Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 160 - 179)

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 indeed.

  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 being detected.

  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 hearing.

  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 in general.

  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.


 
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