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Intro
At the Front Line of Swine Flu RCGP Pandemic Report 2010
RCGP Pandemic Report 2010
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At the Front Line of Swine Flu RCGP Pandemic Report 2010
Š Royal College of General Practitioners, 2010
Contents
Foreword Introduction Maureen Baker Ian Dalton Neil Formica Christopher Long Miles Mack Kate Adams Huw Evans Turlough Tracey Austin Todd Chris Mitchell Denis Campbell Janet Bullock Sonia Hall David Pruce Conclusion
I II 2 4 5 6 7 8 9 10 11 12 14 15 16 18 19
Luckily, it wasn’t as dramatic as we had initially feared, but it did create a lot of work for GPs who had to deal with worried and sick patients and their families – as well as having to manage the mass vaccination programme. During the pandemic, GPs really stepped up to the mark and performed brilliantly well across the UK. The Royal College of General Practitioners took a lead role in communications with GPs, healthcare professionals and the general public, keeping them informed and reassured. This publication reflects back over a busy year that could have turned out much worse were it not for such good planning and such dedication shown by GPs. Professor Steve Field CBE FRCGP Chairman of Council RCGP
RCGP Pandemic Report 2010 I
Foreword
GPs were at the front line throughout the 2009 flu pandemic.
Introduction
On 11 June 2009, Dr Margaret Chan, Director-General of the World Health Organization (WHO), took to the stage at a press conference broadcast across the globe to announce that a flu pandemic had begun.
Dr Chan said the virus appeared to be of ‘moderate severity’, causing mild symptoms in most patients, but she warned: “The virus writes the rules and this one, like all influenza viruses, can change the rules, without rhyme or reason, at any time.”
Dr Chan’s declaration marked the first flu pandemic for 40 years. It had followed weeks of uncertainty as a completely new and unknown virus spread from Mexico to the USA and Canada, quickly reaching across the world.
In the UK, 882 confirmed cases of swine flu already existed. The Department of Health was operating a ‘containment’ strategy under which patients were given antiviral drugs in order to limit the spread of the disease.
Influenza experts, politicians, public The UK had been preparing for a flu health officials and doctors had attended pandemic for five years under the a series of meetings organised by the spectre of a potential global outbreak WHO since the emergence of the pandemic of the deadly H5N1 avian flu virus. (H1N1) flu, or swine flu, in April, but As early as that April, the then Health there was still great uncertainty about Secretary Alan Johnson had told parliament the degree of threat posed by the virus. that the UK had a stockpile of antivirals On 29 April 2009, the WHO reported sufficient to treat half the UK population. 114 officially confirmed cases in 7 countries. All NHS organisations had pandemic At the 11 June press conference, flu plans in place and the Department Dr Chan told the world’s media that of Health had placed orders with nearly 30,000 cases of swine flu had pharmaceutical companies anticipating already been reported across 74 countries. the development of a vaccine. On 7 July, the WHO reported that the The UK government considered itself virus had spread to 120 countries, as among the best prepared in the well as other territories and areas. world, but officials still knew their plans would be tested to the limit.
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The coming months would see a rapid evolution in the UK’s approach to pandemic disease management, and primary care staff would be on the front line throughout. The first recorded cases of swine flu in the UK were reported on 27 April in a couple who returned home to Scotland from a holiday trip to Mexico. From the end of April 2009, the RCGP began issuing regular bulletins to GPs by email – these were also posted on the RCGP website. The College aimed to provide all the information on swine flu that would be relevant to general practice and to do so in an easily accessible format. During May and June, the government operated a containment strategy. Suspected patients were swabbed and tested, then treated with antiviral drugs. The Department of Health launched a public information campaign and a national director for NHS flu resilience was appointed. In July 2009, the UK moved from its containment phase to a mitigation approach, which recognised that the virus was spreading too widely for containment to be effective.
RCGP Pandemic Report 2010
According to a Health Protection Agency (HPA) review, the first wave of the pandemic peaked around mid-tolate July, where levels of disease were found to have reached around 80,000 new symptomatic cases a week. The HPA established that the over-65s were least affected by the virus, with rates of illness 30–80 times higher among those aged 24 and younger, compared with people aged 65 and over, during this time. HPA data show that, in the first phase of the outbreak, the London and West Midlands strategic health authority areas were the worst hit, accounting for 30% and 12% of cases, respectively, until the end of September. Estimates of the number of people hospitalised ranged from 1.3–2.5% depending on the methodology used to calculate total numbers of cases.
Compared with seasonal flu, the mortality rate was modest and, according to the HPA, no excess mortality was observed in the period up until the end of September. In autumn 2009, GPs began a large-scale vaccination campaign. By the end of 2009, new cases of swine flu in the UK had fallen to their lowest level since the beginning of the outbreak. Chief Medical Officer Sir Liam Donaldson said in a report published in January 2010 that discussions at the WHO’s executive board had reflected “broad international support for WHO’s handling of the pandemic”. But he warned that the world still needed to prepare for future outbreaks, particularly in the 2010 northern and southern hemisphere flu seasons and in sub-Saharan Africa. Analysis of H1N1 transmission in different countries during the second half of 2009 had found that, for most of those infected, their illness was less severe than in previous influenza pandemics of the 20th century, according to the report.
people with underlying health problems, though about one-fifth had been previously healthy. Many of the deaths were attributed to viral pneumonia. Anticipating the return of swine flu in the 2010 influenza season, the Department of Health warned that, should the virus remain unchanged, “most people will not suffer a severe illness but another cohort of children and young adults will be admitted to hospital and some will die from viral pneumonia and other causes”. The Department added if many more people in the recommended groups take up the vaccine then the risks to many individuals in autumn 2010 will largely recede. In the following pages, the clinicians who responded to the 2009 pandemic, the managers who planned for it and others whose working and home lives were affected by it reflect on their experience of swine flu and the new knowledge that will help them prepare for future health emergencies.
The virus had predominantly attacked children and younger adults. The majority of serious complications were amongst
RCGP Pandemic Report 2010 III
Introduction
The National Pandemic Flu Service was launched in England. Systems were put in place to distribute large quantities of flu drugs and, in some cases, retired staff were called back into service.
