.
– draw up a list of key telephone numbers including mobile numbers – review staff contracts and list staff working hours and flexibility – note staff members’ external commitments, eg young children, – prepare a really simple guide to logging on and using the practice computers so that non-practice staff can access them in a pandemic if necessary (eg if a PCO allocates extra resources at peak times bybringing in other healthcare workers to help out) – identify the person in the practice who will act as the practice lead on – prepare to work in clusters with other practices (see buddying-up – consider how the practice could operate on an emergency basis if mains services such as gas, water or electricity should fail – prepare an emergency box with face masks, gloves, aprons, torches and spare batteries, and other consumables. See appendix 5 for asuggested list of contents.
Pandemic influenza: Guidance for GP practices
Action points
It would be good practice to identify buddying-up groups and have apandemic flu contingency plan agreed between the group and the localPCO by 31 March 2009.
Practices should prepare their emergency box now and keep thecontents up to date. All staff must be told where to find it.
Do you have sufficient suitable hand hygiene facilities and waste binsand liners? Are your stocks and supplies of hand cleaning agents and paper towelssufficient? Do you have supplies of alcohol handrub for use on home visits? Does everyone in your practice understand the importance of hand-cleaning procedures and the effective use of cleansing? Display posters (in appropriate languages) about hygiene.
Display posters (in appropriate languages) showing which areas are forflu patients and which are for non-flu patients. Prepare posters/notices in advance of a pandemic.
Prepare a welcome pack for anyone ‘parachuted’ into your practice. This should include a simple guide to using the practice IT systems, howto log on, log off and so on. Such information must be securely keptwithin the practice, as it would give the user access to patients’ details.
The welcome pack should give the key information about the practiceincluding names of staff and whom to contact in an emergency.
As far as practicable, employers should identify in advance of apandemic any tasks that may need to be taken on by staff on a flexiblebasis, so that appropriate training can be given.
5 Command and control
Summary: This chapter sets out the command and control arrangements for an
influenza pandemic and the roles of key agencies. There will be some variance
between the four UK countries to reflect structural differences. Further details for
England can be found in appendix 6.
5.1 Arrangements
5.1.1 Pandemic Flu: A national framework for responding to an influenza pandemic has been published (see appendix 6 for more details) and covers all sectorsincluding health. There is a dedicated crisis management mechanism and aclearly defined hierarchy of command and control structures. GP practices willreceive instructions via their primary care organisation (PCO) and will beexpected to follow these.
Primary care organisations (PCOs)
5.2.1 PCOs are responsible for ensuring that local health plans and arrangements are in place in advance of a pandemic and for managing the local health responseduring a pandemic. 5.2.2 In England, each primary care trust (PCT) should have a named pandemic influenza coordinator who leads on arrangements for providing an effective andsustainable community-based response during a flu pandemic.
5.2.3 Clear command and control arrangements will be critical in ensuring a robust response. A PCT coordination centre will monitor and coordinate the overallhealth response.
5.2.4 Through the pandemic flu coordinators, PCTs will coordinate plans with neighbouring authorities and ensure that social care and other key partners –including private sector and support service providers – are fully involved.
5.2.5 In a pandemic, PCTs will provide advice and public information, collate and report operational information to the strategic health authority (SHA), and makecontingency arrangements for the distribution and collection of antiviralmedicines and for delivering population-wide vaccine if available.
Local Medical Committees (LMCs)
5.3.1 As the representative body for all GPs at local level, LMCs will be involved in planning for a flu pandemic and implementing those plans by working with localpractices and the local PCOs. This may be especially important in adopting theidea of working in clusters in buddying-up groups of practices. LMCs shouldhave the knowledge to ensure that no practices are left isolated and that all areincluded in a local buddying-up group.
Pandemic influenza: Guidance for GP practices
5.3.2 LMCs need to consider developing a ‘duty’ LMC officer rota to provide 24/7 advice and assistance to the PCO during the pandemic period.
5.4 General
5.4.1 In a pandemic, GP practices, working in buddying-up groups, will liaise with their PCO and LMC, sending and receiving information on a daily basis. All medical, nursing and management staff will be involved.
5.4.2 Directions on when non-essential services, such as Quality and Outcomes Framework work, will be suspended in order to cope with the pandemic willcome from the relevant authority. Practice income will be protected. For moreinformation on how this protection will operate, see appendix 1 and read thedocument Pandemic Flu – Joint NHSE-GPC agreement on practice resourcemaintenance at
Social care, community hospitals and other key players
5.5.1 There needs to be strong and sustained communications with social care and local community hospitals at every stage of planning and implementation.
5.5.2 An operational and strategic framework: Planning for pandemic influenza in adult social care was published by the Department of Health in November 2007and is supported by the Social Care Tools and Implementation Pack
5.5.3 The pack advises local authorities of the need to have plans in place with their healthcare partners to allow for efficient and timely referral and response. 5.5.4 GPs and district nurses who assess patients as not requiring referral to hospital but as in need of additional support to remain at home will need to be able to refer onto social care with some confidence that appropriate provision of services can bequickly put in place. Mechanisms may therefore need to be developed, discussedand agreed locally to ensure that primary care colleagues are kept aware of theoperational capacity of social care services during the course of a pandemic.
5.6 Local
5.6.1 Community pharmacies can make an important contribution in support of self- care during a flu pandemic. They can assist with dispensing of routine medicines,signposting other NHS services and supplying regular medicines to vulnerablegroups such as residents of care homes. They can maintain medicine suppliesunder contract with other bodies such as mental health trusts, hospices andprisons, as far as possible. They will of course sell over-the-counter (OTC) flu treatments and provide help and advice to the public. They have an importantrole to play in educating the public on how to make the best use of scarcehealth services.
