http://www.kirklees.nhs.uk/fileadmin/documents/New/Your_health/Coping_in_an_emergency/Swine_Flu_prog

Preparing for the pandemic due to the pandemic (H1N1) 2009 virus Progress to date Report to NHS Kirklees Board September 2009 Introduction After the lull of cases since early August, the advent of the seasonal flu season and the return of educational institutions, means a small rise in cases of influenza is occurring overall. This may lead into a second wave of infection during the autumn which could put significant pressure on our services. Planning is underway to ensure the NHS and its partners can cope with these challenges and provide essential services throughout.

This paper gives: • An overview of the progress of the virus to date • Assurance to the board that local systems are being established and in place to ensure pandemic preparedness. The approach recognises the inter-dependencies and maximises contributions from all parts of the health and social care system A statement of assurance is required to go on each trust’s website – this is a high level statement, but will include a link to the specific board papers for more detailed information.

Background Surveillance: Globally, Nationally and Locally Case definition: the clinical diagnosis is a temperature >38C plus 2 or more of the following: cough, runny nose, etc. This clinical picture can be a range of diagnoses e.g. streptococcal tonsillitis, meningitis or other viral infections, especially in young children. If the diagnosis is made over the telephone i.e. without a physical examination then the diagnosis is even more imprecise.

27 April World Health Organisation pandemic alert level 4: human to human transmission of an influenza virus able to cause community level outbreaks 11 June World Health Organisation alert level 6: sustained community level outbreaks in another country in another WHO region 2 July UK moved to treatment and prophylaxis of high risk groups only In the southern hemisphere, pandemic (H1N1) 2009 is the cause of about 90% of confirmed influenza cases, during their flu season. This wave of infection started at the end of May, reaching a peak in July, and then dropped by 90% in August. Western Pacific region WHO Pandemic Bulletin week 31.

Over the same period, the northern hemisphere had levels of this virus causing 60-70% of all confirmed cases of influenza. So it seems that in the seasonal flu season, pandemic (H1N1) 2009 dominates over seasonal flu, due to having a infectivity rate 2-3 times higher. This has implications for care as there is marked difference between seasonal flu which affects older people and pandemic (H1N1) 2009 which affects younger people, see graph as at 17 September 2009.

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This trend of affecting young people far more than older people has been a constant over time and across the world. Most people, if otherwise healthy, recover within a week or so but for a few people this illness will cause severe illness, dominated by respiratory distress.

Hospital admissions People admitted to local hospitals with suspected swine flu, the number confirmed and co-morbidities as at 17 Sept 2009 90

80

70

Number Of Cases

60

Confirmed cases Confirmed with comorbidities Admitted with comorbidities Admitted

50

40

30

20

10

0 0-4years

5-14years

15-44years

45-64years

65+ years

Age

Source: MYHT . CHFT

It is important to note that those aged over 65 will be half as likely to become ill with this infection than the population overall (Clinical Attack Rate of 15% rather than 30%). However older people have approximately double the complication ratio (30% of clinical cases rather than 15%). The above graph clearly shows that people with pandemic (H1N1) 2009 who are admitted are more likely to have significant co morbidity than those with other infections. It 2

confirms that more serious cases occur in younger people and very few in those aged over 65 years. This has significant implications for the planning assumptions.

Deaths from swine flu in confirmed cases (laboratory tested) Date th

Confirmed Cases

Deaths

27 August 2009

Globally

254,947

2594

9 August 2009

Australia

24.395

77

13,322

70

10 September 2009 Nationally

The number of confirmed cases, both globally and nationally, is an underestimate as not all clinical cases are tested in many countries, since the declaration of level 6 by WHO. It is impossible to calculate death rates accurately, but is likely to be under 0.1%.

In England, deaths are being investigated and reported by the CMO, as follows, the results for 67 deaths are: Age distribution of fully investigated deaths

17% 27%

0-15 16-44 45-64 65+ 31%

25%

Source: CMO epidemiological weekly update 17 September 2009

The number of deaths is small, but this age range broadly reflects that within the southern hemisphere, in that most deaths were in those aged 16-44 years and the least in those aged 0-15 years.

