NHS South Cheshire and NHS Vale Royal Clinical Commissioning Groups Pandemic Influenza Plan NHS Vale Royal Clinical Commissioning Group NHS South Cheshire Clinical Commissioning Group
Pandemic Influenza Plan DIRECTOR ON CALL EMERGENCY CONTACT DETAILS If you need to contact the Clinical Commissioning Groups Director On Call please ring 0845 12498671 You will be asked for your name, organisation, a contact number and the reason for your call. The operator will then contact the Director On Call and ask them to ring you. Version 2016 Version 2 Ratified By CCGs Governance and Audit Committee Date Ratified September 2016 Author(s) Responsible Committee / Officers Jo Vitta / Sue Milne Tracy Parker-Priest Director of Transformation and Commissioning Date Issue September 2016 Review Date September 2017 Intended Audience NHS South Cheshire and NHS Vale Royal CCGs Board and employees Members of the Cheshire Resilience Forum Neighbouring CCGs & NHS England Sub Regional Team 1
Further information about this document: Document name Author(s) Contact(s) for further information about this document CCG Pandemic Influenza Plan Jo Vitta Email: joanne.vitta@nhs.net Sue Milne Email: suemilne@nhs.net This document should be read in conjunction with Copies of this document are available from CCG Business Continuity Plan CCG Incident Response Plan NHS England sub regional team Incident Response Plan Jo Vitta Email: joanne.vitta@nhs.net Version Control: Version History: 1 Initial published document September 2015 2 Review for winter 2016/2017 September 2016 2
Contents Description Page No Introduction 4 Aims and Objectives 4 Influenza Pandemic 5 Phases of an influenza pandemic 6 Key planning assumptions 8 Potential impact of influenza in Cheshire 10 CCG roles and responsibilities 12 National coordination 14 Local command and control 14 Communications 15 Reporting 16 Impact on CCG staff 16 Recovery 18 Training and exercising 18 3
1.0 Introduction 1.1 The potential for a new influenza pandemic remains unchanged, although timing and severity of a future pandemic remains unpredictable. The threat and potential impact of pandemic influenza (flu) is such that it remains the top risk on the UK Cabinet Office National Risk Register and this is reflected in the Cheshire Resilience Forum (CRF) Risk Register. 1.2 The CRF has produced a Pandemic Influenza Plan which contains the wider multi agency response and this document focuses on the role of NHS South Cheshire and NHS Vale Royal Clinical Commissioning Groups (CCGs) in support of the wider response. 1.3 The CRF plan describes the local pandemic Influenza response in the context of the national guidance which was revised after the 2009 influenza pandemic [influenza A(H1N1) namely: Department of Health UK Influenza Pandemic Preparedness Strategy 2011. Health and Social Care Influenza Pandemic Preparedness and Response, April 2012. HPA Pandemic Influenza Strategic Framework, October 2012 Preparing for Pandemic Influenza, Guidance for Local Planners, 2013. UK Influenza Pandemic Preparedness Strategy, June 2014 Pandemic influenza response plan, August 2014. 1.4 During a pandemic, NHS and local government commissioning and provider organisations will maintain their existing roles and responsibilities for the management of the local health and social care system. However, some pandemic specific activities will also be required. 2.0 Aims and Objectives 2.1 The aim of this plan is to outline the roles and responsibilities of the CCGs in a pandemic and provide operational guidance detailing response requirements. 2.2 The strategic objectives for the NHS in a pandemic, which the CCGs will support, are to: Provide the public with information. Contain the emergency limiting its escalation or spread. Maintain critical and normal services at an appropriate level, in response to pressures, during the pandemic. Protect the health and safety of staff. 4
Promote self-help and recovery. Maintain timely and appropriate reporting of the situation to inform decisions. Restore normality as soon as possible. Evaluate the response and identify lessons to be learned. 3.0 Influenza Pandemic 3.1 Influenza pandemics occur when a new strain of the influenza A virus emerges that is capable of infecting people and spreading from person to person. The virus spreads rapidly and can be associated with a significant mortality and morbidity because few of the population will have any immunity to the new strain. Control is difficult as it is likely that no vaccine will be immediately available against the new strain of influenza and antiviral medication may have a limited effect in mitigating the effects of the disease. 