5.6.2 To ease pressure on GP surgeries and community services, new powers may be given to community pharmacists (subject to consultation and parliamentaryapproval) to supply medicines and pharmaceutical services in a more flexiblemanner. There will be a formal consultation before any proposed changes to thelaw are made.
5.6.3 Where there are shortages of some medicines, as may happen in a pandemic, pharmacists are well placed to advise on the use of alternative medicines thathave similar effects.
5.6.4 As the pandemic escalates, some of the routine services of pharmacies may have to be reduced or stopped for short, or longer, periods as demands increaseelsewhere. Specialist clinical pharmacists may be able to support doctors in allsettings including primary care. They could be deployed by the PCO to supportGPs in their practices.
5.6.5 Guidance is being developed on the contribution pharmacists can make in responding to a flu pandemic. It will include responses to the legislative changesthat might come into force to improve access to medicines and devices during a pandemic.
Reporting the daily situation
5.7.1 During a pandemic, each PCO and locality area will be placed under pressure, and good communication between these groups will help to make best use of servicedelivery. The normal supply chain may well be disrupted, possibly leading to shortages.
5.7.2 Frontline healthcare workers will become ill and be unable to work. There will be other issues, such as school closures, which will prevent some staff from gettingto work. It is important to make the best use of available staff, and provide acurrent overview for the GP sites, locality and the PCO.
5.7.3 What follows is a suggestion as to how to make the best use of the frontline GP services under these difficult circumstances.
5.7.4 Every day each GP practice/buddying-up group would submit information about available staff in a situation report (sit rep) to the designated PCO datacollection point (this could be also used to report numbers and demographics ofconsultations). Work is under way to determine the optimum timing forsubmitting these daily reports. The report will use a standard national template,which will be developed and agreed.
Pandemic influenza: Guidance for GP practices
To be agreed. This topic is currently under discussion at national level.
Further guidance will follow.
5.7.5 The local data collection office would be able to assess staffing levels in each site, and if any sites were under-staffed/not staffed. This could allow staff to betransferred from one site to another.
5.7.6 If the staffing levels were significantly low, the data collection office could arrange for services to be provided by a reduced number of sites with‘signposting’ for patients.
5.7.7 Using information from the daily sit rep, the PCO would send to GP practices in the area an overall sit rep report giving crucial local information. The exactformat is yet to be developed but could take the form of the example atparagraph 5.8. There is likely to be intense interest in this sort of informationfrom the local media. PCOs will liaise with them on a regular basis. Newspapers,radio and television, and websites will be used to inform the public of thecurrent state of the flu pandemic. More information on communications at anational level can be found in appendix 4.
Example of a daily situation report to GP sites in a PCO area
WHO phase:
PCO status:
The following pharmacy shortages are in: (eg OTC flu remedies) The following community pharmacies are closed: Collection points
Antiviral stocks are available at the following sites: Ambulance
Current respiratory bacterial sensitivities: Pandemic influenza: Guidance for GP practices
Action point
Practices should draw up a list of ‘key numbers’ to contact inemergencies during a flu pandemic when normal services may not beavailable. This must cover social services and all utilities such as gas,water, electricity, fuel, heating.
6 Caring for the general public
Summary: This chapter explains the National Pandemic Flu Line Service; antiviral
medicines; Flu Line Professional; keeping patients separate; direct contact with
symptomatic patients; and the use of personal protection equipment.
National Pandemic Flu Line Service
6.1.1 In order to reduce the extra load on general practice, a UK-wide 24-hour telephone and web-based service will be set up for use by the general public. 6.1.2 At WHO phase 4, the Pandemic Flu Information Line will be activated to give general advice and information to callers. 6.1.3 At WHO phase 6, UK alert level 2 (virus isolated in the UK), the National Pandemic Flu Line Service will be authorised to give people who aresymptomatic access to antiviral medicines (Tamiflu/oseltamivir) as appropriate.
This will be the only route for patients to access antiviral flu drugs.
6.1.4 This means patients will not be able to access antiviral medicines from GP surgeries. Patients can get antiviral medicines only from official collection points and only if they are authorised to do so by the National Pandemic FluLine Service. 6.1.5 It is possible that some dispensing practices will be an exception if they are chosen as an antiviral collection point.
6.1.6 Action point: You are advised to put up notices at your surgery saying:
If you have symptoms of pandemic flu and need access to antivirals, you should
return home and contact the National Pandemic Flu Line Service by calling [insert
telephone number]
or online at [insert URL].
If you are someone’s ‘flu friend’ and need to find out how to access antivirals
on their behalf, you should also contact the National Pandemic Flu Line Service
(see above).
For general information on what people can do to look after themselves when they
have pandemic flu, contact the Pandemic Flu Information Line on [insert telephone
or go to [insert URL].
There are no stocks of antivirals held on these premises.
Practices should fill in the contact details when they are made known.
Pandemic influenza: Guidance for GP practices
6.1.7 The language used for the signs should take account of the needs of any 6.2 Antiviral
6.2.1 The Government is currently in financial discussions with the Treasury and is planning to stockpile sufficient antiviral medicines to allow all pandemic flupatients to be treated up to an attack rate of 50%. This is in line with the worstcase planning in the National framework. This stockpile will be monitored toinform decisions relating to take-up.
6.2.2 Antiviral medicines will not be available on prescription (FP10). Patients who think they have pandemic flu will contact the National Pandemic Flu Line Serviceby phone and non-clinical staff, who have had specific training, will follow analgorithm to find out if the patients have flu symptoms. The National PandemicFlu Line Service can also be accessed by the internet. 6.2.3 In order to use the National Pandemic Flu Line Service, patients must know their NHS number. They will also be asked questions to see if they fall into specified
groups (eg children under 1 year old or patients who are immunosuppressed)
who may need to consult a GP or other health professional. If flu patients have
had their symptoms for less than 48 hours (the maximum time-scale for
effective use of antiviral medicine), they will be given a unique reference
number (URN)
, which will entitle them to collect antivirals from a local centre
called a ‘collection point’.
