Central and North West London NHS Foundation Trust
Executive Office Tel: 020 3214 5760 Fax: 020 3214 5761
4 February 2010
Sarah Hurcombe Assistant Scrutiny Manager Post Point 10 City Hall The Queen's Walk London SE1 2AA
Dear Ms Hurcombe,
I am responding to your request for feedback in relation to London's response to Swine Flu.
!asked my Director of Nursing Practice, who is our Infection Control lead, to consider the questions you asked and he has provided me with the following comments:
1. Communication was a bit of an issue at first but this improved rapidly in time. I generally found that staff at NHS London were doing their best to advise where they could. Teleconferencing was a big help and saved a lot of travel time. One final point is that there wasn't any panic at any time when it was declared to be a pandemic.
2. At some of the meetings members of NHS London could become rather defensive to constructive comments. They appeared to take these as personal attacks. A more open debate on the challenges we were all facing would have been helpful. I hope that the above comments are useful. We look forward to viewing others views and feedback when published on your web-site.
Yours sincerely,
Claire Murdoch Chief Executive
Trust Headquarters, Greater London House, Hampstead Road, London NWl 7QY Tel: 020 3214 5700 Fax: 020 3214 5701 www.cnwi.nhs.uk Dear Sarah,
Further to the letter from James Cleverly, Chair of Health and Public Services Committee, and in answer to the questions posed:
The Ealing Hospital NHS Trust has yet to complete its local debrief, but in general we believe we responded well to the challenge.
Jules Arnould on behalf of Julie Lowe, Chief Executive
Jules Arnould Head of Communications Ealing Hospital NHS Trust Uxbridge Road Southall UB1 3HW 020 8967 5288 Bleep 451 Mobile: 07966 297469 www.eht.nhs.uk
Trust Head Office Goodmayes Hospital Barley Lane Ilford Essex IG3 8XJ
Telephone: 0844 600 1201 Ext 4308
15th February 2010
Sarah Hurcombe Assistant Scrutiny Manager London Assembly Post Point 10 City Hall The Queen’s Walk London SE1 2AA
Dear Ms Hurcombe
In response to your letter dated 20 January 2010 and the request for information regarding the London response to swine flu. The North East London NHS Foundation Trust is pleased to provide the following information:
1. What aspects of the response to swine flu in London were handled well?
The daily ‘Noon Brief’ worked well from the start and throughout the pandemic, and provided an excellent means of communicating and disseminating messages and requirements. It was useful for providing onward communication to internal staff and often meant that rather than lots of emails circulating around the IPC’s, everyone knew that the information had been received centrally by signing up to the Noon Brief. However there is a danger of it outliving its usefulness to some extent, now that the information about the pandemic is falling.
The teleconference concept was good for managing the need to coordinate the information flow and also meant that time was not lost in travelling into London for meetings.
Mental Health specific teleconferences were particularly beneficial and helped prevent mental health being 'lost' in the wider needs of Acute and Primary Care Trusts and provided a forum for mental health specific issues.
Chair: Jane Atkinson Chief Executive: John Brouder
2. What aspects of the response to swine flu in London could have been improved and how?
Online data capture worked well once it was up and running but there were several false starts with ImmForm and then a period when the database was unavailable requiring manual submissions. It would be useful if data sets and collection requirements for organisations could be identified earlier and systems fully tested before going live.
The daily data reporting systems imposed on a national level became overly time consuming as the deadlines were tight for Trusts to submit data each day. The benefits of the relevance of the information requested and what was actually required given the level of activity being experienced proved a source of frustration for local staff. As an organisation which has satellite community teams covering four boroughs, the timescales around the daily sickness reporting meant that often the first couple of hours each day were spent chasing for information, which was often no more than ‘no absence today’. A more measured approach could have been considered with the amount of data reporting required increasing as the activity of the pandemic increased. This was remedied though to some extent as the pandemic progressed with some data elements being dropped from the daily reporting requirements.
If you require any further clarification of the above points, we would be happy to provide additional information.
Yours sincerely
Stephanie Dawe Chief Operating Officer/Chief Nurse
Trust Headquarters Northwick Park Hospital The Trust Office Watford Road Chairman: Mr Tony Caplin Direct Line: 0208 869 2002 Harrow Fax: 0208 864 5511 Middlesex Chief Executive: Ms Fiona Wise Direct Line: 0208 869 2002 HA1 3UJ Fax: 0208 864 5511
17 February 2010
Via email Sarah Hurcombe Assistant Scrutiny Manager Post Point 10 City hall The Queens Walk London SE1 2AA
Dear Ms Hurcombe,
Thank you for your letter dated 20 January 2010 requesting information regarding London’s response to swine flu. I would like to offer the following comments from an acute trust perspective:
NHS London established an ‘incident room’ and communications links set up pan London immediately. There were daily briefings to nominated leads within the Trust which were essential during the first wave as the situation was changing almost daily. This was a very effective method of communication. All Trusts developed robust plans to demonstrate resilience to the Flu pandemic and a number of exercises took place to test plans as part of an assurance process.
In terms of improvement, demands for information in the initial phases came from several different sources. For example, the Health Protection Agency was requesting the same information as NHS London. This could have been better co-ordinated centrally to avoid unnecessary duplication. There were huge strains on laboratory services, particularly at the Regional Health Protection lab at Kings where all flu swabs from London had to be sent. Provision should therefore been made in other hospital laboratories to support the virology service required in pandemic situations.
I hope you find the above comments useful.
Yours sincerely
Fiona Wise
Chief Executive
London Assembly Response: London Assembly Health and Public Services Committee – London response to swine flu. Deadline 26th Feb 2010. Contributors: Dr Sarah Furrow: Consultant Microbiologist and Clinical Lead for Infection Control Dr Sneha Patel: Consultant Microbiologist Derek Cock, Chief Pharmacist Fiona Moore, Senior Nurse, Occupation Health Maggie Clancy, Senior Nurse, Paediatrics and NNU Dr Andy Winrow, Consultant Paediatrician and Divisional Director Penny Williams: Pandemic Flu Lead and Emergency Planning Mairead McCormick: Service Manager and Head of Nursing AE and MAC.
Summary of response: Good planning guidance from NHSL and Department of Health with regularly updated treatment algorithms. However there was very little guidance on contact tracing and prophylaxis treatment until the containment phase was reached. Daily communication to all providers from NHSL which some staff felt was excessive. Flu planning was resource hungry especially for clinical staff within Critical Care, AE and Paediatrics. However despite the heavy workload the commitment to ensuring a workable plan was completed was sustained throughout. The National Pandemic Flu Service opened in July when the AE activity had already peaked in May. The final figure for staff vaccination uptake was good but the Occupational Health and Flu Team had to work hard to balance negative messages.
Overall summary Although it is difficult to anticipate the infectiousness of any flu virus the number of critical cases and deaths remained small throughout. The preparation and response was out of proportion to the virulence of the strain because the plans were based on avian flu which is highly infectious. A case could be made to have flu plans and an operational strategy which would reflect the anticipated virulence of the expected virus rather than have one to cover all types leading to possible over reaction.
To assist in referencing the areas of good practise and areas for improvement the following table is displayed chronologically starting with the pre-pandemic work from Jan 09 to the end of December 09.
P Williams 03/02/10
Date and Phase Guidance received Good practise Areas for improvement. Jan 09 – Mar 09 Local Flu Plan Local Flu Plan and Hospital Wide Lengthy guidance meant lengthy local flu plan which was Pre-pandemic Ref: National Pandemic flu committee not easy to reference. framework for Flu Good Guidance concentrated on early Early plans did not reference contact tracing or Pandemic and management and treatment through AV prophylaxis as guidance from DH concentrated on preparation guidance collection points. management and treatment. for acute hospitals Good clinical guidance for doctors to 2007. patients. Ethical framework for policy and planning. April 09 Infectious diseases Hygiene Information to public Limited labarotory swabbing capacity - only 20 per day Phase 4 Outbreak top line HPA Screening and Assessment at St Georges. . Containment briefing (Algorithm) Algorithm for management of suspected CMO advised that all cases with flu like illness should be phase swine flu cases gave clarity on swabbed but this was retracted after a week. It caused 1st Surge management of cases – when to swab and confusion locally with large numbers of swabs from GP’s when not to swab. . arriving at KHT for onward transfer to labs. Patients told not to attend AE Algorithms changed frequently and often quite subtly. May 09 Excellent antiviral – tamiflu and relenza- Confusing guidance on prophylaxis given: one patient Phase 5 availability. who was suspected by GP was swabbed and given Containment Regional and Local flu response Centres tamiflu but on arrival at KHT did not meet criteria Phase open. All organisations were asked to according to HPU. Ten days later lab report indicated?? provide staffing support. swine flu. HPU asked that all contacts should be given Escalation plans within AE department tamiflu. Over a 12 hour period staff lists prepared and worked well to manage increased activity. tamiflu prescribed by 4pm in afternoon but by 10pm swab came back negative. Huge AV deliveries of over 1M packets was an over supply. Daily report on stock of AV’s of such large quantities was very time consuming.
P Williams 19/02/10 2
AE experiencing increased attendance despite messages to public (av. 303 attendance per day range 281 - 387). Staffing resource allocated to response centres placed additional pressure on nursing staff. Jun 09 Pandemic Flu – Algorithms S5a and S5b split Phase 6 Managing demand community and hospital cases. Containment and Capacity 2009 Algorithm 6 available Pandemic influenza Communication of first swine flu case – Human Resources confirmed in PCT. Guidance Antiviral collection points started
July 09 Swine flu pandemic Excellent workshops led by NHSL on the Very time consuming and tight planning deadlines - Treatment from containment winter/flu planning requirements meant most of August planning for local PCT deadline phase to Treatment Excellent guidance from DoH Guidance very demanding on clinical time (e.g. Service 1st Planning Pandemic flu Service up and running prioritisation) Assumptions (July 23rd) NPFS opened too late as most patients appeared to be DoH guidance FAQ of 125 pages from Cabinet Office using AE’s. “Swine flu National Pandemic Flu Service FAQ had to be edited to more reasonable length. pandemic - from commences 23rd July 2009 and London Information overload. containment to Flu response centre closes July 28th. Absence of guidance on the amount of PPE equipment treatment”. AVC points working effectively at 120 required e.g. X gloves per 100 beds. patients per day. Aug 09 Combined PCT, Acute and SS flu Complex planning timetable added to resource hungry Treatment exercise. process. phase Pre- Good partnership flu planning across the Planning deadline to PCT met but PCT did not pass onto second surge healthcare community NHSL as per instructions Staff Swine flu vaccination protocol in Varying interpretation of “front line” staff categories place. between DH and Hospitals meant later re-write of flu vaccination protocol and confusion on reporting take up. Reduction in AVC points could be considered here.
P Williams 19/02/10 3
Sep 09 Critical Care Highlighting critical care capacity Uncertainty over funding for equipment for adults and Treatment strategy: issues well communicated paediatric critical care phase Managing Excellent guidance from Paediatric Changes to planning assumptions created further Pre-second H1N1 flu ICU network. revisions to flu plan and state of readiness. surge pandemic Table top exercise called “coldplay” Numerous revision of “peak” weeks reduced focus. Revised designed by DH ensured cohesive Vaccine for swine flu still not available planning plans available across healthcare and assumptions social services. September 3rd Seasonal flu vaccine available from end of September. Oct 09 Planning Swine Flu vaccination available from Several false delivery dates and volume for swine flu Phase 6 assumptions Oct 21st. vaccination. 2nd Surge Only one dose required. Consumables were to be delivered with vaccine but anticipated. Good vaccination information for only syringes provided. Prevention staff and patients Late notification of one dose vaccine meant changing phase. Supplies of vaccine improved as PGD’s. programme gathered pace. Delay in provision of swine flu reduced staff’s New planning assumptions show readiness to be inoculated. dramatic reduction in hit rates. Vaccination of high risk in-patients unable to consent were delayed whilst awaiting family etc. Request to assist in vaccination of pregnant women when attending antenatal clinics was arranged but was not required except “those who unlikely to take up the GP’s offer of vaccination”. Four weeks of focused resource required to deliver staff vaccination programme. New planning assumptions reduce hit rate from 30% to 12% and deaths from 20,000 to 1000.
Nov 09 Excellent staff vaccination Intensive reporting process for vaccination uptake.
P Williams 19/02/10 4
Phase 6 programme achieving 43%. Immform for reporting staff vaccination take-up user 2nd Surge Feed-back good from staff with the unfriendly. anticipated. vast majority having no side effects. Take-up by staff impacted by conflict between “duty Prevention Complete Risk analysis completed to of care” V freedom of choice. phase. demonstrate effect of implementation of CRS concurrent with flu peak. Dec 09 Planning Reduction from original attack rate of assumptions 30% to 12% and deaths from 20,000 to 1000. Reduction in planning forecast allowed trust to proceed with CRS IT implementation.