3.2 There were 3 pandemics of influenza during the 20th Century, the most severe, the 1918/19 Spanish flu pandemic is estimated to have killed between 20-40 million people worldwide and caused enormous economic and societal disruption. The 1957/58 Asian flu and the 1968/69 Hong Kong flu, though not as large, nevertheless, had devastating effects worldwide. During the first pandemic of the 21st Century in 2009 there were 457 deaths in the UK (to March 2010) related to the pandemic flu virus. 3.3 It is uncertain when a new pandemic virus might appear. Until it emerges and affects a significant number of people, it will not be possible to identify the key features of the disease, such as any pre existing immunity, the groups most affected, and the effectiveness of clinical counter-measures. Given this, there are 3 main principles that must underpin planning and response. Precautionary plan for an initial response that reflects the level of risk, based on information available at the time, accepting the uncertainty that will initially exist about the scale, severity or level of impact of the virus. Proportionality plan to be able to scale up or down in response to the emerging epidemiological, clinical and virological characteristics of the virus and its impact at the time. Flexibility plan for the capacity to adapt to local circumstances that may be different from the overall UK picture for instance in hotspot areas. 5
4.0 Phases of influenza pandemic 4.1 The UK approach to responding to a pandemic uses a series of phases: detection, assessment, treatment, escalation and recovery (DATER). It also incorporates indicators for moving from one phase to another. 4.2 The phases are not numbered as they are not linear, may not follow in strict order, and it is possible to move back and forth or jump phases. There will also be variation in the status of different parts of the country reflecting local attack rates, circumstances and resources. The Cheshire Strategic Coordinating Group (SCG) will analyse the local, regional and national information and act accordingly to ensure the implementation of partner plans at an appropriate level. 4.3 Detection Phase 4.3.1 Triggered by the declaration of a pandemic by the World Health Organisation (WHO) or earlier on the basis of reliable intelligence or if an influenza related Public Health Emergency of International Concern (PHEIC) is declared by the WHO. The focus in this stage, led nationally by Department for Health (DH) or Public health England (PHE), would be: Intelligence gathering from countries already affected. Enhanced surveillance within the UK. The development of diagnostics specific to the new virus. Information and communications to the public and professionals. 4.3.2 The indicator for moving to the next phase would be the identification of the novel influenza virus in patients in the UK. 4.4 Assessment Phase 4.4.1 The focus in this phase, led by DH /PHE, would be: The collection and analysis of detailed clinical and epidemiological information on early cases on which to base early estimates of impact and severity in the UK. Reducing the risk of transmission and infection with the virus within the local community by: Actively finding cases. Voluntary self-isolation of cases and suspected cases. Treatment of cases / suspected cases and use of antiviral prophylaxis for close / vulnerable contacts, based on a risk assessment of the possible impact of the disease. 6
4.4.2 The indicator for moving from this stage would be evidence of sustained community transmission of the virus, i.e. cases not linked to any known or previously identified cases. 4.5 These 2 phases - Detection and Assessment - together form the initial response. This stage may be relatively short and the phases may be combined depending on the speed with which the virus spreads, or the severity with which individuals and communities are affected. It will not be possible to halt the spread of a new pandemic; to attempt to do so would waste scarce public health resources and capacity. 4.6 Treatment Phase 4.6.1 The focus in this stage would be: Treatment of individual cases and population treatment, if necessary using the National Pandemic Flu Service (NPFS) though it is anticipated there will be a national contract with pharmacies. Enhancement of the health response to deal with increasing numbers of cases. To consider enhancing public health measures to disrupt local transmission of the virus as appropriate, such as localised school closures based on public health risk assessment. Upon the development of the pandemic, to prepare for targeted vaccinations as the vaccine becomes available. 