Examination of Witnesses (Questions 160
THURSDAY 27 OCTOBER 2005
Professor Nigel Mathers, Dr Richard Jarvis, Ms Lynne
Young, Professor David Menon and Ms Helen Young
Q160 Chairman: Coming back to this
general questions, could I ask Professor Menon and the others
how it will affect your work if we have a pandemic?
Professor Mathers: I would preface this by saying
that we think in the College that the Department of Health has
done a good job with the contingency planning as far as they can
go. There is still quite a lot to be done but I think we have
time to do that. That would be our general view of the planning
that has gone on so far. As far as the impact on general practice
and Primary Care is concerned, there is a series of issues. One
is our surge capacity: can we cope with the additional workload?
Another is service continuity and resilience. Another is supporting
essential services and links with PCTs and NHS Direct. There is
the question of communication with the public and the issue of
smaller practices and the impact on our performance targets of
managing a flu pandemic. There is a whole range of issues which
still remains to be addressed, including the position of our surveillance
unit. The Royal College of GPs has run an influenza surveillance
unit for the last 40 years. That has a well-deserved, international
reputation as being the gold standard in surveillance. There have
been some issues with our contract, which I would like to talk
to you about at some point this morning. My Lord Chairman, I am
not sure whether you want me to take each of those in turn or
whether you would like me to focus now on one particular issue.
Q161 Chairman: Perhaps you could
help us a bit with what you are doing for GPs individually? Have
GPs been given the opportunity to express their concerns and how
have these been addressed?
Professor Mathers: The consultation which we
have undertaken as a college has been of our members of the College.
We have 23,000 members; they have had the opportunity to comment
on how general practice could contribute to managing of a flu
pandemic. At the moment, the base line figure is that we have
some 30 consultations per week for influenza-like illness per
100,000 population. That is size of a PCT. In a normal flu pandemic
we would have about 250 consultations per 100,000. In a flu pandemic,
the contingency plans call for 5,000 to 10,000 additional consultations
per week per 100,000 of population, which means that our surge
capacity would not be able to cope with demand like that and that
we would need some alternative provision.
Q162 Chairman: Have you thought about
what that provision might be?
Professor Mathers: Certainly we would have to
work very closely with the Primary Care organisations, such as
the PCT; we would have to work very closely with our nursing colleagues;
we would have to introduce triaging systems; we would have to
have a huge, very sophisticated media campaign as to self-management
and keeping away from practices unless you are one of the unfortunate
number that has complications. We would have to teach people about
self-management, about when to see the doctor, and employ every
health worker that we could to spread the message and to provide
the treatment, but we would have to work very closely with our
PCTs. One of the questions on the list that we were given was,
Has the NHS current organisation impacted on preparation
for the pandemic?" I think, from our point of view in the
College, this is clearly the case. PCTs at the moment are being
reorganised. There are issues around that reorganisation because
there is planning blight and it is very difficult for PCTs actually
to focus down on one particular topic, such as the flu pandemic.
Q163 Chairman: In terms of a media
campaign, have you thought of the needs there? Have you prepared
a brief, as it were, for the media?
Professor Mathers: We have not prepared a brief
but we would be very pleased to contribute to such a brief because
it would not just be the College but us working with other partners
in the health care sector. It would have to have a lot of content
in terms of when to visit the doctor, when to visit the practice,
how a nurse triaging system works. It is a very complicated picture
and there would have to be a whole series of instructions, not
only for practices but also for patients.
Q164 Lord Patel: If I heard you correctly,
there would appear to be a concern about the ability of Primary
Care to carry out the surveillance that would be required to see
where the disease starts and how the disease is progressing. Have
I picked you up correctly?
Professor Mathers: There are two separate concerns.
One is our capacity to deal with the numbers of ill people who
are likely to be involved in a pandemic. The other is a concern
about the continuation of our research unit, the influenza surveillance
unit. Those are issues around our contract with the Department
of Health. As I said earlier, we have had a contract for many
years with the Department of Health. We very much wish to improve
the service that we provide. However, for the last 18 months we
have been trying to get some formal agreement for continuing support.
