Select Committee on Science and Technology Minutes of Evidence


Memorandum by the Royal College of General Practitioners

  1.  The College welcomes the opportunity to comment on the House of Lords Science and Technology Select Committee inquiry into Pandemic influenza

  2.  The Royal College of General Practitioners (RCGP) is the largest membership organisation in the United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general medical practice and to act as the `voice' of GPs on issues concerned with education, training, research, and clinical standards. Founded in 1952, the RCGP has over 23,000 members who are committed to improving patient care, developing their own skills and promoting general practice as a discipline.

THE RISKS

  3.  According to the World Health Organisation (WHO), influenza experts are agreed that another pandemic is likely to occur but are unable to specify when. Given the continuing outbreak of highly pathogenic H5N1 avian influenza in South East Asia since December 2003 there is a justifiable international concern that this could provide the potential for a pandemic in humans, were co-infection with avian and human flu viruses to occur.

  4.  The principal body involved with assessing the risk of pandemic influenza emerging in South East Asia and reaching the UK is the Department of Health, advised by the Health Protection Agency (HPA).

  5.  International veterinary and human disease surveillance activities are critical to both assessing the risk and to responding to the emergence of a pandemic. The UK provides one of the four collaborating centres that form the WHO surveillance network, along with the USA, Australia and Japan. The European Union (EU) also has an influenza surveillance scheme and the UK is part of the 23 country collaboration.

  6.  The UK is further a member of the World Organisation for Animal Health (OIE). This has adopted a new chapter on avian influenza in the Terrestrial Animal Health Code in order to ­improve transparency and control methods of the disease, protection of human health and provide greater protection for countries importing poultry and poultry products while eliminating unjustified barriers to trade".[1] We imagine that Defra will be providing evidence to the House of Lords Committee on this matter.

  7.  There is a concern that for modelling strategies of containment at source in South East Asia[2],  [3] to be successful there will need to be early diagnosis and verification of cases. However this is unlikely to be achieved in practice in many parts of South East Asia. Moreover Sudden Acute Respiratory Distress Syndrome (SARS) has demonstrated the ease with which international air travel can lead to rapid intercontinental spread of infectious disease.

CONTINGENCY PLANNING IN THE UK

  8.  The WHO has set out its role and recommendations for national measures before and during pandemics in the WHO Global Influenza Preparedness Plan. GPs and the Primary Care sector will have to play a critical role within this. Our position statement on major incidents and disasters calls for GPs to be engaged in contingency planning with Primary Care Organisations (PCOs).[4]

  9.  The Department of Health invited comment on its pandemic plan and has reported that GP responses included concern about when GPs would receive training and also how single-handed practices would be supported.

  10.  The Department of Health also issued guidance for health service planners in March 2005. This places responsibility on Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) to ­develop, maintain and periodically test multi-agency contingency plans to ensure resilient arrangements are in place". The Department of Health and the HPA are probably best positioned to assess progress in this regard. Currently there seems to be only limited awareness amongst other services of the impact pandemic flu would have on their own ability to function and the challenges this would present to health. Further there have been some comments in the media in regards to preferential use of antiviral treatment for `essential services'; this has led to questions as to what health plans are in place to achieve this. We would be concerned if Primary Care suddenly were faced with providing occupational health services to the ­essential services" given the pressure GPs would be already under. Guidance is required for essential services on this matter.

  11.  Both the Department of Health and the HPA have usefully provided information for the public in a question and answer format. The public will need clear guidance in the event of a pandemic and NHS Direct has a very important role to play in providing this along with the media and thereby relieving pressure on general practice. Contingency plans should include effective and clear communication strategies to include the media, virologists and politicians. With pre-prepared material that can be made available in the event of a pandemic.

  12.  Advice for the professions will need to be consistent, timely, relevant and achievable. However, as yet there is no knowledge among GPs as to what is pre planned or what Primary Care input has been.

  13.  The Department of Health has announced that Roche will supply 14.6 million doses of Tamiflu over the next two financial years.[5] Clearly were a pandemic to occur by April 2006, there would be a shortfall as only half of the purchase would have been obtained. Effective logistics are critical to ensuring that those who require vaccine and Tamiflu countermeasures at the Primary Care level receive them. GPs will want to know how this will happen for their patients. There will be a huge issue surrounding rationing and delivery of the antiviral therapy and we need to be clear what role Primary Care will play within this.

  14.  Low nasal swab for flu could help to identify those who need isolating. Given that the overall sensitivity of the NPT is low (30-50 per cent), those who test negative are those who are shedding little virus, so it is an ideal indication of those that need to be isolated.