4.7 Arrangements will be activated nationally to ensure that necessary detailed surveillance activity continues in relation to samples of community cases, hospitalised cases and deaths. When demands for services start to exceed the available capacity, additional measures will need to be taken. This decision is likely to be made at a regional or local level as not all parts of the UK will be affected at the same time or to the same degree of intensity. 4.8 Escalation Phase The Escalation Phase will be invoked as the scale of the outbreak or pandemic surpasses the capabilities of the arrangements out in place during the early stages of response and could see more severe impacts requiring an escalated response e.g. school closures, minimising large scale gatherings, increase in the number of deaths associated with the outbreak / pandemic etc. 4.8.1 The focus in this stage would be: Escalation of surge management arrangements in health and other sectors. Prioritisation and triage of service delivery with aim to maintain essential services. 7
Resiliency measures, encompassing robust contingency plans. Consideration of de-escalation of response if the situation is judged to have improved sufficiently. 4.8.2 These 2 phases - Treatment and Escalation - form the Treatment component of the pandemic. Whilst escalation measures may not be needed in mild pandemics, it would be prudent to prepare for the implementation of the Escalation phase at an early stage. 4.9 Recovery Phase The focus in this stage would be: Normalisation of services, perhaps to a new definition of what constitutes normal service. Restoration of business as usual services, including an element of catching-up with activity that may have been scaled-down as part of the pandemic response e.g. reschedule routine operations. Post-incident review of response, and sharing information on what went well, what could be improved, and lessons learnt. Taking steps to address staff exhaustion. Planning and preparation for resurgence of influenza, including activities carried out in the Detection phase. Continuing to consider targeted vaccination, when available. 5.0 Key Planning Assumptions 5.1 Clinical Attack Rate Cumulative clinical attack rates of up to 50% of the population in total, spread over one or more waves each of around 12-15 weeks, each some weeks or months apart. If they occur, a second or subsequent wave could be more severe than the first. Response plans should recognise the possibility of a clinical attack rate of up to 50% in a single-wave pandemic. Up to 4% of those who are symptomatic may require hospital admission. 5.2 Case Fatality Rate Depending upon the virulence of the influenza virus, the susceptibility of the population and the effectiveness of countermeasures, up to 2.5% of those who are symptomatic may die. However, given the relatively low likelihood of a virus with both a high attack rate and severe disease, and against which medical countermeasures are ineffective, it is agreed that local planners should focus on ensuring that robust arrangements are in place for managing excess deaths in a lower range. This range has been set at 210,000-315,000 nationally (approximately 0.4-0.5% of the population). 8
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6.0 Potential impact of Pandemic Flu in Cheshire Cheshire has a total population of 1,381,189 (ONS estimated resident population 2011). Up to 50% of the population may show clinical symptoms of influenza over the course of a pandemic, and up to 25% of those may develop complications. Up to 2.5% of those who become symptomatic may die. Up to 22% of influenza cases can be expected during the peak week of a pandemic wave. Up to 30% of symptomatic patients will require assessment and treatment by a general medical practitioner or suitably experienced nurse. Up to 4% of those who are symptomatic may require hospital admission if sufficient capacity is available. Potential impacts of reasonable-worst case scenarios of pandemic flu on Cheshire (Clinical attack rate 50%, case fatality rate 2.5%) Week % total cases Clinical cases Additional GP consultations Additional hospital admissions Additional Deaths Total Deaths 1 0.1 691 197 28 17 42 2 0.2 1381 394 55 35 60 3 0.8 5525 1575 221 138 163 4 3.1 21408 6101 856 535 560 5 10.6 73203 20863 2928 1830 1855 6 21.6 149168 42513 5967 3729 3754 7 21.2 146406. 41726 5856 3660 3685 8 14.3 98755 28145 3950 2469 2494 9 9.7 66988 19091 2680 1675 1700 10 7.5 51795 14761 2072 1295 1320 11 5.2 35911 10235 1436 898 923 12 2.6 17955 5117 718 449 474 13 1.6 11050 3149 442 276 301 14 0.9 6215 1771 249 156 180 15 0.7 4834 1378 193 121 146 Total 100.1 691285 197016 27651 17282 17307 10