The RCGP set up an emergency planning group after Chief Medical Officer Sir Liam Donaldson began calling on professional organisations to think about how they would support their members in a pandemic. Concern had been building over how GPs would be affected by an avian flu outbreak and the emergency planning group had been working on guidance for practices, as well as setting in place its own guidelines to ensure that everything it published was consistent. Dr Baker says: “I don’t think you needed a crystal ball to know we were going to get a pandemic as they tend to come in intervals of 10 to 40 years. “My vision was always that, in the event of a pandemic, GPs and practices should easily be able to find all the information that was relevant to them. “The last thing we wanted was the RCGP saying one thing, the BMA something else and the Department of Health something else still.” The College followed these principles when it produced guidance on coping with a pandemic, which was published in January 2009. Only a matter of months later, the first swine flu cases began to be reported. Dr Baker remembers: “Scientists tend to be on the look-out for candidate viruses that have the potential to become a pandemic strain. “The interesting thing for me was that there was none of this candidate virus stuff with small-scale outbreaks and one or two human-to-human spreads before swine flu appeared. One day we knew nothing about it and the next day there was a new flu. “That wasn’t what I had expected and it wasn’t what had been planned for – that was the first shock.” As the first cases began to take hold, health professionals knew a little about the virus but did not know how severe it would turn out to be, its clinical manifestation or the age group it would affect most. Dr Baker says: “In the first few months, it was very much emerging procedure. People worked amazingly hard – colleagues at the Department
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of Health were working longer than 12-hour days, every day, for months.” Much of the initial work was to amend existing guidance and revise draft plans. “We always thought there was a lot that we wouldn’t know until it happened,” Dr Baker observes. Throughout the pandemic, the RCGP maintained an important role in providing high-quality information to GPs – a role that Dr Baker believes it will retain in the future. The RCGP collected its own guidance and published it on the College website, as well as sending out regular swine flu messages to GPs. Dr Baker says: “The very clear impression I retain from the experience is the speed at which work was done and information emerged, so right from the start there was a lot of welcome involvement with the College reviewing and signing off documentation and guidance that was being developed by the Department of Health. “We really had to keep up with that, and as soon as the material was finished get it out to GPs. We always used the same email format so people became familiar with it and knew it would be worth acting on. “Getting the information out quickly takes some of the stress out of the situation because GPs know they don’t have to spend two hours a day looking through different websites. “We’ve been asked by the Health Protection Agency (HPA) if we can retain the system in case of something like severe acute respiratory syndrome (SARS) emerging. We’ll have a formal agreement with the HPA.” As well as being used by College members, the information was accessed by clinicians internationally. Portuguese doctors began circulating the RCGP bulletins and they were also passed around by junior hospital doctors. The National Association of Sessional GPs and various BMA local medical committees were among the organisations that helped to circulate the RCGP information, ensuring it was reaching as wide a range of GPs as possible.
RCGP Pandemic Report 2010
“We fairly rapidly established a good way of getting messages out to GPs and that meant when the Department of Health wanted to get messages out, they would come to us.” The RCGP also provided an important service by passing on concerns and information from GPs to organisations such as the Department of Health and the HPA. Dr Baker says: “They all say this was incredibly useful information. It also meant that if someone raised an issue with us, we picked it up with the Department and they sorted it; we could go back and tell the GP what action had been taken. “From my perspective, there seemed to be quite a direct feedback loop.” Although, from the College’s perspective, communications were now running smoothly, problems began to emerge during the containment phase of the pandemic, when clinicians were still trying to slow its spread. Dr Baker says: “GPs were supposed to be going out to people with symptoms, taking swabs. They had to have protective equipment and they also needed swabs. “There was a lot of difficulty getting hold of supplies. There was also a difficulty about who was going to pay for it.” National Director of Pandemic Influenza Preparedness Professor Lindsey Davies and National Director for NHS Flu Resilience Ian Dalton worked together to clarify the situation. Dr Baker says: “Ian Dalton told Primary Care Trusts of the national stockpiles that were to be made available and they had to make sure GPs had got the supplies they needed.”
“Personally I think that trust was incredibly valuable and definitely something that should happen again.” The emergency planning group’s approach of ensuring that messages were consistent was also vindicated. Dr Baker says: “The most difficult period was the time in July when the deaths doubled in a week, rising from 14 to 28. “People started to get a bit edgy and a mixed message went out to women about pregnancy because different views were being expressed by different professional groups. “That was terribly difficult to deal with and unsettled the public as much as anything else. “Certainly a lesson for me was that if you lose the trust and the avenues of communication, you’re no longer able to do your job of helping GPs and practices.” Dr Baker says with hindsight the only two things she would change about the RCGP’s handling of the pandemic would have been to bring the BMA into its working group much earlier and to push for dedicated time to handle pandemic work. She says College staff found themselves becoming increasingly busy as the workload mounted: “For a long time, they were doing bulletins and teleconferences as well as the day job. Having dedicated time definitely does help.”
≥ Key learning point: Consistent messages are important – don’t allow confusion as this unsettles people.
Dr Maureen Baker CBE, the Royal College of General Practitioners (RCGP) pandemic flu lead, was at the forefront of preparations to deal with a pandemic situation and in issuing guidance to GPs. For her it was not a matter of if a global outbreak was going to come but when.
Maureen Baker
Dr Baker says: “We had a pretty good feel early on that most if not all GPs had access to these messages and they were also available on the front page of the RCGP website.
Dr Baker chairs an emergency planning group comprising the British Medical Association’s (BMA’s) General Practitioners Committee, the Royal College of Nursing, practice managers, public health experts and the Department of Health.
Dr Baker believes that, although the work the College put in is not immediately easy to justify from a business perspective, it has been of value to members and has boosted the RCGP’s profile. The College is also considering putting together a resource pack focusing on emergency planning, which incorporates the lessons from swine flu. Dr Baker says: “Before this all started, we circulated a how-to guide on contingency planning but I doubt as many people took notice of it. Now they probably would.”
Another lesson, which Dr Baker says those involved learnt, was that it was essential that there was trust between the different groups: “Ian Dalton had to be able to say things to us without us spinning it or trying to score points.