P Williams 19/02/10 5
Winter/Flu Team Cantilever House Eltham Road London SE12 8RN
Email: [email protected] Website: www.lewishampct.nhs.uk Telephone: 0207 206 3386 23 February 2010
James Cleverley AM Chair, Health & Public Services Committee London Assembly City Hall The Queens Walk London SE1 2AA
Dear James,
Re: London Assembly Health & Public Services Committee – London response to swine flu
Your letter of the 22nd January 2010 was passed to me by Gill Galliano our Chief Executive for reply.
The levels of swine flu experienced in England and Lewisham were significantly lower than the possible pandemic modelling, for example Lewisham saw only 12,000 cases in the peak week of the first wave against a potential 78,000. Therefore the majority of activity was spent putting contingencies in place for a widespread pandemic that, fortunately did not come to fruition.
Frontline organisations such as, community health services, primary care, pharmacists and partner organisations who worked with Lewisham PCT all showed a dynamic and flexible approach. Services such as anti viral collection points, and assessment services, were put in place very quickly, largely due to individual staff member’s willingness to work long hours and show great flexibility in working outside their usual roles.
The second wave of the pandemic peaked in Lewisham at the end of November 2009. The feared impact of a second wave combined with winter fortunately did not occur, given the current challenges health and social care are facing due to the severe weather and winter vomiting bug.
NHS London acted as a co-ordinator for information from the Department of Health to the London PCTs and put a dedicated team and system in place to undertake this function.
The best possible health and well being for people in Lewisham
Chairman: Michael Richardson CB Chief Executive: Gill Galliano
Initial information and guidance from Department of Health could have been more consistent to support communication with frontline staff and make planning more effective.
In addition the role of the NHS London and the Health Protection Agency could have been clearer in the initial stages to ensure consistency of approach however this improved with development of the NHS London noon brief system.
NHS London planning assurance processes with PCT could have been more focussed on the key issues that make delivery on the frontline successful e.g. co-ordination systems, information, communication, surge planning and vaccination and anti viral processes. In addition a merging of the flu and winter planning assurance processes at an earlier stage would have been useful.
A challenge for all NHS and social care organisations going forward is how we can make the uptake of vaccinations both in staff and at risk members of the public greater. This challenge is relevant to the annual seasonal flu vaccination programme and possible future pandemics.
I hope this information is useful in you scrutiny committee meeting with NHS London.
Yours Sincerely
Greg Russell Director of Resilience (winter/ influenza)
The best possible health and well being for people in Lewisham
Chairman: Michael Richardson CB Chief Executive: Gill Galliano
Trust Headquarters Queen’s Hospital Rom Valley Way ROMFORD Essex RM7 0AG
Tel No: 01708 435444 Fax: 01708 435332 Email: [email protected] 25 February 2010
Ms Sarah Hurcombe Assistant Scrutiny Manager Post Point 10 City Hall The Queen’s Walk LONDON SE1 2AA
Dear Ms Hurcombe,
Re: London Assembly Health and Public Services Committee – London response to swine flu
Thank you for your letter of 20 January 2010 regarding the above. Please find attached response from Barking Havering & Redbridge University Hospitals NHS Trust for your information.
1. What aspects of the response to swine flu in London were handled well? • Flu Director post • Guidance from NHSL • Teleconferences were useful means of ensuring consistency in communications and providing a forum for clarification. • Daily briefs that became on-line daily updates (noon-briefings) useful information that reduced inbox pressure • Available telephone and e mail advise for Trust specific queries • Flu & winter dashboard • Staff vaccination programme was well conducted and good learning lessons for next seasons vaccine programme to ensure higher uptake.
Chair: Sir David Varney Chief Executive: Mr John Goulston Specific action points highlighted made it easy to prioritise when several actions were needed
• Data collection through the winter and flu dashboard which provided a NHS overview of the situation and pressure spots across London. • Networking of all organisations involved across London for emergency planning, resilience and recovery plans. • Clear guidance on use of anti viral medication.
2. What aspects of the response to swine flu in London could have been improved and how?
• Instructions overlapping and, at times contradictory with a large number of agencies involved e.g. CMO, NHSL, HPA and COBRA. • Some of the above would have been useful earlier in the planning i.e. on line briefs. • NHSL representation in ONEL earlier to appreciate efforts and highlight deficits. • Communications from NHSL were excellent but some demands were required short time frame and could easily have been missed. • Data collection rather onerous.
Yours sincerely,
John Goulston Chief Executive
London’s response to swine flu
1. What aspects of the response to swine flu were handled well?
Communication / Noon brief
Overview / progression of the epidemic and actions required at organisational level were succinctly communicated by the noon brief.
Antivirals and vaccination
Good inter-agency working with the PCT on antiviral supply logistics and the health economy wide swine flu vaccination campaign.
Clear identification and communication of priority groups for vaccination, informed and drove a well coordinated vaccination programme.
Health Protection Agency (HPA)
The HPA provided invaluable information on the treatment of suspected cases of H1N1 in the form of easy to follow flow charts.
IPC response
The requirement to participate in local IPC response meetings fostered cooperation between acutes, PCTs and local councils.
Flucon level and situation reporting
Adoption of the Flucon levels allowed for coherent internal and external reporting. The reporting process encouraged departments/ divisions/ organisations to scope necessary actions required at each level including prioritisation of services, potential for redeployment of staff and assessment of the likely impact on external partners.
Subsequent departmental, divisional and organisational triggers identified for each Flucon level provided a means of gauging pressure within the organisation in real time. This information was then used to inform the local health economy.
1 of 3
Assurance process
The assurance process ensured that contingencies were identified to:
Maintain
essential services essential supplies safety and wellbeing of staff
Develop
staff training programmes bed escalation plans staff skills mapping
2. What aspects of the response to swine flu in London could have been improved and how?
Communication / Noon brief
Initial communications were in duplicate or triplicate presumably due to a lack of confidence that circulation lists were adequate.
Staff received information via the high level parliamentary briefing, briefings from the DH and also NHS Choices.
Antivirals and vaccination
Initial mobilisation of antivirals from national stockpiles was slow. For medicines management issues more input from London Regional Pharmacy Specialist Services to support Chief Pharmacists in Trusts.
Health Protection Agency (HPA)
Conflicting advice was initially given on the use of FFP3 masks. Updates to flow charts were sent out late on a Friday evening when fewer staff would have been available to pick up on any changes.
2 of 3
Results were difficult to obtain. Individual Trusts were not able to contact the reference lab (King’s) and were instead instructed to contact the HPA who appeared to lack the capacity to respond to requests for results.
A clearly identified, fully staffed central point for results would have assisted the clinical management process.
IPC response
N/A
Flucon, Critcon, A&E Con level and situation reporting
There is an unavoidable delay in providing a London wide report which means that once collated centrally the report is no longer live. It is not clear how the report could be made available in real time.
For critical care a more immediate response could be orchestrated by the network and NHS London. Any organisation in difficulty would communicate simultaneously and immediately with their local IPC response team and NHS London.
Assurance process
The process could have been improved by providing clearer guidance as to the level of written assurance / evidence required.
3 of 3
25 February 2010
Regarding London Assembly Health and Public Services Committee- London response to swine flu
Dear Ms Hurcombe
As requested please find the feedback from NHS Harrow regarding London’s response to swine flu.
What aspects of the response to swine flu in London were handled well
• NHS London sent regular updates and Flu team were always available Dr Chloe Sellwood was very helpful. • NHS Harrow had daily meetings with good representation from all teams within PCT during initial phase. These meetings allowed effective communication about the quickly changing situation along with a coordinated PCT wide problem solving approach. Meetings were an effective way to ensure delivery of actions allocated to members of staff. • Escalation process in place within primary care, provider services and the acute trust worked effectively and Flu resilience lead made aware of any issues within the health economy of Harrow. • Good use of systems already in place to support processes for swine flu. For example using pharmacies to dispense A/Vs meant the process remained familiar for the public and no additional man power was required to operate an ACP. • Strong working relationships with pharmacist supported the process for distributing antiviral medication. Good network of pharmacies across the borough allowed an evenly distributed location to access medication • Out of hours pharmacy rota already established which NHS Harrow were able to build on to support the service • Good email links with all pharmacies allow distribution of information and control of actions and subsequent ACP work
What aspects of the response to swine flu in London could have been improved and how?
• In the initial phase, some guidance from HPA and DH was conflicting, this caused confusion in primary care • In the initial phase clinicians were not able to contact the HPA to discuss swine flu cases as requested. • In the initial phase, time was not allocated to operational staff to focus on H1N1 and yet there were ongoing actions required from them • In the initial phase, there were unrealistic expectations from HPA/ DH about processes – e.g. swabbing cases particularly when disease was widespread within communities
The Heights . 59-65 Lowlands Road . Harrow-on-the-Hill . Middlesex . HA1 3AW Tel: 020 8966 1001 . Fax: 020 8426 8646 Website: www.harrowpct.nhs.uk
• It was difficult to share information with some partner’s e.g. residential homes in a timely fashion due to e mail details being absent or not up to date, fax was used as an alternative. • Local communication plans were sometimes delayed waiting for the national communications lead.
Best wishes
Denise Thiruchelvam Public Health Specialist (Deputy Director Flu and Winter Resilience)
Cc John Webster Chief Operating officer Dr Andrew Howe Director Public Health NHS London
The Heights . 59-65 Lowlands Road . Harrow-on-the-Hill . Middlesex . HA1 3AW Tel: 020 8966 1001 . Fax: 020 8426 8646 Website: www.harrowpct.nhs.uk
St. Helier Hospital Wrythe Lane Carshalton Surrey SM5 1AA
Tel. 020 8296 2000 Direct Dial Tel. 0208 296 2267 Fax. 0208 296 3462 E-Mail: [email protected] 25th February 2010
Sarah Hurcombe Assistant Scrutiny Manager Post Point 10 City Hall The Queen’s Walk SE1 2AA
Dear Sarah
Re: London response to Swine Flu
Thank you for your letter of 20th January 2010, requesting a written response from the Trust on our views on London’s response to swine flu.
You asked for our response on two particular questions:
1. What aspects to the swine flu in London were handled well?
The NHS London Command, control and communication within health was clear and well established. NHS London provided leadership and regular communication across all organisations. The stock management and supply was very successful, including Personal Protective Equipment, Anti-virals, vaccine and vaccine consumables. Cross organisation working within health was effective, with networks established for Paediatrics and Critical Care.
2. What aspects of the response to swine flu in London could have been improved and how?
There could have been improved learning across organisations by sharing good practice and examples and we feel the Sector working could have started earlier. There were issues in relation to staff and training, particularly for Paediatrics and Critical Care which would have been improved with a London wide response.
It may also have been helpful if Social Service colleagues had been involved much earlier in the overall planning process and as such they may have been able to be clearer on what further support they could have brought to the acute hospital to manage admissions and discharges during a full pandemic. That said, the overall local partnership working was very good.
/…
Patient Advice and Liaison service (PALS) 020 8296 2508 Main Switchboard 020 8296 2000 www.epsom-sthelier.nhs.uk Page 2
Please do not hesitate to contact me if you require any further information.
With best wishes
Yours sincerely
Samantha Jones Chief Executive
Patient Advice and Liaison service (PALS) 020 8296 2508 Main Switchboard 020 8296 2000 www.epsom-sthelier.nhs.uk
London Assembly Health and Public Services Committee – London Response to swine flu
The notes below are a summary of Imperial College Healthcare NHS Trust response to the request for information on what aspects of the swine flu response in London were handled well and what could have been improved.