Potential impacts of reasonable-worst case scenarios of pandemic flu on Cheshire (Clinical attack rate 25%, case fatality rate 2.5%) Week % total cases Clinical cases Additional GP consultations Additional hospital admissions Additional Deaths Total Deaths 1 0.1 345. 98. 14 8. 29 2 0.2 690. 197 28 17. 37 3 0.8 2762. 787 110. 69 89 4 3.1 10704. 3051 428 268 288 5 10.6 36602 10431 1464 915 935 6 21.6 74584. 21256 2983 1864. 1885 7 21.2 73203. 20863 2928. 1830 1850 8 14.3 49377. 14073 1975. 1234 1254 9 9.7 33493. 9546 1340 837 857 10 7.5 25897. 7381 1036. 647 667 11 5.2 17955. 5117 718. 449 469 12 2.6 8977. 2559 359. 224 244 13 1.6 5524. 1575 221 138 158 14 0.9 3107. 886 124. 78 98 15 0.7 2417. 889 97 60. 80 Total 100.1 345642. 98508. 13826 8641. 8661 11
7.0 CCG Role and Responsibilities 7.1 The CCGs are most likely to receive notification of a pandemic from the following sources: NHS England Public Health England CAS Alert Director of Public Health 7.2 The primary role of the CCGs is to manage local pressures in provider organisations during a pandemic and may need to represent NHS England at the local Influenza Pandemic Coordination Group. NHS England may not have sufficient resource to attend every group and NHS involvement is important. 7.3 The CCGs Pandemic Flu Lead (or deputy) will liaise with the appropriate NHS England Pandemic Influenza Incident Response Team (PI-IRT) and may need to attend the Pandemic Influenza Incident Coordination Centre, however teleconferences are most likely. 7.4 The CCGs have a role in supporting NHS England regional and area teams and providers of NHS funded care in planning for and responding to an influenza pandemic. 7.5 The detailed roles and responsibilities of the CCGs have been set out in the NHS England publication Guidance on the Roles and Responsibilities of Clinical Commissioning Groups (CCGs) in Preparing for and Responding to an Influenza Pandemic, gateway reference 00857 and are outlined below. 7.6 Before a pandemic The CCGs have identified a Pandemic Influenza Executive Lead who will lead internal planning activities in light of national and international developments, advice and guidance. The CCGs have business continuity plans in place that are suitable for use in a pandemic to mitigate the shortage of staff that may arise. Communicate plans with employees, contractors, and affiliated organisations. Participate in relevant planning groups to discuss, plan, exercise and share best practice. Ensure early engagement of communication professionals to devise, deliver and maintain internal, external and stakeholder/cross-partnership communications before, during and after a pandemic. 12
Work with their commissioned service providers, in planning for a surge in relation to elective work and the possible financial implications if there is on-going disruption to normal service levels over the period of a pandemic and its recovery phase. Participate in appropriate assurance processes regarding their arrangements and be assured that their commissioned services have adequate provisions in place for managing a pandemic. Work with NHS England to identify appropriate local providers to support the delivery of a pandemic influenza response, particularly regarding the provision of antiviral collection points through community pharmacies. 7.7 During a pandemic Support the national pandemic response arrangements as laid out in Department of Health and NHS England guidance issued prior to or during a pandemic occurring. In line with other guidance, ensure 24/7 on-call arrangements remain robust and maintained, particularly with respect to surge and responding to major incidents. Lead the management of pressure surge arrangements with their commissioned services as a result of increased activity as part of the overall response. Support NHS England in the local coordination of the response, e.g. through tried and tested surge capacity arrangements, appropriate mutual aid of staff and facilities, and provision of support to the management of clinical queries. As necessary, share communications with locally commissioned healthcare providers, through established routes. Participate in the multi-agency response as appropriate and agreed with NHS England to ensure a comprehensive local response. Maintain close liaison with local NHS England colleagues, particularly when considering changes to delivery levels of NHS commissioned services. Enact business continuity arrangements as appropriate to the developing situation to ensure critical activities can be maintained. 13