RCGP Pandemic Report 2010
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Ian Dalton reflects back on his first day as National Director for NHS Resilience. “On the first day I did sit here and feel a bit daunted, but five minutes later I was getting on with the job. “The task was made significantly easier by all the work that had been done over several years previously. “All the clinical engagement work that had been done meant that we were in a fortunate position going into this compared with many countries. “We had a plan, a very significant stockpile of some of the key personal protective equipment and antiviral medication. “Commercial arrangements were also in place that would see us getting vaccines early in the pandemic, so the starting point was strong.” In addition to this, the pandemic flu team had started to identify what work was needed to support NHS organisations in their preparations. Mr Dalton and his team began to set out a series of further steps to ensure the health service was as well prepared as possible as the pandemic progressed. The first of these was to work very closely with the NHS and GP representatives on a ‘mobilisation strategy’ to ensure that people would have access to drugs such as antivirals that could help reduce the severity of the disease. Another strand of the work to support general practice was the introduction of the National Pandemic Flu Service. He says: “This meant we could take the pressure off general practice and keep it going so there would be sufficient space in GPs’ workload for them to be able to see the small but significant number of patients who had complications from swine flu.” Mr Dalton’s team also worked with Strategic Health Authorities and Primary Care Trusts, hospitals and ambulance trusts to develop their plans over the summer to make sure they would be able to ‘surge’ capacity if necessary, with plans to boost adult and child critical care bed numbers for instance. The next step was to ensure that the NHS would be able to offer the best protection to the
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public from the virus. This meant introducing a scientifically based and high-quality vaccine programme that would be ready to begin as soon as the vaccine became available. In addition to these practical steps, Mr Dalton asked every single NHS board to take corporate ownership of this issue and identify a director responsible for flu so that they could ensure they were ready for the outbreak. Mr Dalton says: “At this stage in the pandemic, we’d only had reports from Mexico and they were quite alarming in the context of the clinical attack. “We wanted boards to assure us that they were ready, that staff were ready, and that they would keep going.” The Department of Health also set up training sessions for clinicians across the country as part of a national exercise looking at how the NHS would respond to a potentially severe flu attack. Mr Dalton says this work was underpinned by reviewing command and control strategies across the service. Supply chains for crucial equipment and communication channels were scrutinised. He says: “That work was put together quickly and stood the test of time. Those elements were the right ones and doctors and managers have done excellent work across the last nine months in those areas.” GP involvement was critical. Mr Dalton says: “We were clear we needed to support general practice because GPs were going to be at the front line of any pandemic. “This was one of the things we put a lot of effort into and we really appreciated the support of primary care organisations, particularly the RCGP and the British Medical Association’s General Practitioners Committee.” As a result of this work, the Department of Health published guidance on buddying schemes for practices and ways of managing excessive demand. The two GP organisations were also involved in decisions about when to begin using the National Pandemic Flu Service. Additionally, initial hitches over equipment supply to GPs were ironed out quickly, with systems
RCGP Pandemic Report 2010
Mr Dalton says: “The way we worked with and had the support of those representing primary care was absolutely crucial to us.” By this point, the Department of Health had put in place a comprehensive strategy to deal with the pandemic. The one thing civil servants could not plan for was the nature of the pandemic itself, particularly as, until swine flu appeared in the summer, public health experts had been warning of an H5N1 bird flu threat. Mr Dalton says: “The interesting thing we found – and thank goodness for this – was that it turned out not to be the kind of pandemic it could have been. “It is still a serious disease and has caused deaths, and our response is geared around trying to save every life we can. “Whereas we had anticipated that a wave of bird flu would strike the country uniformly and rapidly, in the summer we saw a disease that spread rapidly but patchily. “In some areas, particularly the West Midlands around Birmingham and Inner London, GP consultation rates moved to very high levels in a very short time. Yet only a few miles away, there was relatively little disease. “Some places in the West Midlands went from normal summer background levels of influenza to being affected by swine flu in a period as short as 72 hours. “This required a great deal of agility from both GPs and those running the NHS, who had to respond to a virus that moved in a different way than we’d anticipated.”
but he promises: “I’m very interested in hearing from the clinical front line what the experience of hard-working GPs and their staff has been and if they have any messages for us.” He is relieved that the 2009 swine flu outbreak was not as deadly as a bird flu pandemic may have been – though he stresses that swine flu was catastrophic for some patients. But the pandemic, which gripped the country last year, has been a major test of the NHS pandemic resilience plans. Mr Dalton says: “It has helped immeasurably – very, very significantly. The NHS is now in an even stronger position than it was when we went into this pandemic, and we went into this in a very strong position internationally. “We’ve demonstrated we’ve got plans to support primary care, to assess people for antiviral medication, and to get it out quickly, including out of hours. “We can run high-quality vaccination campaigns with the support of primary care, and the command and control logistics and organisation are in an even better and stronger place than they were at the beginning.
≥ Key learning point: We are still fighting swine flu but we need to learn the lessons and build upon the successes we’ve had because the moment swine flu finishes we start preparing for the next pandemic.
In May 2009, only days after the swine flu pandemic was declared, Ian Dalton left his post as Chief Executive of NHS North East to become National Director for NHS Flu Resilience, at the Department of Health.
Ian Dalton
strengthened in order to ensure supply of personal protective equipment to GPs.
As he sat in his new Whitehall office preparing to co-ordinate the response of the world’s biggest health employer to what looked set to be one of the most serious challenges in decades, Mr Dalton viewed the job with both trepidation and pride.
But he warns that the NHS must use the experience to prepare for the next pandemic, which could be more serious: “We don’t know what type of disease we’ll be fighting – the likelihood of a severe flu pandemic is in no way lessened. “My impression is that we go into that in a much stronger place but I want to keep the whole NHS focused on the next pandemic.”