As it currently stands, our contract runs out in April 2006, which
gives us problems with the continued employment of the staff.
It is almost as though there is a planning blight. Although we
understand the Department is very supportive and wishes to see
the service continue, we do not have any formal arrangement, and
we have been trying to do this for the last 18 months. That is
my concern around surveillance.
Q165 Chairman: We take that on board.
Perhaps we could move to Ms Lynne Young?
Ms Lynne Young: There are several issues here,
given that we are dealing with huge uncertainty, but, even with
the good news, we could safely anticipate a lot more nursing work.
I think it is really important to step outside the setting of
intensive care in the hospital. I could give you the district
nurse as an example. District nurses may nurse older people at
home who are very fragile and very frail. All it takes is for
many of those older people to have a heavy dose of flu and the
workload of the existing district nurse workforce will just rocket
and may be unsustainable. We have issues about looking at the
population and not just those who are severely ill and will need
an intensive care bed. We could safely say that most people will
not need that but will need extra nursing in the Primary Care
setting. The College is working very closely with the Department
of Health to make sure that all the Department of Health information
is circulated to the nursing population, and we will continue
to do that and give all the support we can. I think we do need
to start thinking about if it does become pretty bad, we could
put a call out, for example, to recently retired nurses, nurses
who have actually chosen to leave the profession but would be
very keen to come and help, should the population require that,
but that would take quite a lot of work. There are issues in terms
of nurses who have been out of work a little while and whether
they are safe to practise and what kind of support they would
need. A lot of co-operation will be required in terms of Department
of Health organisations, such as the Royal College of Nursing,
the Royal College of General Practitioners and community organisations.
That is quite a challenge but the RCN is very committed to doing
what it can to limit damage. Even without a lot of newly ill people,
there is again extra nursing work in terms of delivering a mass
vaccination programme. That also has to be taken very seriously
Q166 Chairman: Have you looked at
the actual numbers of retired nurses who might be available?
Ms Lynne Young: I do not have those figures
available. I can find them. We do know there are about half a
million nurses on the NSU register, some of whom are not working,
so there is an opportunity there to seek those nurses out if we
need to do that.
Q167 Chairman: Do you think it would
be feasible to give them a briefing update, as it were, just on
flu? Would that be a feasible thing to do?
Ms Lynne Young: Yes, we can do that. In fact,
currently at this moment, we are preparing a briefing that would
help with very basic simple information to nurses to help them
know what to do: not panic, not be anxious, but help to become
involved and deliver effective care and management.
Q168 Chairman: Perhaps Ms Helen Young
could tell us about NHS Direct?
Ms Helen Young: NHS Direct has worked in collaboration
with the Department of Health and, based on modelling that the
Department has done (and our contingency plans are based on those
figures) we are estimating that a potential of 3.2 million clinical
cases would appear between week six or week seven of an outbreak.