To be agreed. How people will find out their NHS number is currently underdiscussion at national level.
6.2.4 The antiviral medicines should be started preferably within 12 hours, and not more than 48 hours from the onset of symptoms, to be effective and to limit thespread of infection by taking them early on in the illness. The local primary careorganisation (PCO) will decide the location of the collection point centres. These will not be located at GP surgeries and only very exceptionally at selecteddispensing GP surgeries.
6.2.5 Via a nationwide publicity campaign, patients will be asked to nominate people who can collect their antiviral drugs for them. These helpers will be known as
flu friends.
6.2.6 Security measures will be in place to make sure there is no unauthorised or 6.2.7 Adult treatment courses of antiviral drugs will be in pre-packed capsules.
Separate paediatric flu guidance is being produced. Children aged 13 and underwill get an age-related dose of oseltamivir in the form of lower-dose capsules.
Information relating to children’s doses can be found at appendix 3. 6.2.8 Where children are not able to swallow the capsule whole, parents/children will need to be advised to empty the contents of the capsule into a small amount ofsugary solution, to mask the taste of oseltamivir. Children under 1 year of agewill receive oseltamivir solution prepared by designated hospital pharmacymanufacturing units. Discussions are taking place to decide how this solution willbe made available for infant patients.
To be agreed. This topic is currently under discussion at national level. Furtherguidance will follow. 6.2.9 Dosing schedules for children are available in appendix 3 and in the Department of Health guidance for primary care trusts (PCTs). The document can be foundat the following link
6.2.10 Within 24 hours of UK alert level 2 being announced, PCO antiviral collection points will receive initial supplies of antivirals for adults and children. 6.2.11 After this, further allocations of antiviral drugs will be made to the PCO on an ordering and re-supply basis. A national coordination centre will be set up totake orders for further supplies, oversee transportation and manage the nationalstockpile of antiviral medicines.
6.2.12 The National Pandemic Flu Line Service will be capable of activation from spring 2009. Should a pandemic arrive in the meantime, PCOs have been asked toagree local alternative arrangements for managing and responding to demand.
This must involve discussions with Local Medical Committees, local GPs and theout-of-hours service.
6.2.13 At the same time as the National Pandemic Flu Line Service is activated, a web- based Flu Line Professional service will be introduced. This will not be available
to the public but will give doctors and healthcare professionals access to a
patient’s National Pandemic Flu Line Service record and allow them to check for
previous antiviral authorisations. Flu Line Professional will allow doctors and
healthcare professionals to authorise an antiviral without going through the
standard National Pandemic Flu Line Service process (including the clinical
algorithm). They will be able to generate a URN that can be presented at a local
antiviral collection point in return for an antiviral.
Pandemic influenza: Guidance for GP practices
Keeping flu patients separate
6.3.1 Wherever possible, patients with flu should stay at home to minimise the spread of infection. This will be a key message in the public information campaign.
Keeping flu patients separate from non-flu patients should be a principal aim ininfection control. Despite advice asking patients with flu to stay at home,inevitably some will arrive in the GP practice. Where possible, separate roomsand waiting areas should be used for patients who may have flu. Patients mightbe separated on an upstairs/downstairs basis, or kept to a section of the practiceif, for example, there is a rear door for entrance and exit.
6.3.2 Separating patients by timing is another or additional possibility. A surgery for non-flu patients could be held first thing in the morning or last thing in the day.
Practices should apply the regular hygiene controls needed throughout apandemic.
Direct contact with those patients who are symptomatic –
means of transmission

6.4.1 GPs will need to see some patients who fall outside the National Pandemic Flu Line Service algorithm or present with complications.
6.4.2 Flu spreads easily by droplet from person to person via the respiratory route when an infected person talks, coughs or sneezes. It also spreads via hand-to-face contact if hands are contaminated.
6.4.3 The incubation period (time from exposure to first symptoms) is between one and four days. People are most infectious soon after they develop symptoms. 6.4.4 Children have been shown to transmit virus for longer and at higher levels 6.4.5 Adults with flu but without additional complications may be away from work for 6.4.6 More detailed information on flu viruses is available at Personal protective equipment (PPE)
6.5.1 Fluid-repellent face masks will be the main form of PPE needed in a pandemic.
They will provide a physical barrier and should be worn by any healthcareworker who will have close contact (within one metre) of people with flu.
6.5.2 The Government is planning to place orders to stockpile face masks on a UK-wide basis. These will be held centrally until a change in WHO flu phase status triggers despatch to PCOs. The point at which the face mask supplies aredistributed to GP practices has not yet been decided and will be for PCOs todetermine. However, each practice should be prepared to store several largeboxes of face masks. The masks will be supplied to practices free of charge.
not be allowed to dangle round the neck after or between each use not be touched once put on until removed for disposal be worn once only and then discarded to an appropriate bin as clinical waste; hands should then be washed/cleansed after disposing ofthe mask.
6.5.4 In practice, if there is a surgery for flu patients, or a GP/nurse is visiting patients in a nursing home, it may be more pragmatic to wear a single mask for thewhole time or until it becomes moist and needs replacing.
6.5.5 Even with UK stockpiling, face masks will be in limited supply and should be 6.5.6 The Government will not provide renewable supplies. All stocks will be distributed and may not be refreshed, simply because of sourcing difficulties.
This may prove particularly difficult if there is a second or third wave of a flu pandemic.