Underlying conditions information for fully investigated deaths

19%

Healthy 9% 50%

Mild Moderate Severe

22%

Source: CMO epidemiological weekly update 17 September 2009

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Healthy Mild Conditions Moderate Conditions Source conditions

No medical conditions, no medications High blood pressure, controlled by tablets e.g. Diabetes, controlled by insulin e.g. Leukaemia

So 3 in 4 deaths were in people with a significant underlying medical condition.

In summary pandemic (H1N1) 2009 virus is: • Is 2-3 times more infectious than seasonal flu, so will dominate the coming flu season • Will be most common in people aged 5-24 years • Will affect more severely people with significant underlying conditions • Has a low death rate • Is a minor illness for most people but not so for some.

How many people will be affected?

The Cabinet Office published revised planning assumptions at the beginning of this month.

Another peak will not happen until October and that any future peak could be much higher than the one already experienced in July.

Planning assumptions to mid May 2010 from the Cabinet Office on 3 Sept 2009 Potential effects of for the general population of pandemic (H1N1) 2009 Clinical Attack Rate * Up to 30% population Peak Clinical Attack Rate Nationally, up to 6.5% population per week Locally, 4.5-8% of population per week Case Complication Ratio Up to 15% of clinical cases Case Hospitalisation Ratio Up to 1% of clinical cases, of whom up to 25% could require intensive care at any one time Case Fatality Ratio Up to 0.1% of clinical cases Peak Absence Rate Up to 12% of workforce *Attack rates are defined as “the proportion of the population who become ill with influenza” or display symptoms.

They are based on a reasonable worst case scenario and do not take into account the impact of the vaccine. These graphs are illustrative curves to aid planning, not true predictions of what will happen.

The figure for a local area is higher than UK wide as local outbreaks may occur with a much higher peak clinical attack rate than the UK as a whole over the relatively long time period.

Locally this occurred in Dewsbury in July, and resulted in far more clinical cases reported there than in Huddersfield.

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N u m b e r o f A tta c k s

SHA Predicted Attack rates for Kirklees total population 34000 33000 32000 31000 30000 29000 28000 27000 26000 25000 24000 23000 22000 21000 20000 19000 18000 17000 16000 15000 14000 13000 12000 11000 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0

31991

31991

19437

19032

18627

19032 15388

14578 11743

10124 8909

8099

7694

6479 4859

1

2

3

4

5

6

7

8

9

4454

10

11

12

13

14

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Week Number

Worst Case

Best Case

Forecasting the timing of week 1 is not possible at present, due to the low numbers likely to be seen in the early weeks as they will be similar to background levels of influenza-likeillness, so may only be retrospective. Similarly it may not be possible to know the peak has been reached or past except in retrospect up to 2-3 weeks later. The curve of the best case seems to have occurred in Australia.

Absence from work One of our biggest challenges is how many people will be absent from work at the peak of the local epidemic because of illness or caring responsibilities. During the peak absence rates may go to 12%, in addition to “normal” holiday leave and non-Swine Flu illness. The best current estimate of the length of illness is that: • Half of those people becoming ill will recover within 7 calendar days.

• A further 25% need up to 10 calendar days to recover.

• 25% have symptoms for more than 10 calendar days, but not necessarily debilitating.

• On average, the duration of illness is 9 calendar days.

Current data and analysis of previous pandemics suggests an average unavailability for work of approximately 10 calendar days for clinical cases without complications and 14 days for those with complications. If schools close this could cause an additional 15% of the workforce to be absent to care for children for the duration of the school closure.

Treatment The National Pandemic Flu Service became operational in England on the 23rd July 2009 i.e. week 29. This profoundly reduced the number of GP consultations for Influenza Like Illness.

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Antiviral Collection NHS Kirklees has 7 community pharmacies acting as antiviral collection points, to maximise patient safety and convenience. Since the start of the pandemic in Kirklees on the 27th June a total number of antivirals distributed by 6th September were 7851, 4319 in the North and 3532 in the south. Two PCT staffed points were mobilised and then stood down as activity decreased during August. These can be reopened within 24 hours. Kirklees has the highest rate of antiviral drugs being collected after contacting the NPFS, at 82%, in the week ending 18 September.