On that basis, our understanding is that all of those people will
need access to either antiviral treatment or, at the very least,
clinical triage. We believe that we would be capable of being
the gateway that my professional colleagues have referred to for
patients who have been affected. In order to do that, there are
a number of contingency plans that we would switch to. It is clear
to us that if we do that, we would be unable to continue with
what we call the core business, the business that we currently
do. The plans would be to become a potential gateway for patients
or those affected by a flu pandemic to receive information and
clinical assessment to aid my clinical colleagues in the community
so that those who actually need to have face-to-face consultation
are given access to a face-to-face consultation and those that
do not and might receive information, i.e. the worried well or
those who might be able to self-care, are directed to our existing
self-care channels. Members of the Committee may be aware that
we already have a successful website, an on-line service, on which
information around the flu pandemic currently exists, but there
is also information around bird flu on that website, as are our
self-help guides actually on-line. For those who are not able
to access on-line services, we currently run a digital television
service. Again, we propose to keep current the information about
the two, both the flu pandemic and bird flu. We are able quite
rapidly to change information on both those channels to meet the
demand. The telephony service that we run, which traditionally
NHS Direct is known for, would therefore seek to take calls from
those who have been directly infected by the flu. We would, through
messaging, be able to divert those who could not get information
elsewhere to our other channels. We would seek to triage, or to
assess, or speak to those people who felt they needed to speak
to somebody. We would clearly seek to outsource some of the call
handling. For instance, we would use all of the NHS Direct staff
currently employed to deal specifically with the flu outbreak,
and we have geared our staff up to know that is exactly what we
would expect them to do. We would be able to outsource, through
the virtual technology we have, the call handling. That basically
means that for those people who would call us and we would get
demographic information from, et cetera, and assess, we would
outsource that. All of that is predicated on us being part of
a multi-system planning, which the Department Health is engaged
in doing at the moment. My points around capacity are that, yes,
I believe that NHS Direct would be able to cope with the capacity;
it would be a big challenge, but we have plans in place to be
able to do that. We would seek to take as much of the public demand
for information to our alternative channels, such as digital television
and on-line, and also our self-help guide, which is in the back
of the Thomson Local Directory. There are 18 million which
already have access to that. We would probably seek to triage
appropriately those patients who need face-to-face consultations
with someone in Primary Care and en bloc that will stop
the panic that might ensue for those who feel that they need to
have a face-to-face consultation.
Q169 Lord Patel: May I ask a supplementary
at this stage, my Lord Chairman? I think that sounds pretty good.
The problem would be that when a pandemic starts you would get,
as you describe it yourself, hundreds of thousands of calls, each
one of them describing symptoms that are akin to flu symptoms,
and each one of them expecting immediate access to drugs, such
as Tamiflu. How would you deal with that?
Ms Helen Young: Calls to NHS Direct would clearly
be triaged. We would seek to do what we normally do, which is
to triage the most severely infected cases. The information about
what drug therapy is available, when you might expect to receive
it, and where to go to get it, would be available through the
on-line services, through the information in patient leaflets
and through the information that is available on digital television.
Q170 Lord Patel: That would tell
you exactly who they are and where they would get the drugs?
Ms Helen Young: We have a knowledge management
system, as you may well know, which basically has a list of all
the areas, both GP contacts and walk-in centres, clinics, pharmacies,
et cetera. The Department and ourselves would work together to
ensure that that knowledge management system, that database, was
fully up-to-date to show people and help people on where they
would be able to receive face-to-face treatment, information,
and where they would be able to get access to the drugs. That
is our planning.
Q171 Lord Howie of Troon: As I understand
it, and you will tell me if I am wrong, a pandemic would start
fairly slowly and then peak quite sharply before it is over. You
have obviously done a good deal of work. At what point on the
first bit of the curve do you become convinced that a pandemic
has actually started?
Ms Helen Young: I feel, as I am a non-scientist,
that may not be a question that I can personally answer. May I
refer to colleagues on the panel?
Professor Mathers: The Department of Health
contingency plan described six phases and four alert levels, depending
upon the cases which are reported. I understand, though I have
no direct experience of this, that a pandemic portal has been
created by the Department of Health whereby all the sources of
information about outbreaks, care and the rest of it can be collected
into one dataset so that we can get up-to-date information. The
other point is that under our surveillance unit, the Royal College
surveillance unit, we have at the moment a twice-weekly return
service. There are 75 practices plus another 31 just coming on
line across the UK from which twice a week information is automatically
downloaded from their computer system into the one central research
unit so that we can monitor cases and see the rate at which the
cases are increasing because you have to reach certain criteria
to move on to the next phase. The Department of Health would be
responsible for issuing alerts depending on how many cases were
Q172 Lord Howie of Troon: I am wondering
where this portal is that you mention. How many cases are there?