6.5.7 Practices must use a risk assessment in using PPE. Detailed guidance on infection control in a flu pandemic is available on the Department of Health website
6.5.8 Gloves are not needed for the routine care of patients with flu but standard infection control principles require that gloves are worn for: contact with sterile sites, non-intact skin and mucous membranes all activities that a carry a risk of exposure to blood, body fluids, secretions(including respiratory secretions) and excretions handling sharp or contaminated instruments.
Pandemic influenza: Guidance for GP practices
6.5.9 If glove supplies become limited during a flu pandemic, priorities for glove use may need to be established. Do not attempt to wash or disinfect gloves forreuse. Once worn, dispose of as clinical waste and wash hands.
6.5.10 Disposable plastic aprons should be worn if there is a risk of clothes or uniform becoming contaminated when examining the patient. They are single-use itemsand should be changed between patients and disposed of as clinical waste.
Gowns are not required for the routine care of patients with influenza. Staffneed to be aware that PPE will be a scarce resource in the event of a pandemic.
6.5.11 With all PPE, users should carry out a risk assessment when deciding whether to use it or not. Further advice on PPE will be provided. Action points
Display notices in surgery advising patients with flu symptoms to stayat home and contact the National Pandemic Flu Line Service.
Make sure all your practice staff understand how flu spreads and thatthey are trained in hygiene practices.
Do you have adequate stocks of cleaning products? Does everyoneknow where they are stored? It would be a good idea to have aninformation manual for the practice so that everyone knows where tofind things.
See paragraph 6.5 on personal protective equipment for information onface masks/gloves etc There will be centrally produced information sheets for patients tellingthem the facts and what to do to limit the spread of the virus in their homes. Discuss whether your practice cleaning arrangements should change ina pandemic.
In a pandemic, to minimise the spread of infection you should removeunnecessary soft furnishings/toys etc from your surgery. Plan now for what can be removed and where it can be stored until after the pandemic.
Identify and plan ongoing training for staff in the use of face masks.
7 People who will be and could become
vulnerable in a pandemic and where
GP involvement is more likely

Summary: This chapter highlights the need to identify vulnerable patients who will
be particularly at risk in a pandemic and where GP involvement is more likely.
Identifying vulnerable patients
7.1.1 People who are vulnerable in ordinary situations will be even more likely to fall outside the system during an influenza pandemic. An example might besingle people living alone and with few contacts. These potentially vulnerablegroups would be in addition to patients who could be clinically ‘at risk’ becauseof existing illnesses. 7.1.2 Vulnerable patients, such as those with learning difficulties, may not be able to comply with the self-care principles involved in a flu pandemic. They may nothave a telephone to contact the National Pandemic Flu Line Service, forexample. Primary care organisations (PCOs) will work with social services andvoluntary and faith groups to plan to meet the needs of vulnerable individuals.
As primary care will be under pressure the advocacy role staff play may have tobe passed to others, eg voluntary sector volunteers.
7.1.3 In general where specialist services, such as those provided for substance misuse patients, are provided for vulnerable groups, efforts should be made to continuethese services for as long as possible during a pandemic. To be agreed. This topic is currently under discussion at national level. Furtherguidance will follow.
7.2 Non-registered
7.2.1 In a flu pandemic, general practices may experience a surge of demand from non-registered people seeking help. PCOs will seek discussions with practicesregarding how this demand might be coped with, including the possible greaternumber of temporary patients.
7.3 Maternity
7.3.1 Pregnant women form one of the groups of patients for whom it is important that essential clinical services be maintained. Guidance on providing maternityservices during a flu pandemic is available on the Department of Health website at:
Pandemic influenza: Guidance for GP practices
7.3.2 There are approximately 635,000 live births in the UK each year. A 50% attack rate in a flu pandemic would lead to around 80,000 pregnant women getting fluduring the 15 week course of a pandemic wave. Most pregnant women with flu would be cared for at home. There may have to be some adjustments inantenatal care because of the pandemic. Current thinking is that all pregnantwomen will be referred to primary care and not be assessed by the NationalPandemic Flu Line Service.
7.4 Paediatric
7.4.1 Caring for children will be a crucial part of the pandemic. Midwives, health visitors and school nurses may be able to help with the assessment of children.
All children under 1 year old will have to be assessed by a GP or healthcareprofessional in order to get the oseltamivir solution available for this age group.
Hospital facilities will be a scarce resource. With this in mind, work is being doneto produce a tool kit* for GPs to use when deciding whether to refer a child tohospital. The principles should be accepted by both primary and secondary care. *To be agreed. This topic is currently under discussion at national level.
Further guidance will follow.
Mental health services
7.5.1 Caring for mental health patients is a critical service, which must be maintained as far as possible during a pandemic. With 95% of patients with mental healthproblems being cared for in the community the impact on general practice ishigh. A pandemic is also likely to precipitate new demands as people experiencedisorders such as anxiety or depression for the first time. Healthcare workers often act as patients’ advocates but in a pandemic, they maybe entirely taken up with clinical obligations. All those involved in communitymental healthcare teams should plan for alternative advocacy arrangementsduring a pandemic, such as using current volunteer or befriending systems.
Guidance on mental health services and pandemic flu are available on theDepartment of Health website.
People who will be and could become vulnerable in a pandemic and where GP involvement is more likely 7.5.2 The Department of Health, England, is preparing guidance for health and social care services for their contribution to psycho-social responses required by people who are involved in major incidents and events of all kinds including a flu pandemic. To be agreed. This topic is currently under discussion at national levels.
Further guidance will follow. 7.6 End-of-life
7.6.1 Inevitably, there will be a greater demand for end-of-life care during a flu pandemic. Every effort must be made to draw on the expertise of specialistsboth within and outside the NHS such as hospices. This may be particularlyimportant when coping with the increased call for bereavement counselling.