Over the next few months, the Department of Health will be embarking on a consultation exercise where GPs and other health professionals will be able to give their feedback about how the NHS handled the pandemic and how plans can be further improved. Mr Dalton says he wants to avoid prejudicing this consultation by speculating about things he would have done differently in advance of the exercise,
RCGP Pandemic Report 2010
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Neil Formica
Dr Neil Formica, an Australian public health physician/infectious disease epidemiologist, joined GSK (UK) in May 2009 as a Senior Medical Advisor. His role since then has primarily been to provide medical and public health support to the provision of GSK’s pandemic influenza vaccine and influenza antivirals in the UK.
≥ Key learning point: Even though this pandemic came from a strain that we were not expecting, the tremendous efforts made by national governments, the WHO, physicians, nurses and the manufacturers ensured that populations were protected as quickly as possible with a variety of tools.
Dr Formica describes the challenge for his company as making sure it could develop, produce and deliver safe and efficient vaccines as quickly as possible once governments started requesting drugs to combat swine flu. “GSK has had specific teams focused on pandemic flu and we’ve been talking to governments about pandemic preparation for the last two to three years – a long time in advance of the outbreak of the current pandemic. “The H1N1 pandemic vaccine approval builds on all the work and data generated for the H5N1 vaccine that GSK developed in response to the public health concerns about avian flu.” Dr Formica says his company has been working on pandemic preparedness for over a decade because of the complex and expensive nature of the challenge – and because in a pandemic situation large amounts of the product will be needed in a short time. After the pandemic was declared in June 2009, GSK worked closely with governments and health authorities around the world, boosting resources across the company to meet the unprecedented global demand for vaccine and antivirals. GSK started vaccine production that same June, growing the vaccine virus in eggs after the World Health Organization (WHO) supplied the seed strain. The resulting drug, Pandemrix™, was licensed in Europe three months later in September. GSK has agreements to provide drugs for more than 40 governments including the UK. The company has also donated 60 million doses to the WHO for distribution in developing countries. By the beginning of February 2010, 12.7 million doses of pandemic H1N1 vaccine had been sent out to the NHS in England and the total number of doses given to the priority groups in England was 4.25 million.
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In Europe, more than 125 million doses of pandemic H1NI vaccines have been distributed and 32 million people had been vaccinated. Of these, 68% received GSK’s H1N1 vaccine. Dr Formica says the experience of producing the H1N1 vaccine has been a useful learning experience for GSK. He says: “We have learned that it is important to increase the speed and volume of vaccine or antiviral supply as much as possible to give governments options to intervene. “We have also learned of the importance of rapidly reviewing and sharing scientific data to inform public health responses. “The cumulative safety experience with our H1N1 vaccine is reviewed on a weekly basis and to date the number of adverse events reported has been within the expected range based on experience in clinical trials and with other flu vaccines, such as seasonal flu.” Dr Formica believes the 2009 swine flu pandemic has been a significant public health event that has required action from both governments and industry. He says: “GSK has seen that we as a company can play a role in helping governments meet this public health need and we are proud of the efforts that we made. That said, as in any health emergency, we can and should learn lessons to improve future responses. “We will co-operate with organisations such as the WHO, which are committed to examining the performance of the H1N1 response in a balanced and objective manner, in order to improve responses to future pandemics and other public health crises. “As a responsible public health partner, GSK encourages the evaluation of vaccine development to be included in these ‘lessons learned’ exercises.”
RCGP Pandemic Report 2010
“When you start testing plans and assumptions to destruction, you get to a point where systems won’t work. “There’s an expectation that the chain of command will survive and everyone will behave in a rational way, whereas in fact you get to a point where it’s just not going to work so you have to think about very localised responses rather than dancing to a national tune. “A lot of our plans assumed people would respond in what we considered to be a rational way, for instance in the uptake of the flu vaccine by the public and healthcare staff, the approach to Tamiflu, the guidance around turning up at accident and emergency departments. “We had a rational set of assumptions that said people would have their jabs and wouldn’t go to accident and emergency, and unfortunately that wasn’t how they responded.” Mr Long feels that, in future, a pre-emptive approach to messages around vaccine safety will be important. He thinks the health service and the Department of Health should be ready to communicate messages about the safety of vaccines before the inevitable rumours begin to circulate.
RCGP Pandemic Report 2010
He adds: “We do need consistency of message – the areas where vaccine uptake has been high have largely been where senior clinical leaders have had it and demonstrated leadership in getting their colleagues to have it too.” The issue of capacity became increasingly important for the PCT as the pandemic took hold: “What it highlighted across the board is just how little flexible capacity we’ve got in terms of clinical capacity and – to a lesser extent – managerial capacity”, he reflects. “Even though it didn’t affect us as badly as other areas like the West Midlands, the expectations of the regulators and the Department of Health were still there. “They were carrying on as normal, just as we were trying to crank up our response. It did make for some fairly challenging decisions about what our priorities were. “There was a huge requirement in terms of the ever increasing amount of direction from the Department of Health, which more than kept people busy throughout.” But Mr Long and his colleagues were able to rely on strong relationships with clinicians to help them negotiate the pandemic period: “Fortunately, in this patch, the relationships are very good, so the time we’ve spent investing in relationships paid off. The system did work well and, by and large, people were keen to do what they could to help.”
≥ Key learning point: Managers should not base their pandemic planning on the assumption of a rational response from the public and healthcare professionals.
NHS Hull Chief Executive Christopher Long was prepared for swine flu when it appeared on his patch, but the arrival of the pandemic still provided him and his colleagues with a valuable opportunity to test out their emergency plans.
Christopher Long
He says the extent to which dealing with swine flu was a learning process became increasingly apparent as the pandemic progressed: “From setting up the antiviral clinics to ensuring we could account for every face mask in the region down to the cupboard it was located in, and making sure capacity and resilience plans were sound, we were learning as we went along.
Mr Long recalls: “We were watching the progress of the virus from its outbreak in Mexico – it was very much on the radar from the early phase onward. We had a pandemic plan in place led by our very able director of public health.”
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Miles Mack
Dr Miles Mack, a GP near Inverness, Scotland, was well prepared by the time swine flu arrived at his practice. He says: “It’s a long time since we’ve had something similar to swine flu and there was a time at the beginning of the pandemic when I wondered what the implications were for me and my family.”