Aspects of the response handled well
• NHS London set up an early process for communication across London and for queries through incident • Teleconferencing facilities set up to improve communication and reduce need to attend meetings • Noon brief was an excellent mechanism for communication and update – improved significantly when new information was highlighted in blue • Reporting and feedback of proportion of staff vaccination coverage achieved by Trusts. This could be used more widely as a quality benchmark. • External reinforcement provided for cross site, local infra structure in a recently merged multi-sited Trust. • Additional reporting of the impact of norovirus across London in terms of ward closures was an excellent addition in January. Although, introduced some weeks into the marked increase in norovirus activity. This would be useful in future winters. However, if the data is not fed back and shared with Trusts the intelligence cannot be locally actioned and preventive measures targeted. There is also an HPA reporting requirement for norovirus by Trusts, it would be a useful opportunity to join these up and discuss with Prof. Mike Catchpole at the HPA. • Local partnership working and networks formed during flu are being adopted into plans for incidents internal and external going forward • Exercise Peak Practice was well received by senior management and aided senior level buy-in for flu
Version 3 22nd February 2010 Sarah Rodenhurst/Merlyn Demaine/Alison Holmes
Aspects that could have been improved (and how)
Topic Issue Improvement Communication • High volume of communication from multiple sources often • Single point of information entry coordinated with conflicting advice – especially in the first few months through NHS London or Lead PCT • Volume of data requests with short notice deadlines, multiple • A single point of coordination for data requests is sources and different formats.The resources required to essential when significant volumes of regular data address these multiple, overlapping reporting requirements is required undermines capacity for local action. • Lack of information sharing across DH/HPA/SHA – compounded the issues above • Feedback on epidemiology was slow and uncoordinated. • Feedback in note form from a single source Difficult to get an understanding of the emergent picture and directing to move detailed papers as required therefore plan in detail. Had to read multiple detailed papers to gain information Process • Change in process of communication part way through the • Maintain agreed process – flu leads process for pandemic – flu leads changed to flu Directors, delay in communication worked well and linked into information cascade as Directors were under the impression Directors as appropriate that flu leads were also receiving the information. Resulted in shorter deadlines and added another level of reporting. • Short notice implementation of new procedures, reporting and pandemic levels – change from UK alerts to FluCon • Discussion and coordination before process required significant re-writes of plans and training with very change, taking into account impact and short deadlines in order to meet ongoing assessment competing pressures deadlines • Short notice request for staff from Acute Trusts to assist the HPA when the organization was under significant internal • Process for surges in activity and resilience pressure • Lack of clarity of information initially – stockpile only to be • Communication mechanism to coordinate across used for pandemic not pre-pandemic, even though we had SHA/DH/HPA cases pre-pandemic • Confusion around the requirements for combined winter/flu • Single point of information coordination planning and the flu assessment process
Version 3 22nd February 2010 Sarah Rodenhurst/Merlyn Demaine/Alison Holmes
• Emergence of reporting for flu and overlap with capacity – • Forward planning of anticipated information required additional information analyst support and cost requirements for all untoward events implications • Continued assessment requirements – impacting on ability to respond • FluCon, CritCon, A&ECon, WinterCon reports caused confusion around the role of EPLO and Capacity Managers Diagnostics • Diagnostic capacity at Kings, back up facility and process for • Process for surges in activity and resilience getting results back fell down very quickly should be in place • Delay in retrieving results impacted on our ability to manage capacity – especially side-rooms efficiently Treatment • Information on prophylaxis for high risk, vulnerable and • Ensure all specialist groups are considered in specialist groups was late. planning process • PCT capabilities to address antenatal vaccination and • Should be considered in planning stages and vaccination of other groups could not be realised without factored into the response plans acute care involvement. • Poor arrangements for frontline staff prophylaxis and early treatment, conflicting with message from NHS about protection staff.
Version 3 22nd February 2010 Sarah Rodenhurst/Merlyn Demaine/Alison Holmes
Central Office Ground Floor King’s Dental Hospital Denmark Hill London SE5 9RW Tel : 020 3299 3030 [email protected] 26th February 2010
James Cleverly Chair, Health & Public Services Committee London Assembly City Hall The Queen’s Walk London SE1 2AA
Dear Mr Cleverly
London Assembly Health & Public Services Committee – London Response to Swine Flu
Thank you for your letter of 20th January detailing a request to share our experience of swine flu pandemic. You will appreciate that our comments reflect our status as a major NHS Foundation Trust, delivering a complex range of acute clinical services in SE London.
1. What aspects of the response to swine flu in London were handled well?
• Contingency / emergency planning for a flu pandemic : this was co-ordinated effectively by NHS London across the capital, with helpful training sessions, detailed guidance and a centrally run assurance process.
• Communications : this was a difficult task given the number of agencies involved and the limited information available – at least initially - around the virulence of the virus and around the timescales for the delivery of adequate stocks of antivirals and vaccines. Daily briefings by NHS London, supplemented with additional information on the demand for hospital facilities in each area, were established very rapidly and were very helpful in managing operational pressures locally.
• Hospital Services : The initially high attendances in hospital A&E Depts tailed off rapidly following the establishment of the National Pandemic Flu Service in the early summer – this was a major benefit. Thereafter the pressure on hospital services was relatively modest; many fewer patients were admitted to King’s with the H1N1 virus than had been anticipated in initial planning process and the heightened state of alert had no material impact on the normal functioning of the hospital.
2. What aspects of the response to swine flu in London could have been improved and how?
• Proportionality : It is accepted that – certainly initially – there was limited information about the virulence of the virus and public agencies need to have robust plans in place to deal with a ‘worst case’ scenario. Nonethless some of the planning process and central reporting requirements was perhaps more onerous than was necessary, particularly in the latter stage of the alert when the risk of large numbers of fatalities had been downgraded. Indeed, for most hospitals across the capital the normal increase in workload over the winter months was significantly more challenging than the incidence of H1N1.
I hope you will find this useful.
Yours sincerely
Ian Jackson
Flu Lead King’s College Hospital Trust
Quality Assuring the NPFS …and further RCGP reflections on Pandemic H1N1 (2009)
Final RCGP Pandemic Influenza Report to the CMO for England
February 2010
Dr Maureen Baker (CBE DM FRCGP)
RCGP Pandemic Flu Lead
Contents
1. Introduction…………………………………………………………………………………………….. 3 1.1 Clinical Impact of the Virus………………………………………………………………………….. 3 2. The National Pandemic Flu Service (NPFS)……………………………………………… 4 2.1 NPFS Background and Role………………………………………………………………………….. 4 2.2 GP Liaison Monitoring Project (RCGP)…………………………………………...... 5 3. GP Workload…………………………………………………………………………………………… 5 3.1 Containment Phase……………………………………………………………………………………. 5 3.2 Out of Hours Services…………………………………………………………………………………. 5 3.3 Impact of the NPFS on Workload…………………………………………………………………. 6 3.4 Workload and the Vaccine Programme…………………………………………………………. 8 4. Safety and Efficacy………………………………………………………………………………….. 9 4.1 Safety and the NPFS……………………………………………………………………………………. 9 4.2 Antivirals and Efficacy…………………………………………………………………………………. 10 4.3 GP Diagnosis and Treatment……………………………………………………………………….. 11 5. Communication……………………………………………………………………………………….. 12 5.1 Communication and the RCGP……………………………………………………………………… 12 5.2 NPFS and the Interface with Primary Care…………………………………………………….. 13 5.3 Communication and the Vaccine Programme………………………………………………… 14 6. Conclusions and Lessons…………………………………………………………………………. 16
Annex A: List of GP Liaisons…………………………………………………………………….. 17
Quality Assuring the NPFS (RCGP, February 2010) 2
1. Introduction
Countering the A/H1N1 (2009) pandemic outbreak would involve the application of innovative public health approaches, unfamiliar medications and novel fast‐tracked vaccines. In England the National Pandemic Flu Service (NPFS) represented a unique attempt to reduce predicted workload pressures in front‐line primary care services, by empowering self‐assessment for symptomatic patients, and enabling traditional NHS pathways to be circumvented in the accessing of antiviral medication. The clinical aim was to reduce symptom severity, complications and transmission in the community, as well as spreading good practice advice. While examining the impact of the wider pandemic programme on general practice, this report will focus primarily on the perceived strengths and weaknesses of that particular approach, informed by the experiences of RCGP experts employed in monitoring the NPFS, and by the countless communications received from the wider College membership.
A key feature of the pandemic campaign was the extent to which clinicians looked to Government and professional bodies to provide solid operational information, as well as reassurances about risk and efficacy. Given the discrepancy between what was expected and what happened, this would also entail adjusting perceptions to a less potent outbreak, while acknowledging and guarding against the devastating effect of the illness in some individuals. The spectre of future, and more dangerous pandemics, makes a thorough and honest review critical in honing our next response, and creating a robust legacy resource for successors.
1.1 Clinical Impact of the Virus
1.1.1 Although such material may be familiar to many, a brief outline of the clinical impact of the virus in the UK will serve as a useful contextual preface to this paper. A more accurate assessment of morbidity and mortality rates will only be possible in time. While initial indications and planning had suggested a far more lethal threat, it is evident that the A/H1N1 2009 virus was a relatively mild self‐limiting illness for the majority of those infected. Early Department of Health (DH) data suggested a mortality rate of 26 deaths per 100,000 cases of swine flu in England1, estimates which compare favorably with other recent pandemics. While the mortality rate for the 1918 Spanish flu was 2‐3%, subsequent 20th century pandemics (1957‐8 and 1967‐8) recorded a rate of around 0.2%.
Table 1: H1N1 (2009) influenza deaths in UK (as of 21 January 2010)
UK Country % of total UK population Flu deaths % of UK flu deaths England 84 279 71.5 Wales 5 28 7.2 N. Ireland 3 17 4.4 Scotland 8 66 17
1.1.2 While overall morbidity and mortality was thankfully not as high as first feared, the virus clearly behaved differently from ‘normal’ seasonal flu. A central finding has been that a younger age group was affected across most indicators, including those most frequently infected, hospitalised, requiring intensive care, and dying. In summary:
• Young adults 15‐24 years of age had the highest estimated rates of clinical illness, with the lowest rate in adults >65 years. The cumulative rates of illness among people aged 24 years and below may have been 30‐80 times higher than for those aged 65 and above. • Death from swine flu amongst young adults was 30 times higher than the same age group in the 2008 flu season.
1 Donaldson LJ et al. Mortality from pandemic A/H1N1 2009 influenza in England: public health surveillance study. BMJ 2009; 339: b5213.
Quality Assuring the NPFS (RCGP, February 2010) 3
• Clinical concern quickly became focused on the management of small subsets of patients who rapidly developed severe progressive pneumonia. • Rates of hospitalisation were high amongst the under‐fives, and Flu Clinical Information Network (Flu‐CIN) figures show that 85% of children aged <5 years admitted did not have pre‐existing comorbidity. • Flu‐CIN figures also demonstrate that around 20% of hospitalised 16‐45 year old females in the UK were pregnant.
1.1.3 During the pandemic UK case estimates were published openly and routinely, but were subject to significant margins of error and methodological complexity, and were also difficult to compare directly between UK countries. In England, Health Protection Agency (HPA) modeling combined sentinel GP consultation rates with swab positivity and NPFS activity. Some epidemiologists raised concerns that the use of NPFS data (which is possibly more highly attuned to the vagaries of healthcare‐seeking behaviour) may have biased overall estimates of flu activity. For instance, the use of an "on‐demand" medication service for "hoarding" may involve an over‐reporting of symptoms with no immediate intention to medicate.
1.1.4 Swab results were also suspected to be a confounding factor in establishing accurate estimates2, as false negatives were inherent to test sensitivities (age‐related positivity rates were conspicuous) and sample degradation. Certainly the wide‐circulated statistic that 90% of those receiving antivirals via the NPFS did not have swine flu created some understandable resistance within the overall campaign. GPs may have been more inclined to code illness generically as ‘other respiratory virus’ rather than specifically as H1N1 as the pandemic progressed, and the undetermined level of asymptomatic flu was a further complexity.
2. The National Pandemic Flu Service (NPFS)
2.1 NPFS Background and Role
2.1.1 The National Pandemic Flu Service (NPFS) was established on 23 July 2009 to provide rapid access to antiviral treatment for all patients with flu symptoms in England. The service was formally envisaged in Pandemic flu: a national framework for responding to an influenza pandemic (DH, November, 2007) which predicted that ‘general medical practices will not be able to expand their collective telephone call‐taking capacity sufficiently to meet the level of demand anticipated.’
2.1.2 While the NPFS was deployed in England, GPs in N. Ireland, Wales and Scotland continued to assess all symptomatic patients in and out of hours, and were able to prescribe/dispense antiviral medication. This distinction is important, not only in considering infrastructure and workload, but in understanding the differing clinical assumptions underpinning treatment. Whereas the clinical protocol supporting the NPFS algorithm – that all symptomatic contacts are treated with antivirals ‐ extended to GPs in the field in England, clinicians elsewhere in the UK worked on the basis of targeting antivirals at vulnerable patients in at‐risk groups.
2.1.3 The NPFS was not a ‘diagnostic’ service, but a facility for establishing flu‐like symptoms and authorising antiviral medicine where appropriate. It used a clinical algorithm developed with advice from a range of clinical and remote assessment services. The algorithm was built around existing national guidelines on the assessment/management of fever and respiratory symptoms, including the identification of ‘red flags’ indicating urgent medical review. The service had two arms (1) a web‐based self‐assessment algorithm, and (2) a call centre service utilising an identical protocol.
2 Fleming D. Influenza surveillance, the swine‐flu pandemic, and the importance of virology. Clinical Evidence, 2009. http://dev.clinicalevidence‐bmj‐com.internal.bmjgroup.com/downloads/16‐11‐09.pdf
Quality Assuring the NPFS (RCGP, February 2010) 4
The two parts employed the same software, but call centres provided non‐clinical human operators to assist patients in using the self‐assessment tool.
2.2 GP Liaison Monitoring Project (RCGP)
2.2.1 At the request of the CMO for England, Professor Sir Liam Donaldson, and funded by the DH, the RCGP worked closely with NHS Direct (NHSD) during the pandemic, supporting quality assurance of the NPFS. The role was one of medical liaison, with no formal remit to provide clinical supervision. The association ran successfully from inauguration of the service until closure on 11 February 2010.