Training for front line staff During May – August, 1724 staff attended awareness training of infection control and this pandemic. This included staff from NHS Kirklees, KCHS, Local Authority and Care Homes.

Further training was provided for independent contractors including GPs, GDPs and Community Pharmacists.

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The preparedness of the NHS response The PCT preparedness has been assessed by various methods: • The SHA have requested detailed outcomes against a Winter Planning Checklist • The HPA flu preparedness toolkit has been completed, see appendix • The SHA have requested a full ‘Surge’ planning document, which was submitted on 28th August.

• A confirm and challenge event was held on the 10th September 2009 by the SHA of the lead PCTs who collated the preparedness reviews of each PCT. The SHA is overall content with NHSK’s level of preparedness as given in their feedback, and is aware of the identified areas of risk, see risk log later.

The contents of this document are taken from across these documents, to provide a concise picture of contingencies in place. It will also identify ongoing work and areas of risk.

Leadership There are robust plans for Winter, Flu and Surge in place for Kirklees. This has been coordinated across the health and social care economies, fostering extremely good collaboration and understanding of each others roles. The overall response for Kirklees is led by the Executive Director of Public Health supported by an Acting Director, Tracy Small, to lead the NHS response in particular.

Overall strategic decisions are made weekly by the PCT directors acting as the Strategic Command Group. Reports and issues arise from the tactical decision making group, the weekly Command and Control Group of the lead officers responsible for the nine work streams, which are: • Communications Mick Gudgeon • PCT Antiviral Collection Points Pat Andrewartha/ Jan Giles • Antivirals Neill McDonald • Infection Control / Immunisation Jane O’Donnell • Human Resources Ian Hazlehurst • Surge Tracy Small • Primary Care Mark Jenkins • Volunteers / Self-care Nicky Hoyle • Recovery Terry Service There is also a stakeholder group, the Kirklees Wide Pandemic Flu Committee, which includes all the main agencies to share issues, review planning within and linking across services and resolve issues...

Command and Control / Governance With Yorkshire and Humber there is a clearly defined infrastructure for command and control.

There are 4 levels of command: 1.

A Regional Strategic Command group of the lead PCT CEOs, that coordinates regionally and escalates issues nationally as appropriate.

2.

Each sub-region within the SHA area of operations has a lead PCT that provides oversight of the sub regional response. For West Yorkshire, NHS Kirklees is the interim lead PCT. These arrangements are facilitated by Memorandum of Understanding between the lead PCT and SHA that facilitates links to forums such as the Local Resilience Forum and its relevant work streams.

3.

Across the local health economies it is likely that strategic command across the Calderdale, Kirklees and Wakefield will require a specific CEO led group, that relates to the lead PCT or Regional Strategic Command Group, as well to the individual organisational command groups. At tactical level, a weekly teleconference is held

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between organisations to identify pressures and to provide information about services.

These teleconferences will increase in frequency as the pandemic ‘surge’ occurs.

4.

At individual organisation level: In NHSK, this is SCG, see above.

Communications Communication for all meetings is available via structured minutes which are posted on the Z drive. Rigorous recording of all decision making, epidemiology and issue logs have been in place since the start of this pandemic in May. Briefings and resources to staff and public is overseen across Kirklees by the PCT communication team and the DPH, liaising with the SHA acute Trust and Council communications as appropriate to ensure consistency. This includes other community languages, where possible.

These are posted on the internal, and where possible, the external website, with links to the Council website. A specific GP, Pharmacy and dental electronic link is being tested. Regular press briefings are issued. The DPH acts as the main spokesperson for the public, unless there are specific issues to cover where another director is more appropriate.

Resilience The DPH and Director of Performance attended the Peak Practice exercise on 22 September.

All PCT planning has been in line with DH and HPA guidance. Pandemic plans have already been stress tested by the outbreak experienced in Dewsbury.

Human Resources The action across NHS Kirklees has been informed by guidance which has been published by the Department of Health. We have also conducted workforce risk assessments in response to an SHA led process.

Staff deployment in response to swine flu Staff and managers within NHS Kirklees and KCHS have worked collaboratively. The original arrangement for antiviral centres using local pharmacies has been supported by the establishment of 2 PCT antiviral collection points which have been staffed by provider and commissioner staff. As clarity has emerged regarding the types of roles within the antiviral centre, the management and staffing role has passed more to commissioner staff in order to enable KCHS to sustain front line care.