Professor Mathers: As I said earlier, the base
line is around 30 consultations per week per 100,000 population,
peaking at about 250 in normal seasonal flu. Once we get beyond
250 additional consultations per week per PCT population, then
we begin to start moving through the phases, but there are other
sources of data as well.
Q173 Baroness Finlay of Llandaff: I
apologise for being late and also if perhaps this question has
already been asked. When you were talking about triage, I wondered
what the criteria are by which you will put people into the different
categories and how do you then safeguard against exaggeration
of symptoms in order to access drugs?
Ms Helen Young: The algorithms that NHS Direct
use are to do that very thing; they take the worst case scenario
and work backwards. I do understand the risk and potential risk
of having a telephone consultation with people who do exaggerate
their signs and symptoms. I guess to a certain extent we cannot
particularly stop that, but with the information that is made
available to people and the information that we would make available
to people about what alternatives they have, we can trust very
much on our nurses' ability to be able to make the triage and
be able to get information from them and give information. A lot
of it is based on our experiences with the public when they use
us currently, that they are genuinely quite honest with their
clinical answers because they want to be in the right place at
the right time. I do believe there is public information and public
education, and that is exactly what our nurses would do. I cannot
give any guarantee that we would get it right 100 per cent of
the time. We would use our best clinical judgment and our best
clinical decision making, which, based on current evidence and
current experience, we are reasonably successful at doing.
Q174 Baroness Finlay of Llandaff: Do
you have those algorithms up already?
Ms Helen Young: Yes, we have algorithms available
currently for a flu outbreak. We have algorithms available for
a potential flu pandemic. We are also working on system contingencies
to see that, if there are any technical failures in our system,
we can use a stand-alone system; in other words, we can operate
that system also.
Q175 Baroness Finlay of Llandaff: What
are the criteria for triggering a referral or obtaining advice?
Ms Helen Young: I am very happy to give you
the information for the algorithm and I will pull it out. I do
not have that information at this point. I am happy to share the
algorithm with you.
Q176 Lord Soulsby of Swaffam Prior: From
the answers you gave to the first rather extended question, it
seems to me that you are reasonably content with the plans that
each of you in your various professions has of dealing with an
endemic flu outbreak. There is always a gap somewhere. Is there
a gap? What more needs to be done to be assured that we could
handle the thing? The second point is: have you tested your plans,
either collectively or individually? Firstly, what more needs
to be done?
Professor Mathers: From our College's point
of view, there needs to be a lot more detail as to how Primary
Care would respond to the challenge. Some of the issues are around
service continuity. For example, the contingency plan suggests
that if you develop influenza-like symptoms in the middle of a
pandemic, then you should go into voluntary quarantine. If you
are in a practice of, say, four receptionists, two nurses and
three doctors, then if you have someone in a practice who is going
to follow the guidelines, very rapidly you are going to close
down the practice. That is one issue which needs to be progressed.
The other is resilience. If we are dealing with patients during
a pandemic, then of course there is the usual core business still
to be done. That needs to be addressed as well because that, of
course, will have an impact on our performance-related contract
if for three or four months we may not be able to deliver on the
core business because we are dealing with the pandemic. The other
difficulty is around how we support essential services. In the
plans it recommends that we support essential services, but it
does not actually define what that is. Does that mean we give
priority to health care workers for antivirals, for example, or
consultations? We are not sure about that. Also, there is the
particular problem with smaller practices. If you have a practice
of, say, four or six people and one or two or those go down with
influenza, then there is a problem about continuing to manage
the service. There is also the issue about how we manage our visits.
My colleague Lynne Young has suggested that some of the issues
are going to be that the workload will increase exponentially
if people are ill and told to stay at home and require a visit;
that may be from a nurse or a doctor. That is an issue which has
not been resolved satisfactorily yet.