≥ Key learning point: GPs had a chance to show the importance of their ability to work with public health to vaccinate, treat and assess large numbers when responding to a new virus.
“Another part of me was excited and feeling that as GPs we could potentially provide a completely invaluable resource through the core skills of triaging, assessing patients, accessibility and quality of care. “There was a potential opportunity to revisit some of the old values of general practice – it became a really interesting time to be around.” Dr Mack’s area was one of the last to be hit by the virus and he noticed the difference when visiting other parts of Scotland that were already quite badly affected. “I was somewhat bemused – we were aware it was there and had spent an awful lot of time on whatif scenarios but had no time to practise them.”
“Nearby practices were reporting 40% of people with flu-like symptoms testing positive for swine flu. “The illness surge did change the way we worked – particularly the way we dealt with phone advice.” Scottish patients did not have access to the National Pandemic Flu Service and Dr Mack says he would welcome a discussion about whether such a system should be rolled out north of the border. “Personally, I think you would be very hard pushed to find a service to do what we were able to do but we were not as stretched as we anticipated we could have been – it could have been very different.”
The virus eventually arrived in October. Dr Mack says: “It wasn’t much different from the normal flu season – it’s just that it happened then rather than after Christmas. “I’m pretty proud of how we handled the practice swine flu vaccinations. We sent out letters to patients and employed retired members of nursing and admin staff to assist with the workload.”
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RCGP Pandemic Report 2010
“This year all of us had to work hard, particularly in the out-of-hours service, which operates with a very limited number of doctors. “With the sudden media hype about swine flu and reports of deaths, we became completely inundated. “We had such huge numbers of phone calls that we were building up long waiting times and I was concerned about patient safety.” Dr Adams was disappointed that more GPs did not volunteer to take on out-of-hours shifts when the pressure was at its most intense: “Obviously GPs were busy in their own surgeries but for a while the out-of-hours service really struggled to find doctors willing to work.
“It proved very useful because the service couldn’t cope – there weren’t enough people on the ground.” As the pandemic developed, Dr Adams began to see lots of patients with cold and flu symptoms, who were otherwise well, asking for Tamiflu, but she was able to explain the pros and cons of the drug with the result that many ultimately opted not to use it. She says: “Having to go out with a mask and apron to visit patients was extraordinary looking back. “At the outbreak, initially I was quite scared and thought that things might get bad as I’d never worked through an outbreak of pandemic flu before.”
≥ Key learning point: The NHS must reflect upon and learn from the experience of dealing with the swine flu pandemic so that the knowledge is available for the next major health scare.
Dr Kate Adams, a GP working in the London boroughs of Hackney and Tower Hamlets, found herself covering a swine flu hot spot during the pandemic.
Kate Adams
Dr Kate Adams had to deal with an unseasonably high workload, amidst concerns for patient safety: “Generally in summer the workload in practice eases off – it’s the lightest time of the year.
As well as in-hours GP work, she also works for an out-ofhours primary care provider. In addition, she is one of the RCGP GP liaisons for the National Pandemic Flu Service.
“People are so accustomed now to not working out of hours that they didn’t see it as their role.” She says the initial processes for reporting suspected swine flu cases were arduous, particularly for the out-of-hours service, but this improved when the system was changed. The arrival of the National Pandemic Flu Service was also a relief: “Suddenly the pressure was off.
RCGP Pandemic Report 2010
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Huw Evans
Dr Huw Evans is a GP in Conwy, Wales. His first experience of swine flu was when a resident of a local army base arrived at his surgery with a respiratory tract infection. He says: “There was no mention of flu and I wasn’t really thinking about it at the time but we quickly put him in a separate quarantine room and called for advice.”
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≥ Key learning point: It would be useful to have plans in place for dedicated pandemic centres with 24-hour staffing, should a serious pandemic occur and take up more GP time, perhaps building on GP out-of-hours capacity.
Dr Evans then donned mask and gown to swab the patient, who tested positive for swine flu. Following the diagnosis, the surgery experienced an increased number of calls as local residents became concerned they might have swine flu and phoned for advice. Dr Evans says: “We had to be careful that we weren’t saying everyone had swine flu just because they had an infection.
Dr Evans is keen that the reorganisation of NHS trusts currently underway in Wales should not distract the Welsh health service from its pandemic preparations. He says: “The new trusts will also need a pandemic response plan and everyone needs to agree it before it happens.”
“We had more calls and more visits. We felt we could cope with it pretty well ourselves – probably better than a call centre – because we thought about what other illnesses a patient might have other than swine flu and, as a result, probably gave out less Tamiflu.” Dr Evans believes the challenge of dealing with a pandemic situation fits well with the skills that GPs naturally possess: “We deal with risk all the time – we have to weigh things up, explain things to patients and work on probabilities so we’re probably ideally placed to deal with it.”
RCGP Pandemic Report 2010
Dr Tracey says the workload for GPs in Northern Ireland was increased because the population there did not have access to some of the telephone information lines available to patients in England: “The pandemic flu information line wasn’t available in Northern Ireland and there was no NHS Direct. We were prescribing Tamiflu and there was no one to absorb the work for us. “The big thing was the National Pandemic Flu Service. It would have taken a bit of pressure off practices – plus we did get a lot of phone calls asking for information about swine flu.” He adds that in common with GPs in other parts of the UK, GPs in Northern Ireland initially struggled to keep on top of the deluge of swine flu information: “The problem was really that, at the start, there were so many bits of paper and so many emails that it was impossible to keep up to date with the situation.
Dr Tracey believes the timing of the outbreak contributed to media hysteria about swine flu: “It happened over the summer when there wasn’t much else going on. This did hype it up an awful lot. People were coming in concerned and frightened.” He points to the fact that the Northern Irish Department of Health switched from daily press conferences to weekly updates in a bid to calm the swine flu paranoia, but he believes Northern Ireland’s Chief Medical Officer (CMO) and the CMO for England managed to co-ordinate their messages well, avoiding confusion. Dr Tracey says: “I remember one of the first cases here was a child who died from pneumonia and there was swine flu involvement. “The child had an open coffin and there was concern amongst the mourners that they might have got swine flu. The CMO did try to dampen that down.”