8 Managing surge capacity and patient
Summary: This chapter describes how additional capacity will be freed up in
a pandemic by introducing prioritisation of services and patients in a systematic
manner, and gives reference to the underpinning ethical framework for the surge
demand work.
8.1 Working
8.1.1 Effective communications will be key to managing surge demand in an influenza pandemic. This means not only communications with the public, but alsocommunications with all aspects of the health services, social services and thevoluntary sector. Improved collaborative working should result in improved careand transition to the recovery phase of the pandemic. Appendix 4 gives moreinformation on national communication plans.
8.1.2 In order to manage demand surge, prioritisation of services will be needed. As hospital beds fill up, patients who in normal circumstances would have beensent to hospital will have to be managed in the community. GPs will be lookingafter patients in the community who are more seriously ill than under normalcircumstances, as well as caring for their normal patients and those with flu.
8.1.3 It will be important to maintain normal services for as long as possible, but at some point, the pandemic workload will be unsustainable without removingsome of the normal workload. At a given signal from the local NHS body(strategic health authorities (SHAs) in England), practices will be told to stopdoing work which is not essential to current clinical demand. Appraisals, workrelating to the Quality and Outcomes Framework (QOF) and non-essentialclinics will be suspended along with other areas of work. 8.1.4 In making these decisions the SHA (or equivalent body in the devolved countries) will liaise with its primary care organisations (PCOs) who must liaisewith their Local Medical Committees (LMCs) and Local PharmaceuticalCommittees. Together they will determine when resources are stretched to thepoint at which services should focus on delivering essential work only. Thesedecisions will need to be confirmed with the Department of Health in England orequivalent Health body in devolved administrations. At all stages, the responseneeds to be proportionate to the threat of the flu pandemic. LMC officersshould discuss with their PCOs any issues and training needs that arise and howbest the LMCs might be deployed.
8.1.5 As a substantial part of practice resources comes from performance-related pay (QOF), agreement has been reached with the Government that during a flupandemic, practice resources will be protected at the level of the preceding year, plus any intervening Doctors’ and Dentists’ Review Body awards. The Government does not intend any general practice to be disadvantaged financially by responding to a flu pandemic.
Managing surge capacity and patient prioritisation 8.1.6 The Royal College of General Practitioners (RCGP) and the British Medical Association (BMA) have issued joint guidance on service continuity. Suggestionsas to which functions could be reduced, stopped, or be delivered throughalternative means, include: cancellation of outside activities (meetings, teaching etc) suspension of some chronic disease management suspension of (some) new routine referrals team working with neighbouring practices.
8.1.7 The use of telephone triage will also be important throughout a pandemic.
8.1.8 Out-of-hours services will be critical in a pandemic. PCOs will want to bolster this resource wherever possible with additional staff. Normal surgery times maywell differ during a pandemic and practices will want to discuss this with thebuddying-up group, PCO and LMC. Buddying-up clusters may be asked to helpbolster out-of-hours services and this would have an impact on the ability todeliver ‘normal’ in-hours services. If this happened, it might be necessary tointroduce an earlier suspension of normal activity. Practices will receiveinstructions if this is the case. 8.1.9 There is specific guidance for managing demand surge across the whole of the health and social care system. This includes national admission criteria to helpthe management of demand across the primary and secondary care interface. This guidance, Pandemic influenza: Surge capacity and prioritisation in healthservices, can be found on the Department of Health website
Managing surge demand
8.2.1 A staged approach will be used. When demand reaches a certain level, services which are not immediately essential to pandemic healthcare will be suspended.
Non-urgent operations (electives), for example, will not take place so thathospital facilities can be cleared to create extra capacity. At the next level, onlyemergencies will be referred. Pandemic influenza: Guidance for GP practices
After that, only patients with life-threatening problems will be referred. If eventhis demand is too large for hospitals to cope with, patients will be prioritisedbased on who will benefit most from available treatment. As the pandemicwanes, the stages will be reversed towards a gradual return to normality.
8.2.2 The decisions on when stages are activated will be made at a regional level – by SHAs in England and the appropriate level in the devolved administrations –and communicated to primary and secondary care. Doctors will have clearinstructions about which stage we are at and which clinical referrals can bemade. It is not possible to know in advance how severe a flu pandemic will be,but it is necessary to plan now for a worst-case scenario.
8.2.3 The Medical Defence Union and the Medical Protection Society say that doctors who have concerns will be able to look to their medical defence organisationsfor advice in the usual way and for assistance with any medico-legal mattersarising from the professional services they provide during a flu pandemic.
8.2.4 No one will like this kind of healthcare. While most people may well accept the general need for prioritisation, it will be hard for families and friends to accept asituation when their loved one is not being referred for hospital treatment. It willbe difficult for doctors too.
8.2.5 The General Medical Council (GMC) is producing a special edition of Good Medical Practice to cover what will be expected of doctors in a flu pandemic.
8.2.6 Work is under way developing objective admission criteria for adults with pandemic flu and complications. An admission criteria tool for use with childrenis also being developed. The use of pulse oximeters to measure oxygensaturation is an accepted and validated measure of hypoxaemia as a surrogatefor respiratory distress. If purchase of pulse oximeters is contemplated, specialistguidance should be sought as to the suitability of different models. The RCGP isin discussions to develop criteria for the purchase and use of pulse oximeters,including their use and suitability for very young children.
To be agreed. This topic is currently under discussion at national levelbetween the RCGP and health professionals. Further guidance will follow.