Maintain local data collection processes to support the overall response to the pandemic, including completion and submission of relevant situation reports and participation in coordination teleconferences. Throughout the pandemic, undertake and contribute to appropriate, timely and proportionate debriefs to ensure best practice is adopted through the response. 7.8 After a pandemic Contribute to local, regional and national health post-pandemic debriefs and consider the implementation of recommendations from any subsequent reports. Acknowledge staff contributions. Assess the impact of the pandemic on the provision of commissioned services and ensure that the on-going service level is sufficient to meet the demands of the system. Ensure the recovery of services to business-as-usual as soon as appropriate. Review response update plans, contracts and other arrangements to reflect lessons identified, particularly where these have been commissioned locally. Collect financial and contractual impact information from commissioned providers. 8.0 National Coordination 8.1 The Department of Health is the lead government department for pandemic preparedness and response. All other departments are directly or indirectly involved in preparing and play an active role in informing and supporting contingency planning in their areas of responsibility. 9.0 Local Command and Control 9.1 NHS England will monitor, manage and support the health community during a pandemic. Where possible and appropriate, existing arrangements and procedures will be used, underpinned by major incident coordination processes. 14
9.2 NHS South Cheshire and NHS Vale Royal Clinical Commissioning Groups will act on behalf of and in support of NHS England. 9.3 NHS South Cheshire and NHS Vale Royal Clinical Commissioning Groups will put in place internal command and control structures in line with its Major Incident Response Plan. 9.4 The CCGs will identify a team to lead their response to the pandemic. This will include: Pandemic Flu Lead Pharmacist Lead Director of Commissioning and Performance Urgent Care Lead Communications lead (via CSU) Admin support 9.5 This team will have responsibility for ensuring all actions relating to the pandemic are carried out: reporting; briefing senior CCG staff and attending the Local Influenza Pandemic Coordination Group and participating in teleconferences as necessary. 9.6 The CCGs Pandemic Response Team will ensure they keep detailed records of all decisions made and actions taken. These records will need to be stored securely following the pandemic. 9.7 The CCGs will set up regular teleconferences with their commissioned services to assess pressures and incidents. This function may be coordinated by NHS England during a pandemic. 10.0 Communications 10.1 A robust communication strategy is an important part of the response to a pandemic. Nationally this is outlined in the UK Pandemic Influenza Communications Strategy 2012. 10.3 NHS England will lead health communications messaging and will coordinate with CCGs to distribute local messages. 10.4 NHS England s communications at all levels with the NHS, partners, stakeholders and the public during a pandemic will build on existing mechanisms and good practice. NHS England staff will be trained and briefed to provide messages to audiences in a timely and appropriate manner. Additionally, communications cascaded will be used to ensure information reaches audiences. Where appropriate, messages will be developed and delivered in partnership with other organisations, including PHE and CRF partners. 15
11.0 Reporting 11.1 The requirements for reporting will be set by NHS England as the pandemic emerges. 11.2 Incident reporting is fundamental to the identification of risk and response management and all staff are actively encouraged to use the CCGs existing incident reporting mechanisms. As the pandemic reaches the UK and numbers of cases increases, there will be a requirement for regular situation reports (SitReps) from all organisations, including CCGs. The daily rhythm, ie how frequently these reports are required, will be defined depending on the severity of the pandemic as it progresses. 11.3 The CCGs will maintain their usual incident reporting mechanisms for non-flu related incident to ensure these continue to be managed during a pandemic. Flu related incidents will report into the CCGs Pandemic Response Team. 11.4 The CCGs Pandemic Response Team will ensure there are robust processes in place to document and record decisions made and actions taken during the pandemic. A decision log will be used to record all communications and activities, including time the decision was made, who made it and the rationale behind the action or decision. 