2.2.2 Support was provided to the NPFS by a small network of GPs (six regional leads) who had particular knowledge and skills in telephone assessment, OOH services and/or pandemic planning (list of Liaisons in Annex A). Working together under the co‐ordination of RCGP Pandemic Flu Lead Dr Maureen Baker, Liaisons were allocated to individual NPFS call centres, and became known and trusted colleagues to NHSD account managers and call centre management. As well as conducting routine visits, GP Liaisons contributed their clinical expertise to the design and clinical content of the algorithm via real time observation and user acceptance testing. A weekly RCGP teleconference was held with GP Liaisons and DH/NHSD colleagues to discuss the latest operational developments and any issues emanating from visits. Discussions and actions were fed back to the CMO via weekly RCGP Pandemic Influenza Reports (20 produced).
2.2.3 The efficiency with which the NPFS was established was a notable achievement, and showcased the telecommunication and organisational capabilities of the companies responsible for call‐ centre delivery. Contrary to some adverse media, GP Liaisons consistently noted the quality of call handlers they observed in action, and were equally impressed with the technical set‐up and the professionalism of supervisors and managers. The exceptional perseverance and patience of handlers when dealing with difficult caller circumstances, such as language differences and multiple household assessments, was specifically noted. One‐to‐one monitoring of handler calls by supervisors was appropriate, frequent and robust.
3. GP Workload
3.1 Containment Phase
3.1.1 While the clinical impact of the early ‘containment phase’ is yet to be determined, at least in terms of ultimate infection numbers, the HPA tell us that containment measures (prophylaxis, isolation, swabbing/testing etc) ‘bought time’ during the six month vaccine manufacture and delivery process. However, running the containment strategy was extremely resource intensive in primary care, especially in ‘hotspots’ where containment quickly became contemporaneous with a large surge in assessment and treatment. Although the circumstances of each pandemic will be different, we feel it is important to question whether the inevitability of sustained community transmission of pandemic flu justifies the heavy workload burden placed on frontline workers before the extended rigours of the treatment and vaccination campaigns. One doctor wrote to us that: ‘Care of individual patients is taking second place to flattening the pandemic curve.’
3.2 GP Out‐of‐Hour (OOH) Services
3.2.1 Given the irregular geographical impact of the virus in the UK, it is difficult to characterise a ‘typical’ experience in general practice. However, the 2009 pandemic appears to have demonstrated how little routine ‘surge capacity’ there is in existing OOH services, with reasonably small increases in workload causing exaggerated capacity difficulties. Colleagues have testified that OOH services
Quality Assuring the NPFS (RCGP, February 2010) 5
came under immense pressure at times, particularly in viral ‘hot‐spots’, and that local commissioners had not always planned additional capacity for such exceptional circumstances.
3.2.2 Data from Tower Hamlets (London) OOH services provides some anecdotal illustration. In July 2009 the service experienced 6,731 patient contacts (telephone triage/advice, face‐to‐face contacts and home visits), a level which was more than double that of July 2008 (3,297). The stretching of services was exacerbated by pronounced spikes within weekly activity. In some areas in England it appears that workload amelioration was evident immediately after the NPFS was ‘switched‐on’ on 23 July 2009. By August 2009 OOH monthly workload in Tower Hamlets had fallen back to more typical seasonal levels (3,284 contacts). This mollifying effect was also apparent during core hours. GP consultation data shows that the number of swine flu cases coded as such by Tower Hamlets GPs fell from 1908 in week ending 14/07/09, to 305 in week ending 28/07/09.
3.3 Impact of the NPFS on Workload
NPFS Headline Statistics
2,732,000 assessments (1,482,000 ((54%) online and 1,250,000 (46%) telephone) 1,800,000 (66%) resulted in antiviral authorisation Of these 1,160,000 antivirals collected (64%)
3.3.1 Overall the first mass application of non‐clinical based triage appears to have been a qualified success story. The early impression is that the NPFS succeeded in absorbing excess clinical and administrative workload experienced in general practice in England. While in core hours it enabled routine services to be maintained for non‐flu patients and those with complications of flu (therefore preventing potential displacement to secondary care) its impact was felt most keenly by OOH services. Even so, it is important that we learn more about the comparative experiences of the devolved countries, where the NPFS did not operate.
3.3.2 The service served as an important acknowledgement that a large ‘surge capacity’ cannot be sustained routinely within primary care, and that additional remote capacity can be activated via the commercial sector in times of national need. Its independence from geographical catchment enabled the NPFS to disperse pressure mounting in localities over a national service, effectively providing the NHS in England with an ability to mobilise and deploy resources to ‘hotspot’ areas. The ability to rapidly align its capacity according to microscopic demand trends meant that the NPFS could also anticipate particular times of the week when caller volume would be high.
3.3.3 Undoubtedly future iterations of this model would seek to reduce levels of hand‐off to GP and emergency ambulance services. During the pandemic only a quarter of all assessments were dealt with exclusively by the NPFS (i.e. ‘self care’ with no advice to contact another service). Over 40% were advised to contact their GP at some level, with 32% referred urgently to a GP. An 8% hand‐off to 999 services is a particular concern in terms of intensive resource use. How many of those referred actually contacting GPs or emergency services is undetermined, but clearly high referral levels can potentially challenge service rationale. One RCGP member wrote: ‘as with every other such programme the last comment seems to be: if you are in any doubt, contact your GP.’
Table 2: NPFS Endpoints Analysis (23/07/09 to 11/02/10)
Endpoint 999 Urgent GP GP Self Care NHS Direct Other Total 220,313 870,148 228,502 694,265 706,433 12,911 % 8.06 31.84 8.36 25.41 25.85 0.47
Quality Assuring the NPFS (RCGP, February 2010) 6
3.3.4 Observation by GP Liaisons suggests that call handlers generally referred in accordance with the algorithm, but that thresholds for referral were ultra‐cautious, with inappropriate calls considered an acceptable price to pay for identifying severe or complicated cases. An NHS Direct GP Referral Audit of the service found that the main trigger for GP hand‐offs was ‘additional symptoms’ suggestive of complications, particularly phlegm color. While scripting was tightened up over time, and referrals fell slightly, GP Liaisons felt that access to some sort of limited clinical triaging support on site may have significantly reduced displacement to other services.
3.3.5 It is important to ‘disentangle’ the behavioral and interactional factors involved in determining referral rates. For example, urgent referral to GPs was higher in users of the call service (40.2%) when compared to those self‐conducting online assessment (24.8%). 999 referrals were more frequent in web‐based users, and thresholds for antiviral authorisation were slightly lower in telephone assessments (69%) as compared with online (64%). The potentially differing illness status of those using each arm of the service, and the influence of call agent interpretation, are factors that need to be examined. Identifying an ‘optimum’ level of urgent referral to GP or 999 services is difficult, balancing the considerations of safety, efficacy and workload. Overall we must acknowledge that without the NPFS a large majority of nearly 3 million assessments would have fallen clinically and administratively on GPs, OOH and emergency services.
3.3.6 NPFS call agents were rated largely on their ability to adhere rigidly to scripted protocols. As many call handlers had a background in commercial call centre work, where the establishment of rapport is foremost, the inability to use the full repertoire of their soft communication skills could be frustrating. Observation showed that where handlers strayed into an inappropriately chatty style, or did not adhere to exit scripts, they could inadvertently solicit questions they were ill‐equipped to handle. As the pandemic progressed, and patients tended to know more about the illness and desire further information, this issue became more apparent, and Liaisons noted an increasing tendency among call handlers to defer ambiguity to GPs.
3.3.7 The College received many communications from GPs concerned about issuing sickness certification for those off work for more than seven days, who had been assessed solely by the NPFS. DH guidance issued during the pandemic stated that a telephone consultation would suffice in these circumstances as long as the GP was ‘able to make an adequate assessment of the patient’s fitness or non‐fitness for work’. Concerns fell into several categories:
a) Patients often came into the surgery to acquire certification, potentially increasing community transmission. b) Clinically unnecessary consultations were held purely for certification purposes, undermining NPFS rationale by duplicating patient contacts. c) Issues around medico‐legal liability caused anxiety for those authorising certification over the phone to patients who had not been spoken to or prescribed for at the practice. This was exacerbated by the lack of information provided back to the surgery on whether antivirals had been issued, and by ongoing uncertainties in respect of the infectivity period.
Without details of patient assessment/medication being logged and routinely sent to the GPs by the NPFS, certification over the phone was only ever another form of hearsay. While it increased workload, it was no more effective than self‐certification in distinguishing genuine and fraudulent requests. What is more, incomplete GP medication records have the potential to compromise individual patient care, and limit the ability to monitor populations for any long‐term adverse effects of a relatively little used agent. Should a similar approach be used in future, infrastructural needs associated with sickness certification also need to be addressed from the outset, in order to get maximum benefit from a system designed to protect GP workload.
Quality Assuring the NPFS (RCGP, February 2010) 7
3.3.8 Pandemic planning was understandably informed by a perceived threat that the NPFS could be used for private ‘hoarding’ from a limited antiviral stockpile. This appears to have been an unfounded concern, and the inability of the NPFS to conduct more than one assessment per user, or issue repeat courses of antivirals, created some extra workload for practices. In the case of patients who had lost or wrongly noted reference numbers, the flexibility of a seven day expiry of such numbers would have allowed patients to be reassessed by the NPFS rather than having to go to their GP. Given that many patients who received antivirals initially from the NPFS would not have had swine flu, the need for patients experiencing two or more flu‐like illnesses to visit the GP for repeat assessments/antivirals has the potential to delay the effect on practice of each wave.
3.3.9 Furthermore, GPs reported that many patients were contacting them for ‘second opinions’ on whether to take antivirals issued by the NPFS, or to clarify the ‘diagnosis’. Others rang to find out basic information such as where the nearest collection point was and when it was open. Given the unfamiliar system, and the novelty of these medications for patients, it is unsurprising that many viewed their GP as the default authority on uncertain clinical and organisational issues.
RCGP Member comment: Patients phone the practice asking for a medical certificate when they have been off work for seven days (having received their antivirals via the NPFS), and of course we then have to see them (which is medically unnecessary because they are getting better anyway) in order to give them a Med 3. Thus in some circumstances a visit has to be made purely to enable a sick note to be given. This creates additional work for GPs and also creates unnecessary exposure to the virus.
3.4 Workload and the Vaccine Programme
3.4.1 The vaccine programme placed a heavy burden on practice staff, and that this was characterised by a logistic and administrative load that was sometimes disproportionate to the task. The volume of calls associated with running two parallel vaccination programmes (seasonal and pandemic), and the workload involved in planning clinics, arranging patient call/recall, preparing forms and paperwork meant that some practices reported facing a choice between core responsibilities and flu vaccinations. One GP wrote that: ‘For us to attempt to immunise the majority of these patients by the end of the year would require significant suspension of our routine nursing clinics, and is impacting on our routine and QOF work. We are seriously concerned that routine medical/nursing care with QOF achievement for clinical domains will be undermined.’
3.4.2 Practices had problems defining and communicating with vaccine priority groups, and particularly in identifying immunocompromised (including household contacts) and pregnant patients on their lists. The initial staggered approach of vaccinating priority groups in set order was laden with complexities, which were amplified by supply uncertainties. This logistic impracticality was later acknowledged by central directions enabling practices to vaccinate all their priority groups together. There was also ongoing uncertainty on dosage regimes and a lack of guidance on particular clinical issues, such as when to vaccinate patients in relation to chemotherapy cycles.
3.4.3 The manufacture and delivery of vaccines within the agreed timescale was a major achievement, with the UK leading the way internationally. However, due to the inherently piecemeal nature of production, the Government and its advisors were faced with an unenviable choice. Either supply all practices with initial doses that were inadequate for large practices, or ration to particular geographical regions. The course taken seems the correct one, even though it proved discriminatory in areas with a preponderance of large practices. However, for large practices there was a lack of central direction about exactly how to ration and prioritise their initial doses within priority groups, and this unquestionably caused extra workload. Some surgeries prioritised pregnant women and immunocompromised patients, while others selected randomly or simply offered the vaccine to anyone in the at‐risk group who wished to have it, until it ran out.
Quality Assuring the NPFS (RCGP, February 2010) 8
3.4.4 The nature of the vaccine itself compounded these logistical problems. Whereas target groups for seasonal flu vaccine can be seen on an ‘opportunistic’ basis during routine appointments, H1N1 vaccines necessitated special clinics due to the need to use all of a multidose vial shortly after opening. Nursing and Midwifery Standards, which stated that registered nurses must not prepare substances for injection in advance of their immediate use, or administer medication drawn into a syringe or container by another practitioner when not in their presence, added further complexity.
3.4.5 Given that early data showed healthy children under five to be vulnerable to severe illness, the delay in their inclusion until the 'second wave' of immunisation in late December 2009 may be viewed as a missed opportunity. Delays caused by drawn‐out contractual negotiations meant that this second wave clashed with the Christmas holiday, and would also need to be conducted at a time when the pandemic was publicly perceived to be petering out. It is unsurprising that the take‐ up has been low, particularly as the need to arrange provision through local contracts has resulted in patchy delivery. This was a unique opportunity to immunise healthy young children (who are not routinely included in seasonal priority groups), and this may be of concern if H1N1 re‐emerges as a more severe virus.