Managing surge capacity and patient prioritisation 8.3 Ethical
8.3.1 To ensure fairness and equity, an ethical framework has been prepared to underpin all the flu pandemic planning. By agreeing this in advance, andapplying it when a pandemic strikes, everyone can be assured that scarce healthservice resources are being used in an even-handed manner and as effectively as possible.
8.3.2 You can read the ethical framework at
Prioritising patients and services
8.4.1 Clinical prioritisation of some sort will occur at all stages of a pandemic. Work is under way to produce tool kits, which use a scoring system for use by GPs tohelp in making referral decisions. With any such system, both primary andsecondary care must apply the same principles if it is to work equitably. 9 Prescribing
Summary: This chapter explains the need to avoid overloading the pharmacy
supply chain.
9.1 Medicines
9.1.1 Practices should continue to issue repeat prescriptions with the same interval as normal. Patients will not be encouraged to stockpile medicines. Further pressuresshould not be placed on the pharmaceutical supply chain by issuing longer thannormal repeat prescriptions.
9.1.2 The issuing of post-dated prescriptions for normal length repeat medications should be considered so that the number of contacts with the practice formedication is minimised without significant impact on the pharmaceutical chain.
GPs may wish to consider repeat dispensing where they are able to issueprescriptions for up to one year with pharmacies being able to dispensemedicines on an instalment basis. 9.1.3 Antibiotic therapy is not generally required by influenza patients, unless they have complications. It may be needed where there is a pre-existing infection,where the diagnosis is unclear or where there is a marked deterioration in thepatient’s respiratory system.
9.1.4 The Government is taking steps to ensure there are stocks of appropriate antibiotics available. In a flu pandemic local community pharmacies may have an enhanced role to play.
10 Death certification
Summary: This chapter explains mortality modelling and new arrangements for
death certification in an influenza pandemic using retired doctors.
10.1 Mortality
10.1.1 Deaths from any new pandemic may be up to 2.5% of symptomatic patients. In previous pandemics, the fatality rate was between 0.2% and 2%.
10.1.2 To help with planning, the Government has done some modelling (see table below) based on various clinical attack rates and fatality rates. It shows thenumber of deaths in the UK possibly being between 55,500 (the least badscenario modelled) and 750,000 (the worst scenario modelled).
10.1.3 Range of possible excess deaths for various permutations of case fatality and clinical attack rates based on UK population.
Range of possible excess deaths in the UK Source: Pandemic flu: A national framework for responding to an influenzapandemic, Cabinet Office/Department of Health 10.1.4 Even with a low attack rate, it is likely a modified system of issuing cause of death certificates will have to be introduced in a pandemic. The cremationcertification process will also be relaxed. Full details of the proposals on how thiswill be carried out in England and Wales can be found on the Department ofHealth website. Find the document at
In Scotland, guidance has been produced for doctors. You can find guidance to
medical practitioners for death certification during an influenza pandemic at See under Frameworks and Guidance.
Pandemic influenza: Guidance for GP practices
10.1.5 If the level of pressure on local services requires it, there will be a centrally made decision to relax the legal requirement (Regulation 41 of the Registration ofBirths and Deaths Regulations 1987) to refer a death to the coroner if the doctorissuing the Medical Certificate of Cause of Death (MCCD) has not seen the patient for 14 days. The period will increase from 14 days to 28 days.
This brings England and Wales in line with Northern Ireland and will requirelegislation.
10.1.6 At local level, the (non-statutory) practice of reporting to the coroner all deaths that occur within 24 hours of admission to hospital may be suspended where fluor its complications are involved. Practices will be told by their primary careorganisation (PCO) when this takes place.
10.1.7 A change will be made to the law to allow doctors who have not attended the deceased patient to issue an MCCD where pandemic flu is believed to be thecause of death. The doctor can also complete Cremation Form B.
10.1.8 There will be a change to the Cremation Regulations to bring in a streamlined Cremation Form B. The requirement for Cremation Form C will be suspended,removing the need for a second doctor to confirm information.
10.1.9 As at present, only registered medical practitioners will be allowed to complete the MCCD cause of death form in a flu pandemic. To increase the number of doctors for this work, retired doctors will be called on for this role. The British Medical Association (BMA) is working with theGovernment to provide a list of retired doctors willing to help. You can read moreabout it at
10.1.10 PCOs have been asked to develop and keep up to date a list of retired doctors willing to help with death and cremation certification in a pandemic. At WHOPhase 5, doctors on the PCO list will be contacted, and others encouraged tocome forward.
10.1.11 Doctors carrying out this work will have to be registered with the General Medical Council (GMC). Legislation is proposed which would permit the GMC,under new emergency powers, to grant a doctor registration subject toconditions. In England, primary care trusts (PCTs) would pay the costs of GMC registration for this purpose.
10.1.12 The NHS indemnity insurance arrangements would cover temporary staff.
However, NHS indemnity may not cover all temporary doctors’ indemnity andmedico-legal needs during a pandemic. 10.1.13 Returning doctors are advised to contact a medical defence organisation to apply for temporary membership for the duration of the pandemic so that theywill be able to seek medico-legal advice, assistance and indemnity for work thatNHS indemnity does not cover.
10.1.14 In a flu pandemic, doctors will also be able to take on the role of medical referee 10.1.15 Other arrangements will be put in place during a pandemic for nurses and other healthcare workers to confirm the fact of death. Regulatory requirements will beavailable on the appropriate websites. 10.1.16 Additional MCCD forms will be needed in a flu pandemic. PCOs will supply these to the retired doctors on their list. Action points
Retired doctors are asked to contact the BMA or their local PCO if theyare willing to help, even if they stopped work some time ago. At thesame time they are advised to contact a medical defence organisationto apply for membership.
GP practices can prepare for a pandemic by checking they will havesufficient MCCD forms and making plans to increase their supply as necessary.