Ms Lynne Young: I think we need to acknowledge
that in many areas community nursing is actually under pressure
right now; it is struggling very hard to meet even very essential
demands. Because of the demand very rapidly to make savings within
the Primary Care trusts, agency, part-time staff, bank staff perhaps
have been told that there is currently no work for them. That
therefore puts more pressure on existing services. That is very
important. I think we have to take very seriously indeed the fact
that if we suddenly get a large number of people who are newly
ill and can be cared for in the community, the essential services
that are currently being carried out will have to be put on hold.
We will need to be very clear about priorities and emergencies
making a different set of priorities. The front line of nurses
and doctors will need a lot of support from their organisation,
and indeed from the Department of Health, in order that they do
not come under increasing pressure from a very disgruntled public
who, even for the short term, are not receiving the services that
they are used to receiving.
Dr Jarvis: I think the overwhelming feeling
is that the flu pandemic plans in this country are very good.
As you intimate, there are holes and problems with that. The areas
where we think there are adequate plans already in place include:
vaccination and provision of antivirals for vital staff; alerting
mechanisms, both international and national; cascading of professional
advice; and production of public advice. I think more preparation
is needed in a number of areas, particularly organisational plans
both within the NHS and in the wider private community. We need
to be able to provide effective triage systems. I think these
will change as the course of the pandemic progresses. I think
we also need time-sensitive flu management algorithms for front-line
staff. Most of all, there are major challenges that a flu pandemic
throws up for which it is actually very difficult to plan and
particularly in service-wide demand management. In a system that
runs at very high levels of efficiency, it is very difficult to
provide surge capacity and also maintenance of adequate staffing
levels when staff are likely to be unwell. To answer the final
question, which was about exercising and making people aware of
these things, exercises are taking place and they are very useful,
but, by the nature of these things, although it is possible to
include most of the organisations involved in flu pandemic planning
in the exercises, it is very difficult to involve individual practitioners
at the front line, and they express a need to be involved in this.
It is difficult to bridge that gap.
Professor Menon: The answer is in two parts.
The published pandemic plans from various sources really make
no mention of intensive care. There is a very big gap. What has
been heartening over the last two weeks is how much involvement
there has been with the Department of Health. While the gaps have
not been filled, at least there is a recognition that the gaps
are there. There are specific issues that worried me and which
we need to address quickly. The first thing is to make sure that
monitoring involves intensive care admissions, as does surveillance.
We have suggested to the Department of Health that the Intensive
Care Research and Audit Centre in London, which essentially audits
80 per cent of the ICUs in England and Wales, provides surveillance
and monitoring so that we can take account of the full spectrum
of disease. We have also taken on board a lot of the capacity
issues. I believe Bruce Taylor, who is sitting here representing
the Intensive Care Society, is chairing the Department of Health
Critical Care Contingency Forum, which is addressing some of the
capacity issues. Finally, we have made some suggestions about
research in the context of the pandemic, which I think is both
a necessity and almost a duty but also a huge opportunity. I hope
that we have a chance to discuss that at some stage during this
Lord Soulsby of Swaffam Prior: May I return
to one matter, my Lord Chairman and that is the commentary about
personnel, the shortage of personnel and personnel being under
pressure? Are there any plans to recruit people from parts of
the Commonwealth, say Australia and New Zealand, and to draft
in people to help out at the peak of a pandemic?
Q177 Lord May of Oxford: Assuming
they do not have it!
Professor Menon: I suspect they are going to
have it. Australia in particular may well see this before we do
because they are closer to the most likely focus of outbreak.
I think a major problem is that I suppose the establishment, which
includes all of us, has in dealing with public expectations is
both ways. First of all, I think people need to realise that we
cannot prepare for the catastrophic scenario; it is simply not
possible because it is unlikely and we would not be able to put
in place the resources. However, even if a less severe pandemic
does happen, they need to be attuned to the fact that we will
not be able to deliver services as usual. All the people sitting
on this side of this room have made it clear that we are doing
our best and we are putting in place plans to deal with some medium-scale
scenarios. However, if things are really bad, we will not be able
to cope and may be unable to deliver the same standard of care.