4. Safety and Efficacy
4.1 Safety and the NPFS
RCGP Member comment: [The NPFS] embeds the idea that there is a magic pill to cure all illnesses and that diagnosis is nothing more than following a flowchart. Who is taking medico‐legal responsibility for this fiasco? Just wait for the first fatal missed case of meningitis or pneumonia? Why are we using Tamiflu anyway? If given within 48 hours it may reduce symptoms by 24 hours – clearly with this evidence everyone with a sniffle needs to be treated!
4.1.1 Much has been written of late about the safety of triage systems such as the NPFS, and cases have been publicly reported in which diagnosis and management may have been delayed because of an initial incorrect assumption of swine flu. A recent letter in the BMJ3 presented several cases, and discussed the limitations of algorithms in replacing comprehensive history taking, clinical acumen, and laboratory support in establishing accurate diagnoses. This was jointly responded to by GP Liaisons and NHS Direct in the form of a Rapid Response4, and the RCGP is currently writing a short analytical article on the NPFS for the print BMJ.
4.1.2 Throughout the pandemic the College reminded its members that the NPFS, in keeping with other “triage” assessment systems, was not designed to have the acumen of a complete medical assessment. Non‐medical call handlers were not empowered to make diagnostic judgments but rigidly followed an algorithm cautiously weighted (by initial ‘emergency’ questions) to favour safety‐first referral, and structured to eliminate handler discretion. Perhaps the message could have been more clearly communicated to clinicians/patients from the outset, as misinterpretation of function can present dangers in itself. Notwithstanding this, it is inevitable that some clinicians will question the extent to which taking a history over the phone, and interpreting those symptoms to direct a medical intervention (albeit using a decision support system), can be differentiated from diagnosis and treatment.
3 Catherine F Houlihan, Sanjay Patel, David A Price, Manoj Valappil, and Uli Schwab. Life threatening infections labeled swine flu. BMJ 2010; 340: c137, doi: 10.1136/bmj.c137 (13 Jan 2010) 4 Kate J Adams, John Gration, Maureen Baker, Cecily Cook. Strategy and Impact of the National Pandemic Flu Service. BMJ Rapid Response (23 Jan 2010) www.bmj.com/cgi/eletters/340/jan13_3/c137
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4.1.3 Most doctors are familiar with the late presentation, diagnosis or treatment of many conditions. Certain illnesses present with non‐specific or insidious flu‐like symptoms, and even in non‐ pandemic circumstances a non‐flu diagnosis is often only suspected at the second or subsequent consultation. Delays may be attributable to various factors, many of which are not specific to triage algorithms. In trying to unpick individual scenarios the motivation of the self‐assessor is an unknown factor, and NHS Direct found that many ‘incidents’ related to the way patients ‘manipulated’ the algorithm in order to reach a preordained outcome.
4.1.4 Although there have been anecdotal stories circulating about delayed or missed diagnosis, a robust body of quantitative evidence is not currently available. Looking at available data, NHS Direct tells us that from 23 July to 10 November, during which time over two million assessments were undertaken, 1,239 incidents were reported and reviewed by the DH clinical team, of which only five were specifically related to the NPFS, and one to missed diagnosis.
4.1.5 However, clinical incident management within the NHS during the pandemic appears to have been somewhat fragmented. Reports were drawn from the NPSA‐managed National Reporting and Learning System (NRLS), from the MHRA ‘yellow card’ system, as well as via ad hoc from SHA and PCT Flu Leads. These schemes are ‘passive’ and reporter‐dependent. The NPFS Service Centre tool to log and manage incidents (‘MAGIC’) was only introduced in November 2009. With hindsight, and given the experimental nature of the scheme, greater patient ‘buy‐in’ via proactive facilitation of self‐reporting might have been built in from the outset. Certainly any future system should incorporate a patient satisfaction survey for a fixed proportion of patients, enabling feedback on adverse systemic or clinical events.
4.1.6 GP Liaisons noted that more integrated ‘safety‐netting’ of the NPFS would have been beneficial. The possibility of exacerbations in a patient’s illness is a message that failed to stick at times. Such advice should have been received in written form when a patient collected an antiviral, but a perceived corrosion in such infrastructural arrangements over time meant that this did not always occur at collection points. Call handlers also lacked the ability to explicitly ensure that patients had understood lengthy verbal safety‐netting instructions. Web‐based solutions could enable information to be emailed to online users upon completion of assessment.
RCGP Member comment: Taking a history over the phone and interpreting those symptoms (albeit using a decision support system) to determine the cause, and then directing a medical intervention, is in effect diagnosis and treatment – normally a long and complex training programme for clinicians to achieve competence. We must not get complacent about the limitations and dangers of the NPFS no matter how supportive it is in demand management.
4.2 Antivirals and Efficacy
4.2.1 Two thirds (66%) of all NPFS assessments resulted in antiviral authorisation, and this has prompted an ongoing debate in the medical community about the efficacy of antiviral treatment, in particular its indication for all symptomatic patients in England. Current efficacy studies are focused on length of hospital stay, patient outcome and antiviral timing, and Flu‐CIN data shows that only a small proportion of hospitalised patients in the UK were treated with antivirals pre‐admission. The significance of this observation is limited by the absence of a control group, but early indications are that antivirals may have played a significant part in preventing or ameliorating severe complications. Such assumptions were incorporated into DH clinical management guidelines published during the pandemic5.
5 Department of Health. Pandemic H1N1 2009 influenza: clinical management guidelines for adults and children. DH, Oct 2009.
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4.2.2 In terms of antiviral timing, there were question marks around the universal indication for treatment in those presenting up to seven days after the onset of symptoms. Antiviral Summary Product Characteristics (SPC) suggested treatment within 48 hours, and public health officials in some localities advised doctors that there was no point in starting treatment after 48 hours. Emerging information on hospitalised patients with pandemic H1N1 2009 influenza suggests that antivirals given more than 48 hours and up to seven days after symptom onset can confer benefit6.
4.2.3 The targeting of inclusive symptoms with single‐course antivirals, as employed in England, should be brought into direct epidemiological comparison with countries applying a more limited approach. This may not be possible, due to the number of confounding factors, but there is some limited evidence that the treatment of all symptomatic patients with antivirals reduced hospitalisations, ITU admissions and deaths7.
4.2.4 The use of antivirals as prophylaxis has also been contentious. As containment merged into the treatment phase GPs were increasingly unsure as to the categories of those who qualified for prophylaxis, citing differences in central guidance. Furthermore WHO had recommended against the use of antivirals in prophylaxis due to the threat of developing resistance8. The HPA cohort study examining illness and transmission characteristics after antiviral use (First Few Hundred (FF100)) indicates that prophylactic antivirals shortened the duration of illness and were effective in preventing household spread. For example, secondary virologically confirmed household attack rate was found to be >90% lower among household contacts who received antiviral prophylaxis9.
4.2.5 It is clear that the impact of antivirals on mortality/morbidity must be properly reviewed both from public health and cost‐benefit perspectives. The RCGP made this clear in a letter to the DH dated 17 December 2009.
4.3 GP Diagnosis and Treatment
4.3.1 Quite rightly GPs expressed concern at the lack of a robust and publicly accessible evidence‐base for antiviral treatment, and reminded us of the specific need for sound data on number needed to treat (NNT) and number needed to harm (NNH). Others characterised the approach to the use of antivirals in England as 'scatter gun', and admitted that they had advised patients not to take those authorised by the NPFS. Overall the threshold for authorising antivirals in England seems to have been far higher among clinicians than via the NPFS. With the benefit of individual clinical discretion this is to be expected to some extent, and one member told us that: ‘as the situation has evolved many of us feel more confident in not prescribing for low‐risk patients’. Other GPs told us that they had made no changes at all to their normal winter practice.
4.3.2 Doctors and NPFS call handlers noted the low specificity and possible ‘over‐inclusiveness’ of pyrexia >38 as a diagnostic indicator for antiviral authorisation. Lack of standardisation in the type and calibration of thermometers used in general practice, and the failure to deliver a clear public health message encouraging people to have thermometers in their homes to aid self‐assessment, were of particular concern to some members. There was apparent confusion as to whether pyrexia >38 needed to be persistent. This resulted in some clinicians insisting on a pyrexia of >38 at all stages, while others were content with a history of fever as the first criterion for diagnosis. This was further complicated by cases in which patients were controlling their temperature by self‐
6 Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, et al. Hospitalized Patients with 2009 H1N1 Influenza in the United States, April‐June 2009. N Engl J Med 2009; 361 (10.1056/NEJMoa0906695). 7 Deuffic‐Burbanet et al. PLoSCurrents: Influenza 2009 Oct 28:RRN1121 8 HPA recently reported 36 cases of resistance to Tamiflu out of a sample of 10,000, a rate of <0.1%. 9 Health Protection Agency. Pandemic H1N1 2009 in England: an overview of initial epidemiological findings. HPA, 2009.
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medicated antipyretics. On a similar issue, the ability of GPs to measure peripheral oxygen saturation by pulse oximetry (as mandated within the DH Clinical Management Guidelines) was limited by GPs not having access to oximeters. The RCGP has recommended that this inexpensive equipment is purchased by all practices according to GP Airways Group specifications10.
4.3.3 On a more philosophical level, we noted a general anxiety that the expectation of active treatment was being raised subliminally and ‘minor’ conditions being medicalised ‘by stealth’. One GP wrote: ‘why should our patients not expect Tamiflu for the normal winter flu season, which is certainly more virulent than the current outbreak’, while others promoted the view that the pandemic should have been allowed to ‘run its course’ without any extraordinary measures being employed. While there is some currency in guarding against the public expectation of a ‘pill for every ill’, there exists a persuasive counter argument that new drugs/treatment options enable clinicians to be less culturally accepting of ‘excess’ mortality associated with ‘normal’ flu.
4.3.4 There has been understandable concern among doctors that the NPFS represents the ‘thin end of the wedge’ in terms of replacement of GP services with non‐clinical triage systems. While it is worth investigating the further applicability of such systems, the risk of missed or delayed ‘diagnosis’ tends to outweigh the benefits when the level of circulating flu is at ‘typical’ levels. Additionally, and as predicted, the absolute number of emergency referrals from the NPFS remained constant throughout the pandemic, meaning that their proportion increased as overall assessment numbers fell. At a certain level of activity the system therefore becomes less effective in terms of risk and reducing pressures on other services. At present we do not foresee the use of mass non‐clinical triage outside of similarly extraordinary circumstances.
5. Communication
5.1 Communication and the RCGP
5.1.1 Led by Dr Maureen Baker the College has been preparing the primary care pandemic response for a number of years. Working closely with the BMA via the joint Emergency Planning Group (Pandemic Influenza), detailed operational preparedness guidance for general practice was published (with some prescience) in January 2009. During the course of the pandemic this advice (written originally in anticipation of avian influenza) was customised to the 2009 swine flu (H1N1) outbreak, forming a universal resource for practices in understanding the latest evidence and service needs. As a College we aim to maintain our commitment to primary care preparedness work, in anticipation of future flu pandemics or other public health emergencies.
5.1.2 A key challenge for practices was in absorbing the huge amount of frequently‐revised guidance emanating from (and dispersed over) a wide variety of sources. Clinicians reported that they had trouble finding current, definitive guidance due to the flood of information from local and national organisations. Version control was an issue across both electronic and print resources. We feel that a single dedicated cross‐organisational website (e.g. www.pandemic.org.uk) would enhance future responses.
5.1.3 The RCGP Flu Update was sent regularly to over thirty thousand GP members, practice staff and other NHS personnel throughout the pandemic. It summarised operational and clinical guidance, and provided a brief epidemiological overview of outbreak progression drawing on local, national and international experiences. A weekly teleconference with HPA/BMA/GP colleagues provided an invaluable context to these communiqués. Feedback provided by members on the updates has been overwhelmingly positive, and for many they formed a singular trusted source of information. Readers were encouraged to provide comments and suggestions via a dedicated flu
10 General Practice Airways Group. Pulse oximetry in primary care (Opinion paper 28). GPIAG, Apr 09.
Quality Assuring the NPFS (RCGP, February 2010) 12
inbox (flu@rcgp). This proved extremely useful in the early identification of issues encountered in the field. Comments were collated and shared with senior colleagues in UK health departments, forming a constant flow of intelligence from grassroots clinicians to central policy‐makers. Due to the success of the approach the RCGP and HPA are exploring a continuing relationship for disseminating key public health messages to GPs.
5.1.4 The College aligned itself early with a broad church commitment to providing unified and consistent key messages to healthcare professionals. It quickly became apparent that ‘maverick’ positions were untenable in such a climate of uncertainty and rapid change. The overall impression was of a refreshing and unprecedented level of openness and cooperation between agencies in managing and communicating information. The DH rapidly assembled a clinical group to review queries from GPs, responding immediately to issues highlighted by the College and its members.