≥ Key learning point: Information should be provided to GPs via a single updated website – GPs need information but it should be put in once place.
Dr Turlough Tracey is the RCGP’s National Pandemic Flu Service liaison officer for Northern Ireland and a GP in Coleraine.
Turlough Tracey
Dr Tracey reflects on the surge in demand GPs encountered. “During the containment phase it was messy enough getting the samples to the lab. The clinical workload increased significantly in August.”
He says GPs in Northern Ireland started to notice an increase in workload from August 2009: “We were stretched in terms of clinical work and the receptionists were busy with telephone calls.”
“The best bits of information were from the RCGP. The problem was getting email after email contradicting, changing and duplicating. When you’re doing the job on the front line you just don’t have time.”
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Austin Todd
Austin Todd, a medical student and mother of two, had to rush her seven-weekold daughter Kate to hospital in October 2009 after she began vomiting blood. Austin later concluded that a relatively mild illness she had suffered shortly before Kate became ill was likely to have been swine flu.
≥ Key learning point: Distressed patients and carers like health professionals to respond quickly and to feel they are being taken care of – especially when a small baby is involved.
Austin says: “When Kate got ill it was very distressing. The weird thing was that she had been absolutely fine all day. We’d been out that morning and she’d fed and slept well. “When we got back to our house early that evening I was about to feed her when I noticed there was blood around her mouth. “I don’t think that is a common symptom of swine flu and I was thinking of much worse things. “Then about half an hour later she vomited quite a lot of blood. Even with the bits of medical training I have, I absolutely panicked. “I phoned a GP friend who came straight over and we went to the children’s hospital. When we went in, Kate was limp in my partner Simon’s arms. “I don’t think the consultant suspected it was swine flu when she was in the accident and emergency department and, in fact, I found out at the followup appointment some weeks later that they were unsure – until it was diagnosed from blood tests on the morning she was discharged. “She was tachycardic and her respiratory rate was incredibly high and irregular. The surgical team saw her and made her ‘nil by mouth’ in case they needed to operate. “As well as an intravenous drip they put a nasal cannula in – that was really distressing even though it was just to give her oxygen.
“There was a lot of sitting around and it was really upsetting to see Kate hooked up to all the machines. “Luckily, by the second morning, she was much better and was improving relatively quickly – her heart rate and respiratory rate were back down to normal within 24 hours. “Although Kate was only in hospital for three days before the blood test results came back, it seemed endless. It was a relief to finally have the swine flu diagnosed. That said, she had to continue taking medication for some time after leaving hospital. “I had been ill a week or so before, but didn’t consider at the time that I might have had swine flu because, even though I felt unwell, I was still able to get out of bed and perform day-to-day tasks. “I was very happy with the care Kate got and the amount of information that was given to us. As a parent in that situation, you’re completely powerless and to have been told all the different possibilities with a presentation such as Kate’s would have been really scary because there’s nothing you can do. “Staff at the hospital were all quite positive, which was also good – the last thing you want is to have people painting the worst-case scenario or showing that they themselves are confused. We wanted people to respond as quickly as they could and let us know what the plan was.”
“At one point, they even thought it could be meningitis and said they might have to do a lumbar puncture – they also mentioned respiratory tract infections.
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“Many practices set up dedicated flu clinics, or worked with established clinics, ensured effective triage systems to identify and quickly isolate patients who were suspected of having influenzalike illness, trained staff in the use of personal protective equipment (PPE) and ensured timely environmental cleaning. “There was a need for patient education on the use of masks, cough etiquette and hand hygiene. “The RACGP together with local GP networks with Commonwealth support rolled out education and training opportunities around the country to GPs’ practice staff.” He adds: “It was a challenge but general practice coped and new pandemic plans will hopefully better recognise the central role of general practice in revised plans.”
RCGP Pandemic Report 2010
Dr Mitchell says that as a result of the pandemic, Australian GPs have a heightened understanding of the role of triage, the use of PPE, cough etiquette and hand hygiene. He says: “It is now accepted more into common practice to ask patients to wear a mask or for clinicians to wear masks when examining patients. “Practice staff have improved their knowledge on the transmission of viruses and the role of environmental cleaning and PPE.” As of 1 January 2010, there had been 37,553 confirmed cases of pandemic (H1N1) 2009 and 191 deaths reported in Australia.
≥ Key learning point: General practice must have a central role in revised pandemic plans.
Dr Chris Mitchell, President of the Royal Australian College of GPs (RACGP), and a doctor in rural New South Wales, was at the forefront of the Australian response as the pandemic gripped the southern hemisphere, where swine flu coincided with the winter period.
Chris Mitchell
Dr Mitchell recounts the speed of Australia’s response to the challenging situation. “Australian primary care services were initially overwhelmed, particularly in Melbourne, where the pandemic first struck, but were quick to respond.
Dr Mitchell says Australia moved from a ‘delay’ phase, through a ‘containment’ phase and into a completely new phase called ‘protect’ in the space of less than a month between late May and mid-June 2009.
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“At the Guardian, there was a consensus decision to do a lot of coverage but to make it as calm, measured and detailed as possible. Throughout July and August, they wanted a story almost every day.” Mr Campbell believes the need to present accurate information created dilemmas for journalists and civil servants alike. He says: “As a journalist, you’re used to knowing everything, or thinking you do, whereas we were painfully aware we didn’t. “There was a deliberate approach only to state as fact things we knew to be facts and where there was a dispute to give both sides of the story. “Weekly press conferences with the Chief Medical Officer had already begun by then and they were very useful as journalists were able to raise questions, hopefully ultimately to inform and reassure the public. “One thing I remember from that time was the first estimate of the maximum number of people who might die, which was 65,000. Inevitably, some of the next day’s papers splashed on the fact that 65,000 might die. “The 65,000 figure rebounded on the Department of Health in a way but in a sense it’s good that they did release it because if they had behaved differently and been more secretive, we would have all gone away and competed to produce the most attention-grabbing headlines.