The second point is that in the medium eventuality, your hip operation
is going to be delayed, elective surgery is going to be delayed
and lots of things are going to have to wait. People have to realise
that that is a fact of life. There is no getting away from that.
Q178 Chairman: Do you want to go
on and talk about the research that you would like to do here?
Professor Menon: Yes, and in two aspects, one
being the general area of research. The reason why we are not
as prepared as we would like to be is because previous pandemics
have not been subjected to the rigorous research that modern research
techniques allow. The first thing I would say is that we need
to get together our data collection mechanisms and decide how
to do it most efficiently. It would be ideal to have a minimum
clinical dataset so that every patient who presents to the help
lines has some information collected from them, that when they
present to the GP and additional information that is collected;
and if they come to the hospital, further additional information
is collected; and if they come into intensive care, there is still
more information. Second, especially for people who come into
hospital and into intensive care, we really need to know what
the outcomes are. There is no point in our saying a drug is a
good drug unless we know it saves lives, and in order to know
whether this is the case we need to have clinical outcomes on
all of those patients. Those minimum clinical datasets need to
be decided now. Third, there are also regulatory issues. I am
told that in the great epidemic of 1918/19 people dropped dead
on the street. They probably would not drop dead now because ambulances
would bring them in. Many people would come in unconscious. There
is a whole set of regulatory hoops that we have to jump through,
and we have to do this in advance. We have to get Ethical Committee
approval. Many of these patients may come in incapacitated and
so we need to go through the provisions of the Mental Incapacity
Act. We need to address issues of data protection. Many of the
studies we want to do urgently in a pandemic to tell us how best
to use the interventions we have would have to be done under the
aegis of the Clinical Trials Directive, and so we need to put
those in place. All the regulatory issues need to be dealt with
now. I understand that the MRC are chairing or co-ordinating this
kind of initiative. As far as intensive care is concerned, as
soon as the first patient comes into intensive care, we owe it
to that patient and to the patients we are dealing with at the
end of the pandemic to make sure that we deal with them as part
of the scientific protocol-driven study. If we are going to use
antivirals, we need to know: does it make a difference when the
patient came in whether the antiviral was given on day one or
day four? If, on day four, it was making no difference to the
severity of the illness, then that makes a difference to how we
treat people at the end of the pandemic. We need to know, for
example, whether what is killing them is the disease or whether
it is the host response. To explain, if you get a serious infection
and you do not produce a good immune response, you die because
of the infection. If you have just enough immune response, then
you fight the infection and, hopefully, survive. In modern medicine
with antibiotics and hopefully effective antivirals, you treat
the infection but may experience an exaggerated host response.
An excessive immune response which may be genetically-driven may
actually cause you to die because that inflammation kills you.
There is a case to be made for trying to understand the genetics
underlying how badly people do or how well they do. As I have
said, this is not only a duty but also an opportunity because
it will inform our understanding of a lot major illnesses both
infectious and non-infectious. There are generic things that we
can put in place, and that we have to put in place now, that will
advance our understanding, not just of the disease, which would
be very useful, but also more generally on how we deal with pathogens
Q179 Lord May of Oxford: Are you
satisfied that this is being done?
Professor Menon: I do not know. The announcement
about the MRC convening this group was recently announced. When
I spoke to the Department of Health this morning, I said that
we would very much like to be involved. We have also made that
obvious through a submission that we put through the Academy of
Medical Sciences. All of that has been fed in. I think it would
be sinful to miss this opportunity.
Professor Mathers: To add to that, some important
research also needs to be done in general practice and Primary
Care, for example in diagnostic testing. If you do a swab from
the nose, can that help you decide who is infectious and who is
not? There is some evidence but we do not know how effective such
early diagnostic tests would be in the early part of a pandemic.