5.1.5 Throughout the pandemic close relationships were nurtured with other specialist medical organisations, particularly in promoting key messages associated with vulnerable populations. Early on the College co‐authored a letter with the Royal College of Paediatrics and Child Health (RCPCH) and the BMA on guidance for assessing children under the age of one. In November 2009 the RCGP also wrote a Joint Letter (with the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives) aimed at reassuring midwives and nurses on the safety of the H1N1 vaccines, and the over‐proportionate risk of severe complications in pregnant women.
5.2 NPFS and the Primary Care Interface
5.2.1 Whereas the clinical protocol that supported the NPFS algorithm ‐ that all symptomatic contacts would be treated with antivirals ‐ extended to GPs in the field in England, clinicians in other UK countries worked on the basis of targeting antivirals at vulnerable patients in clinical at‐risk groups. The dependency of clinical protocol on geographical location would be a difficult message to communicate from the outset, for governments and the College alike. Potentially GPs in the devolved countries faced a greater workload than their English counterparts, and differing treatment protocols for similar presentations inevitably stimulated debate on antiviral efficacy. Any future unilateral approach will be predicated upon evidence emerging globally regarding the use and effectiveness of antivirals.
5.2.2 Multiple entry points to primary treatment in England led to some confusion in the understanding of how GP services and the NPFS interfaced, most specifically in the third of all NPFS assessments (29%) which resulted in the issuing of antivirals alongside advice to see a GP. Instances where patients were directed back and forth between the NPFS and their GP, and found it difficult to find a point of care within that circular loop, were relatively common. While call handlers were able to correctly identify why a GP referral trigger had been reached (typically due to greater risk of developing complications e.g. green phlegm, chest pains or medical history/status), the system did not enable call handlers to incorporate a specific clinical trigger in advice to patients about contacting their GP. Patients therefore lacked clarity as to why they had been referred to a GP, and in establishing their expectations of such a referral. This had several consequences:
a) Doctors told us that ‘typically patients have no idea why they are ringing us’ but that callers were confident that they have been diagnostically assessed and confirmed with flu, and that the supply of antivirals validated this diagnosis. b) Without patients being armed with a specific clinical ‘reason’ for contacting the GP, and without any indication what kind of triaged case they were dealing with, some doctors may have viewed NPFS assessment and/or the prior authorisation of antivirals as a panacea, and been predisposed towards assuming a diagnosis of flu. c) Patients did not appear aware of the timeframe or mode for contacting the GP or OOH service, often just turning up at the surgery.
Quality Assuring the NPFS (RCGP, February 2010) 13
5.2.3 GP Liaisons recommended relatively early that call handler scripting be changed to incorporate advice to patients regarding the exact trigger symptom(s) for referral, and that it be given in a way that does not presuppose flu. Such a change was precluded by (1) understandable wariness around generating scripting that encouraged call handler judgment in issuing individual referral advice and (2) the inability of the algorithm technology to quickly adopt change. This inflexibility was also exemplified by important changes around possible malarial symptoms only being incorporated towards the very end of the service.
5.2.4 Some patients who rang their GP surgery as a first ‘port‐of‐call’ experienced blanket referral to the NPFS by reception staff, including (inappropriately) children under‐one and pregnant women. This was perhaps unsurprising given the initial thrust of the public health campaign, which might have been construed as advising universal referral of all symptomatic patients. A blanket inability to access family doctor services will exacerbate any health inequalities inherent in remote triage systems, particularly those relating to age and user familiarity with help‐lines and online services. The DH and RCGP worked rapidly to develop a 'checklist' for GP receptionists, making it explicit when GP assessment was expected, either in the first instance or upon referral.
5.2.5 The College worked closely with the NHS Flu Resilience team and the BMA in risk assessing the voucher system used for GP antiviral authorisation in England. Vouchers were deemed safer than using amended FP10s for children under‐13 years, as dosage was integral to the voucher. However, constant revisions to EU recommended childhood dosages meant that vouchers were locked into a short‐term obsolescence cycle. Vouchers were unpopular among some GPs for other practical reasons, one doctor writing that ‘[the vouchers] do not integrate into our clinical systems, with no automated demographics, and no record in the IT system. They are clumsy to use, time‐consuming, prone to handwriting misunderstandings, and are inconvenient for patients or flu friends who have to collect and present them.’ There was also a degree of resentment that call‐centre staff could issue a code rather than a voucher, some feeling this demonstrated a lack of trust in doctors.
5.3 Communication and the Vaccine Programme
RCGP Member comment: The general public has been led to believe that we would have vaccine by 26 October. In our practice the delivery of vaccine was weeks behind the publicity from the DH. We were given no idea of exactly when it would arrive, so our staff were burdened with fielding calls from anxious patients, and then making over 1000 phone calls when the 500 doses finally arrived, as we had been unable to publicise a planned clinic due to uncertainty on delivery. To make matters worse, we discover on the TV news, and not from the DH, that the programme is to be extended to all under 5’s.
5.3.1 Summary data from WHO, alongside frequent, detailed pharmacovigilance updates issued by the MHRA and European Medicines Agency (EMA), indicates the ‘excellent safety profile’ of H1N1 vaccines. No differences were noted in the safety profile of the different vaccines used worldwide, whether inactivated non‐adjuvanted, inactivated adjuvanted, or live attenuated. The HPA also suggests that H1N1 vaccines used in the UK are at least as efficacious in their immunogenicity as seasonal vaccines.
5.3.2 However, the UK vaccine programme encountered a large degree of professional and patient resistance, fuelled somewhat by increasingly alarmist information from sections of the media, and by persistent ‘folk knowledge’ that the vaccine was unsafe, untested, and/or unlicensed. This distrust was fanned by rumours that governments and their expert committees nurtured unhealthy links with pharmaceutical companies and that, having invested so heavily in vaccine/antivirals, were obliged to use them irrespective of clinical efficacy. Negative pressure also emanated from a small minority of individual doctors regarding the benefits and safety of the H1N1 vaccine.
Quality Assuring the NPFS (RCGP, February 2010) 14
5.3.3 As new vaccines will always be an emotive issue for patients (we are still dealing with the legacies of MMR and “vaccine damaged” children) this negative publicity might have been expected. Rather than enabling the media to lead the agenda, future campaigns may demand extra efforts to provide proactive counter‐information centrally. Given the power and ubiquity of internet rumor, strong and focused public health campaigns are more vital than ever.
5.3.4 There was accumulating evidence that some nurses and midwives were refusing to immunise pregnant women or strongly advising them against this option on safety grounds. International differences in the use of adjuvanted vaccine in pregnant women, as well as local variation in advice about applicability to first trimester pregnancies were contributory factors. While some uncertainty, and in some cases hostility to novel vaccines is expected, the over‐proportionate risk of severe complications in pregnant women made this a worrying phenomenon. In November 2009 the College issued a joint letter with the RCOG/RCM, aimed at reassuring midwives/nurses on H1N1 vaccine safety in this context. Cultural resistance deserves closer scrutiny, as these healthcare professionals were undoubtedly working in the perceived best interests of their patients. Nurses appear particularly vulnerable to anxieties about medico‐legal liability, and inconsistent professional advice around issues such as the legal requirement for non‐prescribing nurses to administer vaccinations via a Patient Group Directive (PGD) endured throughout.
5.3.5 Although initial indications suggest that GPs took up the H1N1 vaccine in greater numbers than is customary for seasonal flu, there is still work to be done in this area, not least because the personal example of clinicians is an extremely powerful incentive to patients. However, poor clinician uptake cannot be wholly attributed to resistant attitudes. Trainee, sessional and OOH GPs often found that no specific vaccination plans had been made for them, and there was confusion as to whether doctors should be immunised at work or at their registered practice. Some GPs, including pregnant doctors, encountered reluctance to vaccinate within occupational health services, while others felt patients should be given priority to the limited stock. Concerns about the reactogenicity of the vaccine made some practices reluctant to risk disruption from staff absence.
5.3.6 The extension of the vaccination programme to healthy under‐fives proved a contentious episode. Some GPs expressed anger that the national media was informed before PCTs or GP leaders, and viewed this ‘disenfranchisement’ as symbolic of a lack of trust. GPs often found themselves contradicting their prior advice to parents, and felt this undermined patient confidence. Ambiguity in central guidance on vaccination for essential public‐facing practice staff, such as receptionists, meant that many PCTs unilaterally adjudicated that such staff did not qualify for immunisation.
RCGP Member comment: I have particularly noted the derision with which colleagues seem to treat my decision [to be vaccinated]. [Colleagues] cite suspicion about less than thorough testing, the motives of the Government, and feel that swine flu is mild in the main so will "take their chances". I am puzzled by this response, as I view it as a vaccine preventable disease. It's a concern, because like many vaccination programmes, one of the most powerful ways of convincing patients that the vaccine is appropriate (e.g. with MMR) is to say that one has personally had the vaccine, or that one has vaccinated ones own children.
Quality Assuring the NPFS (RCGP, February 2010) 15
6. Conclusion
Although this paper necessarily draws on specific concerns, the College anticipates that the UK experience will be viewed as extremely positive within the international context, with the strong performance of general practice a significant feature. GPs were able to continue providing ‘service as usual’, particularly in the out‐of‐hours period which is so sensitive to the vagaries of demand. However, this is also an important opportunity to consider whether the NHS is positioned to cope with a more potent virus than that experienced, and the emergence of global evidence on the use/effectiveness of antivirals must be incorporated into future planning assumptions. We have been told that the NPFS model will be subject to fine‐tuning ahead of dormancy and any future deployment, and hope that some of the observations recorded here will support that process.
Lessons for the Future
1. A lack of ‘surge capacity’ in existing OOH services makes the NPFS model a useful weapon to have in the NHS arsenal for further emergencies. Future iterations would seek to reduce levels of displacement to other services, and address collateral workload issues, such as those relating to sickness certification. Fears around private antiviral stockpiling seem unfounded, and the inability of the NPFS to issue second courses of antivirals created difficulties.
2. Clinical incident data could have been gathered more proactively by, for instance, incorporating satisfaction surveys for a proportion of NPFS patients. Patients require more integrated ‘safety‐ netting’ around worsening symptoms and clarity as to why they had been referred between services. The use of the NPFS model outside of ‘crisis’ situations must be considered with caution, as at certain levels of circulating flu the liability of such systems can outweigh the benefits.
3. Differences in treatment protocols between UK countries caused communication difficulties. The impact of antivirals on mortality/morbidity must be reviewed from public health and cost‐benefit perspectives. Concerns over low specificity and ‘over‐inclusiveness’ of diagnostic indicators may have resulted in a higher threshold for antiviral authorisation by clinicians than via the NPFS.
4. Fears about medicalising ‘minor’ conditions are subject to an equally persuasive counter‐argument that new drugs/treatment options enable less cultural acceptance of ‘excess’ mortality associated with flu.
5. The containment strategy was resource intensive in primary care, and impacted heavily ahead of treatment and vaccination phases. If we suppose that sustained community transmission of pandemic flu is inevitable, is a similar containment plan a viable option in the future?
6. The vaccine programme placed a heavy burden on practices, characterised by a disproportionate logistic and administrative load. GPs felt that public and professional communications could have been better aligned. Professional and patient resistance to a novel vaccine, fuelled by alarmist media information, might have been anticipated and countered more effectively by central planning. Cultural resistance within healthcare professions also requires closer scrutiny.
7. The College became a trusted source of operational information for its members during the pandemic, and a continuing relationship in disseminating key public health messages to GPs would be beneficial. Overall the pandemic saw an unprecedented level of openness and cooperation between agencies, representing an extremely positive by‐product of this episode.
Quality Assuring the NPFS (RCGP, February 2010) 16
Annex A: GP Liaisons (NPFS Monitoring Project)
Dr Simon Stockley, GP Liaison for Newcastle and Gateshead call centres.
Dr Kate Adams, GP Liaison for London (Southwark and Watford call centres).
Dr Turlough Tracey, GP Liaison for Bangor and Newry call centres.
Dr Agnelo Fernandes, GP Liaison for Richmond and Kingston call centres.
Dr Fay Wilson, GP Liaison for Birmingham and Ashby call centres.
Dr John Gration, GP Liaison for South‐West (Exeter, Bristol, Cardiff, Swansea).
Quality Assuring the NPFS (RCGP, February 2010) 17
London Response to Swine Flu
February 2010
In response to the London Assembly Health and Public Services Committee’s request for lessons learnt from London trusts, NHS Kingston has produced an overview of our local views.
In terms of swine flu cases the borough experienced a slightly lower attack rate compared to the average seen across London during the containment phase. The number of new cases began to mirror the national picture during the treatment phase with the peak coinciding with the opening of the national flu line.