Mr Campbell feels the media did “a pretty good job” of covering swine flu, managing on the whole to avoid the kind of scaremongering that accompanied the MMR vaccine controversy. But he warns that, as the first point of contact a concerned patient will have with the NHS after having read a news story, GPs need to be abreast of media coverage: “Media reports can be incomplete or sensationalist and GPs, because they are at the front line in any public health emergency, should have their own knowledge updated daily to be able to confirm or refute anything in any media report.” He suggests NHS and GP bodies might also want to prepare concise information sheets that can be handed out at surgeries: “Information from the NHS to patients generally is not great. Often it’s highly technical and sometimes it doesn’t exist in the first place.” But he praises the efforts of RCGP Chair Steve Field and Chief Medical Officer Sir Liam Donaldson, who he says, “seemed to spend their summer encamped in TV and radio studios”.
≥ Key learning point: If you don’t know something, don’t pretend you do. Given the huge uncertainties around the science and the implications, don’t busk it – it’s too important.
Denis Campbell is Health Correspondent for the Guardian and the Observer. He reported on the pandemic as it developed in summer 2009. He says: “Swine flu developed quite slowly as a story at first. There was uncertainty about what it was and what it meant, given that the concern had been that we’d have a bird flu epidemic.”
Mr Campbell believes the legacy of the swine flu pandemic could be a more mature relationship between journalists and the government when public health crises occur: “It was potentially a new template for how any future infection or public health emergency should be covered – a more trusting, open and pragmatic relationship. “The Department of Health seemed pretty much from the off to have realised that hiding things and being very selective with what they gave out was never going to work.”
“I think they had to do it but, in retrospect, maybe there should have been a limit to their candour because even at that time there weren’t thousands of people dying in Mexico and the USA – countries with much bigger populations than ours.” That said, Mr Campbell believes the pragmatic approach was crucial: “If they thought something might be true, they were obliged to acknowledge it.”
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Denis Campbell
Denis Campbell reflects on the switch in media focus. “But in July, the numbers of people getting it, or apparently getting it, shot up and it really went into overdrive.
Janet Bullock
Practice Manager Janet Bullock found herself and the team deluged with paperwork as the swine flu pandemic arrived in Lancashire, where she works. She says: “We received vast quantities of paperwork, all via email, which arrived several times a day. The documents received at the latter part of the day often cancelled the information received earlier in the same day.”
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≥ Key learning point: Ensure that there is a nominated co-ordinator of information within the practice team to cascade information, as well as a deputy in case of absence. For example, frequent daily changes regarding antiviral collection points (ACPs) need to be communicated in order that the practice team can correctly direct and assist patients.
Mrs Bullock comments that, in order to produce easy and accurate pandemic documentation, most of the emailed paperwork sent to the practice needs to be printed off and referenced – the team are also signposted to this regularly updated information. “I currently have four, full to capacity, A4 ring binders of pandemic information.” Mrs Bullock says the pandemic transformed the way her practice operated: “It completely changed everything. Initially there was a great deal of confusion and uncertainty; we were not really sure what we were meant to be doing from one hour to the next. I had to ensure that every article that came in was read, understood and cascaded to the team.” In addition to dealing with the paperwork, the practice experienced a large increase in the number of phone calls from patients concerned they may have had swine flu. Mrs Bullock says: “One of our biggest problems was effectively managing the patients that were suddenly ringing up and asking for advice. “Patients rang to find out what the literature they’d been sent actually meant. We endeavoured to deal with this the best way we could – it involved providing lots of information in and around the surgery building. We also noted a dramatic increase in requested telephone consultations with GPs. We received many emails on a daily basis from a variety or sources. As a result, many required replies and almost immediate action – again this impacted on everyone’s working day.”
The arrival of the swine flu information line did ease the pressure to a degree, but the practice then had to deal with re-directed queries from patients for further advice following their conversation with the flu pandemic information line. Mrs Bullock says the practice team had already contributed large amounts of extra time in order to administer the seasonal flu vaccine, all the while trying to maintain the routine work. “Our core hours have been extended; we are open 8am– 8pm several times a week. We now routinely run seasonal flu clinics on Saturdays.” That said, she is impressed with how the team coped with the pandemic: “Primary care teams effectively handled the massive influx of unexpected work as efficiently as they could whilst ensuring that the provision of routine health care was not affected. “We managed an incredible amount of work in a limited amount of time – we were really hopeful we would receive the swine flu vaccines in time for the commencement of the seasonal flu vaccinations – thus we could have given both vaccines at the same time – but unfortunately the swine flu vaccination deliveries were not readily available to us at this time. “It’s been incredibly difficult time but we recognise that we had to get on with it.”
RCGP Pandemic Report 2010
“We learned very quickly to check emails early in the day to see what the latest news was.” Ms Hall says practice staff began to enjoy the challenge of dealing with the pandemic and now work better as a team as a result. The practice receptionists have even set up a system where one person will care for employees’ children leaving the others free to get to work if schools are closed. Ms Hall says: “We’re just more open in communication than before.” One aspect of the pandemic, which worried Ms Hall, was the impact of turning up at patients’ doors in personal protective equipment.
“As we work in London, none of us tend to drive and one taxi driver refused to let me in his car when he saw my gown. People were very fearful.” Ms Hall says the pandemic flu helpline took the pressure off the practice, but staff then found themselves in the tricky position of being asked to produce medical certificates for patients who had received a phone diagnosis and had no contact with the practice. She says: “It would have been useful if after every contact with the swine flu line someone had sent a message to the practice to let us know.”
≥ Key learning point: Having the pandemic as an agenda item in the weekly staff meeting enabled both clinical and non-clinical staff to express their anxieties about swine flu. This was helpful because non-clinical staff were then able to reassure patients and their relatives.
Sonia Hall is a nurse practitioner in East Dulwich, London. Her first experience of swine flu was when pupils at a nearby school became infected at the beginning of the outbreak.
Sonia Hall
Sonia Hall‘s experience reflects the daily pressures faced in the early days of the pandemic. “Now the systems are in place but at the time we trialled every system there was from contacting the local Health Protection Agency to using particular swine flu centres.
She says: “We had swine flu really early on and we probably caught most of the disorganisation. The problem was that every day what we did changed.”