We have also reviewed options for the supply of staff. A questionnaire has been issued to all staff members within KCHS and NHS Kirklees which has highlighted their potential availability for additional hours if part time; we have looked at the use bank staff and locums and considered the use and availability of retired staff. As part of our role of lead PCT, we have instigated the process for making a mutual aid agreement with other local NHS organisations in West Yorkshire. This has also been agreed with Kirklees Council.

Management of staff absence and monitoring A monitoring arrangement now exists for staffing availability. This looks at staff absence on a weekly basis and provides information to SCG to monitor absence levels on a real time basis. This will assist with identifying areas of staffing pressures, and form a record of the incidence of staff contracting flu locally. This is now required by the DH. Support and resilience of staff Staff have pulled together extremely well. Support services such as occupational health and access to counselling continue to be provided. Flexibility in response to working times and taking time back has been encouraged.

Communication and engagement with staff We have generated a question and answer document regarding staff issues (particularly relating to terms and conditions for additional working). Any queries have been handled by line managers and the HR team. In the questionnaire issued to all staff, we have identified particular skills and also asked them to draw to our attention any of the at risk factors which may impact on the work they are asked to do.

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We have communicated with all staff and expressed appreciation by letter from Mike Potts for their sustained contribution. Formal meetings and discussions staff side representatives have also been maintained through our local partnership forum.

Across Agencies A full staffing and skills review has been undertaken by the PCT, LA and all provider services. These have identified staff who will be available to transfer to priority areas, as the ‘surge’ increases. Identified gaps are being addressed by providing additional training for specialists within critical care areas, to allow for increased capacity within these units.

The problem for developing a GP locum list has been resolved nationally and work is being undertaken to identify additional resources from performer lists and retired GP lists.

The WTD average 17 week average period can be extended to 26 weeks by local agreement. DH are negotiating to extend this reference period to 52 weeks for all staff, except doctors in training.

Immunisations Plans have been developed to immunise front line staff against swine flu, as vaccines become available. DH and General Practitioners Committee have agreed that GP practices will immunise to the priority groups. Incentive schemes have been agreed between DH and GPC to ensure practices achieve highest possible uptake.

Promotion of immunisation to staff is required to raise uptake to as high as possible.

Infection Control For providers contracted to the PCT, Personal Protective Equipment has been made available and full training is completed. Information about the prevention of infections and how to use PPE has been provided to all NHS and independent service providers. The Council also receives an allocation from the national stockpile via the PCT. A telephone support service is provided for clinicians to gain specialist advice as required.

Surge The surge work stream covers all service escalation planning. This section is broken down into sub-sections for ease of reading. All local organisations have assessed inter-operability to ensure one organisation's plans do not unduly affect another organisation. a) Primary Care All independent contractors have been requested to provide business continuity plans.

The following have been received: • GPs – all received but 1 • Pharmacies – 21 of 43 received, those not received relate to multiples • Dentists – template recently sent out, none received back as yet.

All the above are working in clusters to ensure business continuity. There is one outstanding GP practice, which is identified as a potential risk. Work is continuing with this practice.

IQ software and training has been made available for all GP practices. Work is ongoing to populate this software, and to determine how it can be best used during a pandemic peak.

In line with DH guidance on Pandemic Flu: Planning & Responding to Primary Care Capacity Challenges (Aug 2009); an escalation plan has been developed to manage the suspension of Primary care services. This includes specific telephone support by consultants to GPs, to enable patients to be managed by the latter even more.

Communication with patients is available via letter to indicate deferring of clinics/referrals.

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b) Community Services Business continuity and prioritisation plans have been provided by KCHS and Kirklees Council Adult Services. Although the prioritisation plans have been received from Kirklees Council ChYPS, business continuity plans are still being refined.

Adult services have identified potential risks within the independent care sector and their business continuity includes support to this sector. Business continuity plans have been requested by them from all care/residential homes, to assess preparedness. A workshop has already taken place and an additional one is planned to assist the homes with developing more robust workforce plans.