  15.  GPs are at the centre of NHS and Department of Health plans to deal with pandemic flu and have a history of providing a large part of the medical response to previous outbreaks. However there is a concern in Primary Care about the huge potential workload any pandemic would engender. We are confident that many in Primary Care would want to provide additional support to health needs over and above their normal duties. The contract system however that GPs currently work under, with large numbers working part time or to fixed levels of patient available time, may reduce GPs abilities to expand their responses as had previously been the case.

  16.  GPs will not expect to provide extra capacity without reward. Furthermore it is not clear yet how many GPs will want to take out of hours work during a pandemic when normal duties may be taxing enough. In addition GPs will need to have their quality targets in other areas protected if the workload due to a pandemic affects their performance in these areas.

  17.  There seems to be a real problem here in the need for people to self-isolate at home and the ability of GPs to provide home based care on this scale.

  18.  Given these factors it has left questions to be answered about the surge capacity of NHS Direct and Out of Hours services when faced with a pandemic.

  19.  Expectations about additional GP deputies coming from abroad to help build capacity seem optimistic given the situation they would be working in and the situation likely to be occurring in their own country's health care system.

  20.  There needs to be planning for how GP resilience could be tackled. This seems to be an important omission, and whilst individual PCTs may have some thoughts about this few seem to be engaging with practices to find out how they perceive their role, or how much support they will be able to give and will need in turn given a pandemic.

  21.  In a pandemic situation many smaller practices may suffer greatly due to staff illness; however, it is not clear that any support for provisions of masks for either GPs or their staff will be forthcoming from PCOs or central government. In the absence of a strategy few practices are committing to buying any form of mask and the risks are that practices will lose more staff and GPs in the first few weeks and months of a pandemic than would be the case if they could be protected.

  22.  We are further concerned that the figures in the NHS plan around excess GP consultations may be misleading as they qualify the number of excess consultations that will be due to influenza at 2.4 million. However in previous pandemics of ­flu like illnesses" consultations rose from 1 million to 6 million i.e. a 5 million excess. GPs are unlikely to be able to differentiate with much certainty between flu and flu-like illness therefore there will be a need to assess them both with equal rigour. If antivirals are available for the treatment of the sick then it may be that GPs will have to give treatment to those with flu like illness rather than those GPs can be certain have flu. This process will be made more difficult by two factors, antiviral stocks are not yet at levels that make it clear how much will be available for treating patients and secondly, it is unclear how distribution to a point where patients can access it will be achieved. We would also like to note that the assumptions on which the figures are calculated are subject to wide margins of error and that although based on previous virus behaviour, plans could be an order of magnitude out in reality, and this should be recognised in the planning stages.

  23.  There needs to be a clear guide line on Primary Care's role in vaccination policies and their role in reducing other hospital admissions during a time of a pandemic.

  24.  In addition the impact of infrastructure collapse on Primary Care (utilities, fuels and schools) needs to be further understood.

  25.  It is important that, in the event of a pandemic, good will exists between Department of Health, PCOs and GPs. It is important that GPs are highly involved in discussing and preparing for a pandemic and practical support measures taken in advance of a pandemic will help in maintaining good will. There is not much evidence of this happening at present.

  26.  There needs to be a clear research plan in place to ensure that any management lessons are quickly learnt after a pandemic or epidemic so that we are not in the same situation after the outbreak as we were before it. As it is difficult to gear up research quickly we need an emergency research plan as well as an emergency management plan and this research needs to be led by GPs as well as lab and health doctors.

  27.  Secondly, there needs to be a firming up of the evidence surrounding the role of antibiotics in managing flu so that we can issue clear guidance on antibiotic use and make sure we have a sufficient supply.

  28.  Primary Care has a long way to go if it is to be able to meet the challenge of influenza in the 21st Century. Moreover there are some concerns that the previous ability of Primary Care to adapt and expand its capacity to respond to surges in demand may have been lost due to changes in GP contracts. We feel the revised Influenza Contingency Plan does not accurately reflect the increases in GP workload that could be expected and could engender some complacency. It is possible to identify strategies that might improve resilience but few are being implemented systematically and require political decisions to be made before PCOs will commit to any spending.

  29.  Primary Care has a problem in itself that it has little experience in resilience and emergency planning for disease, catastrophe, or attack. Given current global conditions this will need to change and will require work from both government and professional organisations.

209-14. Epub 3 Aug 2005.



1   http://www.oie.int/eng/press/en_05027.htm Back

2   Ferguson Neil M ­Strategies for containing an emerging influenza pandemic in Southeast Asia" Nature, 8 Sept 2005, 437(7056): Back

3   Longini IM Jnr et al ­Containing pandemic influenza at the source" Science 12 Aug 2005 ;309(5737):1083-7. Back

4   RCGP Press Release 16 July 2004. Back

5   DH Press Release. 2005/0083. Improving preparedness for possible flu pandemic. 1 March 2005. Back


 
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