She says: “When we were swabbing, I felt almost as though we were putting a cross on that person’s door. In some areas of terraced housing, you had to put your gown and mask on out in the street.
RCGP Pandemic Report 2010
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“We had quite a field day trying to warn people not to buy Tamiflu on the internet, because they would have no idea what it was and they might not need it – the distribution was quite good for Tamiflu.” As well as the threat of being ripped off, there was an even more serious risk to patients, which the RPSGB needed to highlight.
“We had lots of national pharmacy chains that had been asked to do different things by different PCTs. “This made it very difficult for the national chains in particular to plan how they would get involved. “If the pandemic became particularly bad, the last thing you’d want would be hundreds of people going to the pharmacy to collect Tamiflu – we would be inundated, as well as having people wanting their normal medicines and wanting to buy up simple flu remedies. “We also knew pharmacists and their staff would get ill – there was the potential for the distribution system for medicines to break down.”
Mr Pruce says there were concerns that patients with severe swine flu might even die from complications if they had simply bought the medication online and did not seek treatment early enough.
Mr Pruce says the PCTs with the best plans replicated approaches they were using to discourage swine flu patients from visiting their GPs by setting up flu drug distribution centres to take patients away from pharmacies.
Faced with these challenges, the society launched a PR offensive that achieved an international response.
A further concern was that in some cases pharmacists were not being counted as front-line health professionals for vaccination purposes, raising the spectre of further drug distribution problems if many became infected.
Mr Pruce says: “We put out a press release. The BBC got hold of it and for a whole day it was their lead story. “It was picked up by a lot of newspapers and actually went global. I was being quoted in New Zealand, Argentina and Hungary. “We can be confident that a lot of people who heard the story would have been put off buying Tamiflu over the internet.” Having dealt with the threat of drug counterfeiters seizing on public anxiety over the pandemic, the Society also had to ensure its members were getting the support and information they needed.
David Pruce steered the Royal Pharmaceutical Society of Great Britain (RPSGB) through the swine flu pandemic before leaving his job as the society’s Director of Policy and Communications at the end of 2009. Mr Pruce says ramping up existing work to warn against counterfeit medicines became a top priority for the RPSGB as the pandemic began.
The pandemic also tested pharmacists’ relationships with GPs. Mr Pruce says that systems worked best where strong relationships were already in place between the two professions, but the RPSGB has come to the conclusion that GPs and pharmacists must communicate better in future. “One of the things we saw from the centre is that there is a need to develop those relationships so that, when a crisis happens, the communication channels are already well established.
Mr Pruce says: “The biggest thing we noticed was the variability in how Primary Care Trusts (PCTs) dealt with the pandemic – particularly over Tamiflu – and whether pharmacies were going to be the main suppliers or whether it was going to be given out via distribution centres.
“Communication between GPs and pharmacists should be improved across the board. I’m not sure how many GPs were aware of the plans we had in case of dire emergency, which included potentially issuing out-of-date stock, reusing patients’ medicines for other people and that we’d possibly end up calling up recently retired pharmacists or those who hadn’t yet qualified.
“There was a lot of guidance, which was good, but each PCT was left to come up with its own plans.
“If you don’t have everyone around the table, then you won’t know what you don’t know.”
RCGP Pandemic Report 2010
≥ Key learning point: Make sure all local players – including pharmacists – are involved in pandemic planning.
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David Pruce
Once the pandemic took hold, a trade in medications bought online emerged. David Pruce reflects on the situation: “We detected that once the pandemic started to take hold, Tamiflu, which was being used to treat flu, was being hawked by the same people who were hawking fake Viagra online.
Conclusion
Information dissemination crucial in a pandemic
Wider practice team involvement important
Lessons learnt must inform future planning
All of the primary care staff who found themselves tackling the swine flu outbreak had to deal with a rapidly changing situation and an initial lack of information.
All members of the practice team – including non-clinical staff such as receptionists – should be included in discussions and meetings about the response to a pandemic situation.
Patients value a prompt and sensitive reaction from clinicians at a time when uncertainty is adding to the burden of their illness.
Members of the press and even patients experienced the same lack of information. This shared experience led to a consensus that good information is one of the most critical requirements for successfully negotiating a pandemic.
Respondents said this helped ensure all practice staff were able to communicate a single message to patients about swine flu but, equally importantly, allowed staff to express their own fears and uncertainties while they were working in stressful and uncertain situations.
Firstly, information must be provided in an authoritative and concise manner.
In the wider context, other professionals such as pharmacists and managers must also have a role in discussions about policy at a local level.
Messages must be consistent as confusion unsettles staff and patients alike. Interviewees stressed the need to be honest about unknowns and to ensure that mixed messages are minimised unless absolutely necessary. The second point is that information must be available to all – and all organisations must develop a policy about sharing information. Interviewees said data on how to deal with swine flu must be collated in one place where timepressured clinicians will be able to find it easily. One person should take responsibility for ensuring that everyone who needs to has seen this information.
GPs faced with a pandemic need additional support It was accepted by all that, as the front-line professional in any outbreak, the role of the GP is crucial. But interviewees in England welcomed the breathing space provided by the National Pandemic Flu Service. So while general practice must have a central role in pandemic planning, GPs welcome additional support to deal with vastly increased workloads during pandemics or other public health crises.
But this speed of response must not detract from the learning opportunities offered by present and future pandemics. One unexpected benefit of the 2009 swine flu pandemic was that clinicians and managers were able to test out pandemic plans against a virus that turned out to be relatively mild. Doctors and managers were eager that the NHS should reflect upon and learn from the experience of dealing with swine flu, so that new knowledge could be drawn upon for the next pandemic. No one is under any illusions about the reality of planning for pandemics – as soon as the current one is out of the way, attention must shift to preparing for the next one. But the UK health system, and front-line primary care staff in particular, have demonstrated that they are extremely well placed to take on the challenge.
Statement from the sponsor GSK has made a financial contribution to the general costs of the event for a GSK presentation session on the company’s contribution to pandemic preparedness and response. GSK selected the speaker and developed the presentation for the GSK session. GSK was not involved in the planning, speaker selection or content for any other sessions of the event.
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RCGP Pandemic Report 2010