– check with your PCO for the plan for deployment of additional medical practitioners and of the actions that should be taken if abereaved person contacts the practice seeking a death certificate – ensure that any staff receiving such requests (eg reception staff) 11 Immunisation
Summary: This chapter explains how a mass immunisation programme might
operate when vaccine becomes available and the impact it would have on
GP workload.
11.1 Current immunisation scheme
11.1.1 Ordinary annual immunisation schemes for patients at risk of seasonal influenza should continue as normal (up to WHO Phase 5) in the absence of a pandemic.
11.2 Flu pandemic specific vaccine
11.2.1 Until a pandemic arrives, and the strain of virus can be identified, it will not be possible to produce a specific vaccine to protect people. Even when the virus isknown, it will take some time to prepare a vaccine and longer still to produce itin quantities sufficient for mass immunisation. In practice a pandemic specificvaccine will not be available for some months after the start of a pandemic andtherefore not in the first wave of a pandemic.
11.2.2 The Government has sleeping contracts with vaccine manufacturers for a pandemic specific vaccine. This allows for the provision of up to 132 milliondoses for the UK population.
11.3 How will the vaccine be supplied to practices?
11.3.1 The vaccine will be in multi-dose vials not pre-filled syringes. These can be manufactured more quickly and take up less cold storage space. Needles andsyringes will be needed in considerable quantities. The supply of these formspart of the national purchasing and distribution arrangements for which aframework agreement is in place.
11.3.2 Delivery arrangements are currently being reviewed with key stakeholders. In a pandemic, primary care organisations (PCOs) will be asked to identify a named person and a deputy from local pharmacy services to take the lead role in coordinating the storage distribution and stock control arrangements. This will include the storage of the necessary needles, syringes and any other consumables.
11.3.3 General practices already have standard security arrangements and it would be unrealistic to expect individual practices to have high-level security over and above this. 11.4 Will healthcare workers receive pre-pandemic immunisation?
11.4.1 The UK has limited stocks of A/H5N1 vaccine bought specifically for the protection of healthcare workers. It is not possible to say whether this will beeffective against a pandemic flu strain. It has not been finally decided how thesestocks will be used.* *To be agreed. This topic is currently under discussion at national level.
Further guidance will follow.
11.4.2 PCOs will provide the necessary vaccine if it becomes available and will oversee local arrangements, but the occupational immunisation is an employerresponsibility. GP principals would be responsible for ensuring that their staffmembers were vaccinated if indicated. They would also have to provide data onvaccine uptake among staff. Practice staff also have access to the local NHS occupational health service. It is likely the immunisation would be delivered through the occupational health service.
11.4.3 Healthcare workers will be notified if this pre-pandemic immunisation Action point
Practices should review their current security arrangements. PCOs willneed to support this process, seeking advice as a flu pandemic is likelyto cause high levels of anxiety, which could lead to unusual publicbehaviour and unrest.
12 Recovery phase
Summary: This chapter describes the need for a gradual staged return to normal
services. General practice will still be under pressure with new patient demand and
backlogs of work to contend with.
12.1 Rebuilding, restoring and rehabilitation
12.1.1 There will be a gradual movement towards resuming normal services, probably over many months. GPs and staff will be exhausted and experience has shownthat it is during the recovery phase that stresses and problems can emerge.
Healthcare workers who thought they had survived the influenza pandemic maybe surprised at feeling unwell at this point, but many are likely to do so and willneed time off to recuperate. This absence will be on top of allowing staff to takeany accrued leave and/or compensatory time off.
12.1.2 The recovery phase may well involve the administration of a specific pandemic flu vaccine, putting added pressure on primary care if there is a massimmunisation programme.
12.1.3 General practice will therefore be short staffed in the recovery period, along with the rest of the health service. The recovery period will necessarily link into theresumption of hospital services.
12.1.4 Primary care services are likely to experience persistent secondary effects for a long time. There will be increased demand for continuing care from: patients whose existing illnesses have been made worse by flu patients who may continue to suffer potential medium or long-term healthcomplications from flu the backlog of work from the postponement of treatment for less urgentconditions.
review their staffing levels and availability for work assess the need for psychological support for staff ensure that premises are adequately cleaned and made ready forresumption of normal service check essential supplies and replenish them as soon as stocks becomeavailable communicate with their patients to ensure they know when normalservices are resumed.
12.1.5 Just as there was a staged reduction in normal services in the build-up to the peak of the pandemic, so there will be a staged re-introduction of normalservices in the recovery period. At some point, for example, elective treatmentsin hospitals will be resumed and GPs will again be allowed to refer patients forthese non-emergency procedures. The local strategic health authority (SHA) (or its equivalent in the devolved nations) will announce when this stage hasbeen reached.
12.1.6 Similarly, the local SHA (or its equivalent in the devolved nations) will announce when GP practices will resume Quality and Outcomes Framework activities andany other targets used before the pandemic. Resumption of performance targets will have to take into account the loss ofskilled staff and their experience, problems in recruiting at a potentially difficulttime, and the need for staff to have rest and recuperation.
12.1.7 Announcements from the SHA (or its equivalent in the devolved nations) will be fed through to practices via the local primary care organisations.
12.1.8 As no one can predict the pattern of a pandemic, there could be the scenario of moving into the recovery period only to find that a second or third wave of thepandemic strikes. A second wave could be even more serious than the firstwave. Should this occur the recovery arrangements will be postponed and, onceagain, GP practices will adopt the staged approach to managing services in orderto cope with the needs of flu patients. A pandemic flu specific vaccine could beavailable at this stage, depending on the timing of the pandemic waves. If so,general practice will be called upon to play its part in administering the massimmunisation programme as described earlier in this report. Healthcare workerswho have not been ill may be among the first to receive such immunisation as appropriate.