Work continues in relation to ensuring Adult Services have contingencies in place for dealing with administration of medicines to their vulnerable clients, in the event pharmacies are unable to provide dosette boxes. A solution to this problem still remains unresolved currently, but work is ongoing. c) YAS / Urgent Care Services From attendance at two SHA meetings, where YAS have presented their contingencies it is anticipated that critical care transfers and 999 calls will be prioritised. Patient Transport Services are training additional drivers for urgent response vehicles, to increase capacity, it is unclear as to how much of the Patient Transport Services can be retained.

Local Care Direct (provider of urgent care services) prioritisation list and draft business continuity plan have been submitted and are being refined. d) Secondary care Business continuity and prioritisation plans have been received from both Acute Trusts, who are fully engaged with the flu surge planning. These are essentially similar and include material aid. di) Women and Children’s Services Women and children’s services will remain as Priority 1 (essential services), except for routine none urgent activities which will be deferred.

Assessments have been undertaken to ensure services are not provided from practices where active ‘flu patients’ will be in attendance. Work is still ongoing to identify the community sites from where women and children’s services will be delivered. Details will be provided at the surge meeting on 30 September.

Paediatric services will be increased in capacity and will need to care for children of lower age than usual. Training for specialist paediatric staff is being undertaken in liaison with Sheffield Children’s hospital. dii) Critical Care Services All critical care activity is priority 1 (essential).

Both Acute Trusts have assessed their critical care capacity, using potential ventilators and staff availability. Returns have been forwarded to SHA from each Acute Trust provider. Both have identified an ability to double capacity. Plans to increase this to 300% will have staffing implications and is identified as a risk.

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A national paediatric / neonatal network will be established, which will oversee all PICU activity and ensure all beds are utilized equally, prior to opening additional capacity (to share the burden).

The 3 critical care networks across Y & H will support SHA in managing ITU bed capacity.

This will ensure bed utilization is equal across Trusts. Additional capacity will be increased simultaneously, when current capacity is full. As the critical care capacity decreases Trusts will be informed to stop elective activity, to allow for the increase in critical care capacity.

Specialist services have commissioned a dedicated Paediatric transfer service to commence in November; this however is for usual capacity and does not include additional capacity for Swine Flu. Additional capacity has been requested to YAS to maximise capacity. Retrieval staff have been employed (although depleting ITU areas) to provide a retrieval service, this again is for normal capacity and does not include additional Flu capacity. Tertiary and Acute Trusts have been requested to assist with training additional staff to assist with transfers. diii) Mental Health Demand Capacity Plan and pandemic flu plans have been received from SWYFT. SWYFT have identified services which are priority levels 1-4 (1 being essential). This has been assessed by the surge group to ensure there are no implications from the ceasing of services, upon partner organisations.

The Surge group have been assured that A & E, urgent hospital assessments and where necessary transfers to the Acute Unit will remain as priority 1. e) Additional Bed capacity During the swine flu surge it is anticipated additional bed capacity will be required.

Assessments have taken place to identify extra capacity in both Acute and Community settings. There are 72 beds within the private sector, which CHFT will sub-contract as necessary, following discussion with the PCT. There are 20 respite beds, which it is planned will transfer to intermediate care beds, as necessary. An additional 20 beds are planned on a spot purchase basis. Letters have been sent to all potential homes to identify costs and availability.

Body Storage A review has been carried out of the current capacity for body storage of the Funeral Directors and crematoriums. Given current planning assumptions, this is adequate. Never the less a number of buildings have been considered for temporary mortuary facilities. Plans will be finalised should predictions worsen.

Discussions have also taken place and agreements made with Funeral directors on different ways of working should the need arise to significantly increase the number of funeral services.

Volunteers / Self-care Leaflets and information for the public has been developed to assist with self-care and to help prevent ill health.

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Volunteers have agreed to provide a ‘flu friend’ service, where patients do not have any access to relatives or friends. This will be managed via the ACP system.

Additional work is being undertaken to develop the volunteer role for ACPs, if required, e.g. as meeter and greeter.

Recovery Phase This is work in progress. The PCT has a specific work stream for recovery that is currently reviewing a range of factors impacting on effective recovery arrangements following a pandemic wave. This includes work on primary care, acute care as well and other specialist services i.e. mental health etc.