12.0 Impact on CCG staff 12.1 Absence from work will depend upon the age related attack rate. Absenteeism may also result from staff needing to take time off to care for family members or for child care. 12.2 Modelling suggests 50% of the workforce may require time off at some stage over the entire period of the pandemic. Individuals are likely to be absent for a period of seven to ten working days. These will build up rapidly peaking at between 15-20% of staff at the peak of a pandemic. 12.3 There are also workforce implications for non-nhs/social care organisations in terms of business continuity. The closure of schools would have major impact on business continuity. 12.4 It is anticipated that more detailed modelling would be undertaken as the epidemiology of a pandemic becomes clearer. 12.5 A Staff Skills Audit will be carried out to capture information for use during a pandemic including the number of staff with clinical skills who may be available for redeployment during a pandemic. 16
12.6 People will be the most valuable resource and the most vulnerable during a pandemic. In order to effectively manage this essential resource, a Staff Welfare Team may be formed to assist staff during the pandemic, from recording absences to enabling staff to return to work. 12.7 Below is a list of considerations for the CCGs as part of the response to a pandemic, it is not exhaustive but seeks to provide a guide to best practice. Ensure that contact details and characteristics of the available workforce are captured so that they can be easily contacted in the event of a pandemic, and identifying possible risks in service delivery and find solutions where possible. Identify if a specific workforce or team has a high proportion of people with young children and other personal caring responsibilities that may impact upon their ability to attend work during normal hours, develop plans to support them with childcare or alternative work options. Pool staff as a critical mass, which would enable staff without a set stream of work to be directed towards the most necessary task within their capability. Facilitate arrangements for joint working and buddying up of teams or specialist services. Build on or develop links with voluntary organisations, community partnerships and local businesses to maximise opportunities to support the community at large. Review normal and acceptable minimum staffing levels of core functions and services and address any potential changes to working practices that may be needed to facilitate this. Develop internal systems for monitoring and reporting real-time absence rates. Inform staff in an appropriate way of the risks associated with pandemic influenza and what action they can take to protect themselves and others, and instructing them not to attend work when they are symptomatic but to attend work when they are well. Review locations of staff at home and at work and implement a travel assistance policy in the event that normal transport services are unavailable. Working with local organisations, map out those health and social care professionals who provide services to the same patient and where care could be consolidated. Develop arrangements for staff to access counselling and support services. 17
Review local human resources policies and procedures to maximise flexibility for staff to be able to work and accommodate caring obligations, annual leave and special leave (carer s leave, bereavement leave, etc). Provide education and training, including voluntary and recently retired staff. 13.0 Recovery 13.1 As the impact of the pandemic wanes, the UK will move into a recovery phase. The pace of recovery will depend on the residual impact of the pandemic, ongoing demands, backlogs, staff and organisational fatigue and continuing supply difficulties. 13.2 Health and social care may experience persistent secondary effects for some time, with increased demand for continuing care from: Patients whose existing illnesses have been exacerbated by flu. Those who may continue to suffer potential medium or long term health complications. A backlog of work resulting from the postponement of treatment for less urgent conditions. Possible increased demand for services through post-pandemic seasonal flu. 13.3 The CCGs will work with local organisations and NHS England to return to normality as soon as is possible. 14.0 Training and Exercising 14.1 This plan will be made available to all senior staff for onward cascade to their teams as appropriate. Training will be provided on request and the plan will be updated annually. 14.2 Recognising that CCGs will not work in isolation during a pandemic CCG Leads will participate in local and national exercises and workshops where possible. 18