12.1.9 During the recovery phase, as at every stage of planning for and responding to a flu pandemic, healthcare workers will follow the ethical principles of fairnessand equity which underpin all treatment.
List of acronyms
Appendix 1: GPs’ pay
‘Ministers have endorsed an agreement reached between NHS Employers and theBMA’s General Practitioners Committee (GPC) on the maintenance of General MedicalServices (GMS) practice income where GP practices are involved in responding to aninfluenza pandemic.
This is in line with the principle set out in Pandemic influenza: guidance for primary caretrusts and primary care professionals on the provision of healthcare in a communitysetting, that ‘The Department of Health does not intend any general practice to bedisadvantaged financially by its participation in responding to an influenza pandemic’(paragraph 9.3.3 of the guidance).
The Financial Agreement and the costing methodology can be found on the NHSEmployers’ website at
This contains a guidance note for PCTs on the Financial Agreement. It outlines thebroad principles that have been agreed and some supporting guidance for PCTs.
In addition to agreeing GMS practice payments, NHS Employers is also working with theDepartment of Health on guidance on the broader HR issues for all NHS organisationsin responding to an influenza pandemic.’ Appendix 2: WHO international phases and
UK alert levels
WHO number and phase
Overarching public health goals
Inter-pandemic period
preparedness at global, regional, national and sub-national levels humans; detect and report such transmission rapidly if it occurs Pandemic alert period
notification and response to additional cases 4. Small cluster(s) with limited person-to- Contain new virus or delay its spread to person transmission but spread is highly localised, suggesting that the virus is not 5. Large cluster(s) but person-to-person spread still localised, suggesting the virus spread, to possibly avert a pandemic and Pandemic period
UK alert levels:
Appendix 3: Children’s dosage
Children within the normal weight range for their age who have high fever andcough or influenza-like symptoms should: if aged under 1 year, or of any age if at high risk of complications (due toco-morbid disease), be seen and assessed by a GP or suitably qualifiedpractitioner if aged 1 year or over, be assessed by the National Pandemic Flu LineService staff using a clinically based paediatric algorithm and referred forantivirals and/or to a suitably qualified practitioner if indicated (eg those atrisk of suffering complications of influenza).
Oseltamivir (Tamiflu) is licensed for use in children over 1 year old. TheGovernment has procured appropriate dose capsules from the manufacturer foruse in children over 1 year old and under 13 years old. In the algorithm, dose isdetermined by age as a proxy and is set out below: age 1 year or over but under 3 years (body weight under 15kg) – 30mgtwice daily for five days age 3 years or over but under 7 years (body weight between 15kg and23kg) – 45mg twice daily for five days age 7 years or over but under 13 years (body weight 24kg and above) –60mg twice daily for five days age 13 years and over – 75mg twice daily for five days.
NB: If children aged 1 year and older, seen by a suitably qualified practitioner,
are obviously under- or over-weight, Oseltamivir should be given as directed in
the BNFC (British National Formulary for Children).
GP prescribing for children less than 1 year old
Children under 1 year of age should be given Oseltamivir at a dose of
2mg per kg twice daily for five days. Oseltamivir is not licensed for use in the
UK in children under 1 year old. There is, however, published evidence from
Japan that it has been used safely at a dose of 2mg per kg twice daily in
children under 1 year of age. The dose for this age group will be weight-
dependent. The Royal College of Paediatrics and Child Health has developed a
consensus statement that will help clinicians to make a decision about whether
to treat and the dose to be prescribed.
The Government has purchased the active ingredient powder for thereconstitution into a solution for use during a pandemic. There are sufficientdrums to make up antiviral solution to treat the UK population of under-1s at a clinical attack rate of 23% but this will be increased to cover 50% in line with Pandemic influenza: Guidance for GP practices
plans for the rest of the population. A number of licensed hospital pharmacymanufacturing units will manufacture oral Oseltamivir solution for use bychildren. The shelf life of oral Oseltamivir has been extended following furthervalidation and it now has a shelf life of 12 weeks and can be stored at ambienttemperatures. Once the solution has been manufactured, it will be bottled and labelled at themanufacturing units. Further consideration of how the solution will bedistributed is taking place at national level. Guidance on dosage and the mosteffective way of administering the oral solution should also be provided by ahealthcare professional.
Appendix 4: Communications
The national communications strategy takes the form of measured engagementwith the public in the different WHO phases. In WHO phase 3, the focus is on embedding good respiratory and hand hygienebehaviours with the public. This will be the first line of defence against thespread of a pandemic. In WHO phase 4, the emphasis moves to prepare the population for theemergence of an influenza pandemic and its potential impacts. Activities willinclude the first of two national door drop leaflets together with the launch ofan information line and website. These information sources will explain the roleof vaccines and antivirals and how they will be accessed via the NationalPandemic Flu Line Service and the need for identifying flu friends. In WHO phase 5, the messages focus on developing the public’s understandingof pandemic influenza and how to prepare for it if it reaches the UK. NationalTV advertising will begin and a second national door drop leaflet will bedistributed. The information line and website will be regularly updated and therewill be formal media briefings. Self-care videos educating people on what to doif they contract the virus will be available online and on digital screens in, forexample, town centres and stations.
In WHO phase 6, all channels will update on the status of the pandemic andcontinue to give self-care advice including how to use the National Pandemic FluLine Service. Local healthcare communications are the responsibility of the primary care trust.
Effective internal and external communications will be vital in responding to aninfluenza pandemic. Local communications plans that reflect national activitiesshould be developed in conjunction with local stakeholders. These will include allaspects of the health service, pharmacies, social services and the voluntary sector.


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