Primary Care are planning to defer referrals to the Acute Trust and will maintain a record of patients for referral following pandemic surge, to ensure recovery is as rapid as possible.

Additional work is ongoing to provide exact details of the system; these are due for submission on 30th September 2009.

People who have operations postponed will be prioritised in line with clinical need and length of time they have been waiting.

The Future During the next few months the pandemic H1N1 2009 will pose challenges across the world including how to make best use of limited vaccine and virus antiviral supplies and how to manage demands on health-care resources, which may peak substantially above normal capacity. Thus, while every PCT shares a common goal of minimizing mortality and morbidity, differences in health-care capacity and in the timing of the pandemic will require each organization to tailor its own response and be able to support others.

This report demonstrates the efforts that are going into ensuring that we are ready for the next and subsequent waves of the pandemic and can respond rapidly to minimize disruption and maintain essential services.

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Risk Log

Risk Key Planning Assumptions are incorrect, creating higher volumes than expected

Actions Key DH planning assumptions used and highest rates taken into account for planning purposes

Level of preparedness of the ambulance service and West Yorkshire Urgent Care is unclear.

Engagement to clarify this is continuing.

Escalated to SHA/Regional Flu Group.

Residential / Nursing additional beds may not be available as planned, due to lack of Pan Yorkshire Planning

Paper to submit to SCG to determine option for block purchase, but is likely to not be cost effective

Escalate to SHA/ Regional Flu Group.

Possible failure to comply with delayed discharges Act, making transfer of patients unlawful. ‘choice agenda’

To determine if Act can be suspended over the flu period

Escalate to SHA / DH.

Potential inability to use additional bed capacity, due to registration with CQC, needing to be amended to reflect differing patient usage.

To determine if CQC can amend criteria to allow flexible use of beds during surge.

Escalate to SHA / DH / CQC.

Potential for CQC not to agree additional beds and prevent use for different purpose

Information and re-assurance requested from CQC

Escalated to SHA.

Potential issues with supply of dosette boxes for patients and care homes

Discussions taking place in relation to numbers affected.

Contingency measures being discussed across health and social care.

Training provided for social care staff Work ongoing with Y & H networks to address issues, and provide contingency plans

In progress.

Potential for insufficient paediatric / ITU beds

Concern that Acute providers will not be able to meet 300% increase in ITU capacity

Contingencies to provide 300% capacity discussed.

Acute Trusts able to provide equipment, however, feeling of concern in relation to potential lack of staff.

Present State

Escalated to SHA/Regional Flu Group.

Escalated to SHA/Regional Flu Group.

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Risk

Actions Realistically this may be 200% capacity increase.

Present State

Clinicians unwilling to utilise prioritisation methods, due to litigation issues

To ensure National prioritisation plans are in place with reassurance to clinicians about litigation issues.

Escalated to SHA/Regional Flu Group.

Potential lack of support to practitioners due to NMC codes relating to not working outside competencies, which may be necessary in surge period

GMC message to professionals extremely supportive.

To discuss with NMC. The Nursing & Midwifery Council (NMC) has written to over 90,000 nurses and midwives whose registration has lapsed within the previous 4 years encouraging them to apply for readmission to the register and so make themselves available to employers.

Escalated to SHA/Regional Flu Group.

Additional and/or unexpected resource needs of pandemic flu threaten the achievement of financial control.

Flu costs attributed to cost centre code to identify additional expenditure.

Using mainstream systems to minimise additional costs.

Promotion of vaccine to all front line staff, include all levels of managerial support from Board outwards.

Ensure all GP practices achieve high uptake rates.

Central funding available for GPs. Difficult to sort locally as stockpiling discouraged.

An allocation already in financial plan.

But reality likely to be higher and may be difficult to specify.

Patients will be treated according to clinical need.

Staff needs are crucial to manage return to normality.

Plans in place, good communications systems between NHS and with patients to be ensured.

Vaccine: uptake of health and social front line staff Vaccine: uptake in high risk groups varies, (given by GPs) Supply chain and logistics are delayed due to staff/supplies shortage If higher levels of clinical prioritisation are required, this will be escalated quickly, but recovery will take much longer.

In progress.

In progress.

Further review of BCM plans required.

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