Memorandum by the Royal College of General
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.
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
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".
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, 
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.
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).
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.
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
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
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.
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Longini IM Jnr et al Containing pandemic influenza
at the source" Science 12 Aug 2005 ;309(5737):1083-7. Back
RCGP Press Release 16 July 2004. Back
DH Press Release. 2005/0083. Improving preparedness for possible
flu pandemic. 1 March 2005. Back