Following the peak week the number of cases continued to decrease locally with the exception of a slight increase in late autumn. As numbers continued to fall in early 2010, NHS Kingston organised a multi-agency debrief to discuss the lessons learnt from the swine flu outbreak. Some of the key outcomes from the meeting have been highlighted below;
1. What aspects of the response to swine flu in London were handled well? • The pandemic flu audit in early 2009 provided a useful platform for generally responding to the outbreak later in the year. • The Noon brief was a practical document to ensure actions had been completed locally • Having one point of contact (email) for NHSL • NHSL responding quickly and efficiently to general enquiries • The HPA London flu centre was a helpful point of contact for health professionals • Requesting a ‘Live’ exercise prior to opening the PCT ACP • Relationships were already in place across emergency planning colleagues • Pan-London table-top exercise for executives reiterated the importance of robust plans. • Recognition from NHSL of our vaccination plan
2. What aspects of the response to swine flu in London could have been improved and how? • There could have been streamlining of the reports that needed to be generated across the health economy for NHSL and DH • The delay in receiving final DH guidance materials in the initial stages • The planning phase had not fully explored the issues around using containment as a strategy • Different agencies and government departments contacted certain organisations directly outside of NHS London. This caused confusion as the information was either contradicting or duplicated previous messages sent locally. • Timescales to implement actions were rapid which restricted the amount of stakeholder consultation. • No clear advice on childcare or the rationale for closure of schools and whether children should avoid all gatherings during the containment phase. • Varying opening hours of ACPs across London and neighbouring counties. This resulted in higher volumes of flu friends attending our ACPs over the weekends • National Pandemic Flu Line – we were uncertain as to whether all operators had the skills to fully assess the symptoms of callers
Overall, NHS Kingston successfully managed the response to the swine flu outbreak. A number of lessons learnt have been identified and action plans are now in place to ensure plans are robust for future incidents.
Jonathan Hildebrand Joint Director of Public Health Dear Sarah,
Thank you for your letter dated 22 January 2010.
You asked for our views on two questions – please see answers below.
1. What aspects of the response to swine flu in London were handled well?
1. At the start of the Swine Flu Pandemic organisations had to use existing links for communication between Primary Care Trusts (PCTs), Local Authorities (LAs), Ambulance Services, Acute Trusts, the Police etc. to coordinate our response to the pandemic. In Westminster we found that the existing links with these key stakeholders were very strong, which definitely contributed to the successful response to the Swine Flu Pandemic from NHS Westminster. 2. Teleconferences were an efficient method of communication during the pressurised periods of the pandemic. We attended 2 regular teleconferences: • One was the monthly teleconference with NHS London (for PCTs) which was very useful. We could discuss what other PCTs were doing, get information updates and also give feedback to NHS London on how we were getting on at PCT level. • The second one was our weekly Inner North West London Flu teleconference – this teleconference’s membership included representatives of 4 PCTs (Westminster, Kensington and Chelsea, Hammersmith and Fulham and Brent), the Acute Trusts affiliated with the 4 PCTs, the Out of Hours Service, and the Mental Health Trust. This teleconference was extremely valuable. It gave us a chance to discuss logistical issues, national and local guidance, and our individual responses to the pandemic. 3. The noon brief compiled by NHS London has been useful in conveying important information through one, reliable route every day. Highlighting new information in blue each day was extremely helpful in pressurised periods. 4. A single point of contact at NHS London ([email protected]) was convenient. Queries were answered quickly (mostly within one day) and could be about anything related to Swine Flu (PPE, Antivirals, Vaccines and Vaccine consumables, national guidance, clinical guidance etc.)
2. What aspects of the response to swine flu in London could have been improved and how?
1. Sharing good practice around London on what all the London PCTs were doing. Relevant good practice points were discussed at monthly NHS London teleconferences, but these discussions were mostly opportunistic. In the future, more emphasis on the importance of sharing good practice might encourage PCTs to do so, which will significantly help other PCTs who might be facing the same challenges. 2. Some responses from NHS London in answer to our queries were not very clear. However, we appreciate that clear answers were not always available to the NHS London Pandemic Flu team either. 3. National guidance on the private providers’ role in the vaccination programme took a considerable amount of time to finalise. This was a particular issue for this PCT as we have quite a significant number of private GPs within the Westminster area. In the future, it would be helpful if the DH and SHAs address the private providers’ role during a pandemic earlier on than it was this time around. In addition, PCTs with a large number of private GPs/hospitals (like NHS Westminster) should play some part in the formation of policy regarding the role of private GPs in such scenarios as we have a major stake in ensuring good working relationships and processes with these stakeholders. 4. IT problems at NHS London were problematic at the height of the pandemic. (Noon Briefs was late for a few weeks) 5. More involvement by NHS London during the containment phase of the pandemic could have significantly reduced confusion in this period. The possibility of a containment phase should be included in any future Pandemic Flu plans for NHS London.
I hope this is helpful. Please feel free to contact me if you have any questions.
Kind regards,
Maryke
Maryke Welman Public Health Programme Manager (Swine Flu)
NHS Westminster 15 Marylebone Road London NW1 5JD T: 020 7150 8277 F: 020 7150 8105 E: [email protected]
London’s Swine flu pandemic – views from the capital’s GPs and practice staff on the frontline
Purpose of report for The London Assembly Health and Public Services Committee – 16 March 2010
• To aid the Committee’s discussions with NHS London as to how the capital’s GPs responded and the practical support offered to both NHS London and practices by Londonwide LMCs.
• To answer two questions:
i) What aspects of the response to swine flu in London were handled well?
ii) What aspects of the response to swine flu could have been improved and how?
Context
Londonwide LMCs is the umbrella body for statutory Local Medical Committees (LMCs) across the capital, representing 6,500 GPs, 3,000 practice nurses and 1500 practices across 26 PCT boundaries. The remaining 5 PCT areas are served by LMCs outside Londonwide LMCs jurisdiction but whom often work in collaboration with ourselves.
Facts
• Start of London’s outbreak (June ’09) – Londonwide LMCs Chief Executive, Dr Michelle Drage, offered NHS London’s Director of Public Health our well established communication resources (email alerts, website, newsletters, briefings, LMC meetings) as a direct and practical way of reaching GPs in a timely and effective manner. This was immediately accepted
• June’09 - Feb ’10 :Daily and weekly telephone briefings between Londonwide LMCs Chief Executive to the Public Health Team to keep them abreast of issues, communication blocks, further clarification required on dosage levels, tamiflu pick up points, authorisation vouchers etc
• June ’09 – February 2010: Londonwide LMCs created a specific communications programme: regular, direct key messages to GPs, Practice Managers and Practice Nurses to ensure clarity of messages and to provide a single authoritative source; in addition, a flu hotline was created for practices to report any problems (which in turn were fed back to the Public Health Team for consideration/action)`
Hdrive/London Assembly swine flu response S Broome/v.2 draft 15.2.10
• June – Dec: 500+ enquiries received to Londonwide LMCs ‘flu-line’ ([email protected]) and acted upon; 34 flu-specific briefings emailed to practice
Hdrive/London Assembly swine flu response S Broome/v.2 draft 15.2.10
• Patient information posters created to help practices manage patient expectations/concerns
• Pan-London agreement on payment for vaccinating phase ii of the programme (children under 5s) initiated by Londonwide LMCs and NHS London accepts. Other London LMC bodies accept the agreement. Result: NHS London achieves a rapid solution which avoided 31 separate negotiations taking place at PCT level.
What aspects of the response to swine flu in London were handled well?
• NHS London’s willingness to engage and accept Londonwide LMCs offer of support in getting information direct to the frontline (general practice) bypassed a lengthy and protracted communication cascade between the centre – 31 PCTs – 1500+ practices
• Londonwide LMCs flu line created an immediate communication channel for NHS London in hearing where blocks/misunderstanding/confusion around practices interpreting/obtaining practical advice and assistance
What aspects of the response to swine flu in London could have been improved and how?
• Earlier recognition centrally that each PCT is likely to implement any guidance in their own manner and at differing speeds – that in itself creates its own communication challenges and practical difficulties for practices and ultimately, patients
• At a local level, some of the difficulties encountered by practices included:
- Speed at which information/guidance changed almost on a daily basis
- Individual PCTs appearing to be slower in responding than neighbouring ones, which in itself created confusion eg notification to practices as to the location/opening times of anti-viral collection points
- The geographical spread of anti-viral collection points not consistent, resulting in patient’s advocates having to travel great distances with limited public transport to pick up prescriptions
- Patient/public confusion around who/when/how to deal with swine flu
Conclusion
Together, we can learn much from the handling of the pandemic; the benefits of engaging GPs early as the first points of contact for the worried well and poorly patients is essential. Recognition that the implementation of any plans can quickly disintegrate where you have multiple organisations involved – through no fault of their own. Londonwide LMCs is the voice of general practice in London and willing to offer pragmatic solutions to healthcare needs.
Hdrive/London Assembly swine flu response S Broome/v.2 draft 15.2.10
NHS London response to the London Assembly Health and Public Services Committee (09 March 2010)
This briefing is prepared by the NHS London Flu Resilience Team and the NHS London Finance and Investment Directorate to inform the meeting on 09 March 2010, in response to questions posed by the London Assembly Health and Public Services Committee.
London’s response to swine flu
1. Total figures for the following: • number of swine flu cases recorded by GPs • number of Tamiflu courses given out • number of hospitalisations • number of deaths • rates compared to the rest of the country
• number of swine flu cases recorded by GPs Influenza is not a notifiable disease therefore the NHS does not have a catalogue of the number of swine flu cases recorded by GPs.
At the start of the pandemic in April 2009, cases were confirmed by laboratory testing. This continued for the first 3,000 cases nationally in order to inform the modelling and epidemiological knowledge around the evolving situation. Laboratory confirmation and formal counting ceased when the disease was widespread in the community and there were 3,000 cases in the national database. There continued some testing of samples from patients attending sentinel GP practices around the country. This indicated that many of the influenza like illness (ILI) cases were not due to swine flu, and also that there were few other pathogens circulating.
As an indicator of the number of swine flu cases, NHS London is able to provide information on the weekly rate of GP consultations for ILI per 100,000 population. This data is collected every year by QSurveillance® (see later) as an indicator of the prevalence of influenza in the community. It must be noted that the term ‘ILI’ includes illnesses caused by other respiratory pathogens, and not just by influenza viruses.
QSurveillance® data shows that rates of ILI consultations in London peaked at over 300 per 100,000 population in mid-July 2009, with a much lower second peak in mid-November 2009 of over 60 per 100,000 population. There are currently fewer than 50 consultations per 100,000 population (see figure 1).
The mild nature of the illness in most people and use of the National Pandemic Flu Service (NPFS) to provide antivirals to patients will both have reduced the number of GP consultations for flu as a portion of actual cases.
• number of Tamiflu courses given out NHS London is able to provide an approximation of this.
Tamiflu is one of two antiviral drugs used to treat influenza in the UK, the second being Relenza which is offered to some patients based on clinical need. The Department of Health (DH) had built a substantial stockpile of antivirals, sufficient to treat 50% of the population, as part of preparedness work prior to the commencement of this pandemic.
During the early weeks of the pandemic, termed the containment phase, antivirals were provided as treatment to patients and prophylaxis to their contacts. These were initially provided by the Health Protection Agency (HPA) from stocks held in readiness against an avian influenza outbreak. On 03 May 2009, DH provided a substantial amount of antivirals to Primary Care Trusts (PCTs) across the country to enable local access to antivirals through GP consultation. The UK then moved from containment to mitigation (also referred to as the treatment phase) on 02
1 of 8 July 2009, which meant that antivirals were no longer provided routinely to contacts of cases for prophylaxis. London and the West Midlands both experienced a brief period of ‘outbreak management’ between the containment and mitigation phases in response to local pressure. On 23 July 2009, DH switched on the NPFS which enabled patients to access antivirals following completion of a clinical algorithm either online or through an NHS Direct phone line. In response to decreasing flu activity, the NPFS was turned off on 11 February 2010.
Data from the NPFS shows that in London, from 23 July 2009 to 11 February 2010, 355,354 patient assessments via phone or website have been made, 244,193 antivirals have been authorised and 155,892 AVs collected.
• number of hospitalisations NHS London is unable to provide total hospitalisations, but can indicate daily figures.
NHS London is able to provide data showing the number of hospitalised cases in London on a daily basis since data collation commenced in early July 2009. The total number of hospitalisations is not available. The number of inpatients with swine flu in London’s hospitals peaked at 250 on 17 July 2009. The number of patients in critical care peaked at 42 on the 26 November 2009. There are currently 23 swine flu inpatients, with 3 in critical care (28 February 2010) (see figure 2)
• number of deaths There have been 78 deaths in London confirmed due to swine flu as of 18 February 2010.
• rates compared to the rest of the country London and the West Midlands experienced pressures in the first wave of cases (June/July 2009) in advance of the rest of the country, and greater than the rest of the country. In the second wave (October/November 2009), the pressure was felt in London approximately a fortnight later than that felt in the north of the country.
Rates of ILI consultations per 100,000 population reported through QSurveillance© are available from the HPA and show similar pictures in all regions, although London is regularly slightly higher than other regions (note that this is not significant) (see figure 3).
2. What is the process for capturing lessons learned from the roll out of the National Pandemic Flu Service in London and what are the key findings so far?
NHS London has developed a pack to enable structured debriefs across the NHS in London following the A(H1N1)v influenza pandemic. This will include capturing lessons learned from the roll out of the NPFS as well as other aspects of the swine flu response.
The pack includes an agenda and slide set to guide the discussion. There is also a report template to provide a mechanism to identify lessons and key points in order to create a report and action plan for submission to local Boards and NHS London. Each acute, mental health and primary care trust in London and the London Ambulance Service (LAS) has been requested to submit their report by 05 March 2010. NHS London recommends that each debrief should take place in a multi- agency health economy forum, led by the PCT, involving local health and social care partners (including where appropriate the acute and/or mental health trust, LAS, local authority social care, and independent sector care providers). Other multi-agency partners will also be invited to attend. Local multi-agency, health economy reports will also be welcomed by NHS London.
DH is also undertaking debrief exercises and NHS London has contributed to this, including commenting on the NPFS. NHS London will use the local reports to prepare a London-wide debrief report to submit to DH by 01 April 2010. A regional multi-agency debrief was undertaken by the London Resilience Team in January 2010, to which NHS London contributed.
3. What difficulties have you encountered in London in carrying out the swine flu vaccination programme and how have you responded to these?
2 of 8
As with any rapidly implemented health intervention, there have been challenges which the NHS in London has risen to and met. This included initial lack of clarity about the detail of the programme – for example around the priority groups for vaccination, numbers of doses per patient, when the vaccine would be available, and who would be delivering it. Much of this had to be finalised by national and international bodies (eg DH, the World Health Organisation) before the programme could begin in October 2009.
NHS London managed these challenges by ensuring there was always full and open discussion with the local health organisations, sharing of information as promptly as possible, and regular discussion with the DH about the implication some of the central decisions. NHS London also actively engaged with the Londonwide LMC (Local Medical Committee) which represents GPs in 26 of the 31 London PCTs to reach a regional agreement for Phase 2 of the vaccination campaign (healthy children aged six months to under five years). Similar negotiations were then completed with the remaining five LMCs.
NHS London ensured there was a logistics lead in every PCT and in the SHA to coordinate the deliveries of vaccine and consumables from central DH stockpiles through the PCTs to the GPs. NHS London also set up a Vaccine Clinical Reference Group under the Regional Director of Public Health to address clinical queries and help ensure consistency across the region.
The staggered availability of the vaccine (of which there were two types) in the country, meant the campaign was difficult to coordinate with regards arranging surgeries at general practices and making sure those who were eligible for the vaccine could access it. However PCTs managed this admirably – and the vaccine has been, and is still, available to anyone in the capital who is in the priority groups.
4. What additional acute and public health resources do you estimate that NHS London, London PCTs and the Department of Health put in to tackling swine flu in London? Where have these costs been allocated?
Estimated cost to London PCTs of tackling Swine Flu in London NHS London has contacted all commissioners in London with respect to forecast swine flu costs for 2009-10. This involved requesting information for costs in the following areas: • Administration costs associated with the delivery of the vaccine • Acute commissioning costs associated with additional activity • Other costs
The following table provides the high level figures for the costs incurred in London: Admin costs associated Commissioning costs associated Other Total with vaccines (£000) with additional activity (£000) (£000) (£000) 5,615 9,407* 3,709** 18,731
*It should be noted that the commissioning costs figure is an estimate. Costs associated with swine flu are unlikely to be specifically identified and estimates of costs will be based on discussion with providers and an increase in non-elective activity.
**Other costs include: medical supplies and equipment, contractor fees, emergency preparation costs, communications, vaccine storage costs, and additional staff costs (All NHS trusts were required to appoint a Flu Resilience Director in July 2009 in order for there to be dedicated and committed leadership of the response. Some trusts used existing staff members, others specifically appointed individuals to the role. Organisations also set up Flu Response Teams, using existing and/ or new staff to support the Flu Resilience Directors.)
Department of Health costs NHS London is not able to comment in detail on what additional costs DH put into tackling swine
3 of 8 flu. DH created a dedicated Flu Resilience Team which supported the existing Pandemic Preparedness policy team to lead a robust and resilient NHS response.
DH provided many items to local healthcare providers from national stockpiles (face masks; respirators; vaccine needles, syringes and sharps bins; the vaccine itself; and antivirals) however the local level will have incurred costs in storing and distributing these items onwards. The majority of items were delivered to PCTs for onward distribution to GPs or other NHS organisations. DH also provided PCTs with funding to reimburse GPs £5.25 per dose of vaccine delivered to patients.
NHS London costs NHS London spent approximately £367,000 on the swine flu response which was sourced from strategic reserves. This meant that no other programme of work was compromised by the response. This was used to finance communications, staff (see below) and a London-wide NHS exercise.
The NHS London core Flu Resilience Team comprised of six people (two permanent staff members and four temporary posts), supported by others across the organisation as required.
4 of 8 Figure 1. Weekly GP consultations in London for Influenza like illness (ILI) per 100,000 population (data provided by QSurveillance ©)
350
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0 06-Jul-09 13-Jul-09 20-Jul-09 27-Jul-09 06-Apr-09 13-Apr-09 20-Apr-09 27-Apr-09 05-Oct-09 12-Oct-09 19-Oct-09 26-Oct-09 04-Jan-10 11-Jan-10 18-Jan-10 25-Jan-10 01-Jun-09 08-Jun-09 15-Jun-09 22-Jun-09 29-Jun-09 01-Feb-10 08-Feb-10 02-Nov-09 09-Nov-09 16-Nov-09 23-Nov-09 30-Nov-09 03-Aug-09 10-Aug-09 17-Aug-09 24-Aug-09 31-Aug-09 07-Sep-09 14-Sep-09 21-Sep-09 28-Sep-09 07-Dec-09 14-Dec-09 21-Dec-09 28-Dec-09 04-May-09 11-May-09 18-May-09 25-May-09
Figure 2. Number of inpatients (blue) and critical care patients (pink) with swine flu in London (data provided by NHS London)
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40 Critical Care Inpatients 250
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0 0 02-Jul-09 13-Jul-09 22-Jul-09 31-Jul-09 06-Apr-09 15-Apr-09 24-Apr-09 12-Oct-09 20-Oct-09 29-Oct-09 03-Jun-09 12-Jun-09 23-Jun-09 12-Jan-10 21-Jan-10 01-Feb-10 09-Nov-09 18-Nov-09 27-Nov-09 11-Aug-09 20-Aug-09 01-Sep-09 07-Sep-09 21-Sep-09 30-Sep-09 08-Dec-09 17-Dec-09 31-Dec-09 05-May-09 14-May-09 25-May-09
Figure 3. Weekly influenza-like illness consultation rate by English SHA (all ages) [London is represented by the solid pink line]
(Data provided by QSurveillance®; note that this graph does not align chronologically with Figures 1 and 2)
NOTE: QSurveillance® is run by the University of Nottingham and EMIS (the main supplier of UK GP computer systems) in collaboration with the HPA. It is a not-for-profit network of over 3,300 general practices covering a population of almost 22 million patients (>25% of the UK population). In England, this is based on data from ~3,000 practices (covering 43% of England's population).
5 of 8 The financial position of the NHS in London
5. How will NHS London and London PCTs meet announced government targets to reduce NHS management costs by 30% over the next four years?
Management and administrative support costs must be reviewed and reduced to maximise the proportion of NHS resources that is invested in frontline services. To achieve this, each SHA must meet an aggregate target reduction of 30 per cent in management and agency costs by 2013/14. The expectation is that 20% of these savings will have been recurrently identified by 31st march 2012. It will be for SHAs to determine how this is managed across PCTs. Co-terminosity can be used as a driver; and provider arms are to be included in the aggregate.
The baseline for the management cost savings will be the 2009/10 management costs as published in the 2009/10 accounts. As the 2009/10 management costs will not be known until June, PCTs and SHAs are initially developing plans based on 2008/09 published management costs. The DH is still considering the how the management costs target reduction will be applied across SHAs. This work is likely to conclude in the next couple of months.
NHS London and PCTs are still in the process of planning for 2010/11 and 2011/12 and to date PCTs have submitted initial plans for review by NHS London. The expectation is that these plans will be updated as the planning process continues and meetings are held with the PCTs to discuss and challenge their plans. The final plans will be signed off by NHS London in March and April 2010.
Within the initial plans submitted, the areas PCTs and NHS London highlighted as areas where they expect to achieve the management savings over the next four years were:
• Reductions in the use and cost of interim/agency staff • Efficiencies from new working practices and structures with a review of the need and grade of vacant posts and reduction in duplication of work • Improvement and enforcement of procurement processes • Greater sharing of corporate resources between PCTs e.g. shared use of IT and HR departments • Achievement of economies of scale and synergies from joint initiatives with local authorities • Use of the Sector Acute Commissioning Units (SACUs) and Commissioning Support for London (CSL) to reduce duplication of work and create economies of scale.
NHS London will be closely monitoring PCTs during 2010/11 and 20110/12 to ensure that they are on track to deliver their management cost savings.
6. Will the measures and targets to reduce costs be applied across all PCT and trusts in London or will it be a regional target?
The measures and targets will be applicable to both the SHA and PCTs but this target does not apply to NHS acute and mental health trusts. This is because the trusts are already required to make efficiency savings each year with a target of 3.5% in 2010/11. The Department of Health will be reviewing achievement of this target at a London regional level and have stated that it is for SHAs to determine how this is managed across PCTs. The definition of management costs for PCTs and SHAs are very different: • For PCTs, they exclude non-pay costs and salaries of employees who earn less than a £29,000 threshold unless they work directly for Board members. • For SHAs, they cover all costs, including non pay, other than those of hosted organisations.
6 of 8 The DH has asked all SHAs to compare their management cost calculations to ensure that these are consistent. A consistent approach will be required for reporting 2009/10 management costs. Based on 2008/09 management costs NHS London is well below the national average of management costs based on weighted population.
The SHA will still be looking closely at its own management costs to reduce these as much as possible but when NHS London was formed in July 2006 when the five previous London SHAs were combined, significant management cost savings were achieved resulting in reduced capacity to remove more savings. PCTs were not consolidated or merged at this time.
There is no intention to review PCT management cost methodologies. Based on 2008/09 management costs London PCTs are above the national average of management costs based on weighted population. There is wide variation of management costs between PCTs within London.
NHS London are potentially giving a differential management cost target reduction to the six London sectors and allowing them to determine how much is required from individual PCTs. This will allow better targeting of the savings and not penalise PCTs with low management costs who consequently have limited scope to make savings.
7. How many NHS trusts do you expect to be in deficit at the end of this financial year, which ones are they and how large will the deficits be?
Four NHS trusts (West Middlesex University trust, North West London Hospitals trust, South London Healthcare trust and Barking, Havering and Redbridge Trust) planned to be in deficit in 2009/10 as part of an agreed recovery process with the Department of Health. Therefore the expectation is that all four trusts will post a deficit for 2009/10. There are also two PCTs (Enfield and Sutton & Merton) that are forecasting deficits in 2009/10 that were not planned for (Table 3).
There are risks against a number of these projections which could lead to increases in deficits. NHS London is monitoring the situation and working closely with these organisations and health economies.
Table 3: In year deficits as at month 10 (31st January 2010) Plan Forecast Variance Trust outturn £000 £000 £000 North West London Hospitals (8,165) (8,165) 0 West Middlesex (5,150) (5,150) 0 Barking Havering & Redbridge (8,010) (19,700) (11,690) South London Healthcare NHS Trust (27,100) (37,740) (10,640) Enfield PCT 0 (10,491) (10,491) Sutton & Merton PCT 0 (4,200) (4,200) TOTAL (48,425) (85,446) (37,021)
NHS London developed the Medium Term Financial Strategy and Challenged Trust Board (CTB) process with the aim of eliminating all historical debt by the end of 2010/11. All PCT Boards agreed to make a financial contribution to address this historic debt by investing c.0.8% of their funding non-recurrently in 2009/10 and 2010/11 with the exception of those PCTs that are repaying debt themselves (Hounslow, Hillingdon, Bexley, Enfield and Waltham Forest). There was also a £100m contribution from the Department of Health to the Trust historic deficit.
The CTB comprises representative membership from PCTs and NHS London with the assessment in 2 stages. The allocation of funding will only be made following rigorous analysis of each organisation’s potential for organisational recovery and sustainability, with external experts brought
7 of 8 in to support the assessment process. Organisations will be required to evidence clinical and financial sustainability and organisational and leadership capability (8 “domains” based on Monitor criteria and clinical leadership).
The four NHS Trusts currently forecasting deficits are within the remit of the CTB and are undergoing additional scrutiny and analysis.
Benefits already generated to date include stronger collaboration between Sectors, PCTs and Trusts, and a shift to more realistic strategies on the part of the challenged organisations. However, there remain significant financial challenges affecting a small number of health economies which require solutions varying from individual recovery plans to sector reconfigurations.
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