House of Lords - Science and Technology

Select Committee on Science and Technology Fourth Report

CHAPTER 6: DAMAGE LIMITATION

6.1. If a pandemic reached the United Kingdom, the major challenge for the Government would be to limit the damage and ensure a rapid recovery. The Contingency Plan describes the Government's strategy for meeting this challenge.

6.2. We said in Fighting Infection that the United Kingdom Contingency Plan had for several years been among the best in the world, and we see no reason to change this assessment now. But at the same time we have considerable sympathy with the caveat expressed by Mr Kevin Hawkins, Director General of the British Retail Consortium:

"[One should] remind oneself of Field Marshal von Moltke's famous rumination that no battle plan ever survives contact with the enemy and all contingency planning is based to a great extent on known scenarios, on hard-won experience in the past. The problem with a pandemic is that none of us have had experience of it and we do not know until it starts exactly what the depth of the crisis will be and how many people will be laid low by it." (Q 366)

6.3. With this caveat, we have looked at a number of issues around contingency planning, particularly insofar as it affects health services, local and emergency services, and businesses. Finally, drawing these various strands together, we have asked whether the Government are providing strong enough leadership to ensure that all those who will be affected by a pandemic participate fully in contingency planning; and whether the Government's communication strategy is adequate to keep the public well-informed.

Health services

6.4. The health service response will be crucial in a pandemic. The strain on frontline services will be enormous. While projections are inevitably uncertain, and depend on the virulence of the virus that eventually emerges, it is possible that at the peak of a pandemic there could be over one million new cases of influenza each day, with general practice consultations rising from a baseline of 30 per 100,000 population per week to 5,000-10,000 per 100,000 population per week; pandemic-related occupancy of intensive care beds alone could be over 200 percent of total current capacity. At the same time, health services, like all other organisations, could see illness-related absenteeism of 25 percent or more.

6.5. Responsibility for co-ordinating the health service response in England and Wales rests with the HPA, and the HPA Influenza Pandemic Contingency Plan is in effect a sub-plan of the overarching Government Contingency Plan. It assigns responsibilities to the various NHS authorities, from the Department of Health itself, which will establish a national "Operations Room", through Regional Public Health Groups, Strategic Health Authorities, hospital and ambulance trusts and Primary Care Trusts (PCTs).

6.6. The HPA's top-level plan begs a number of questions. For instance, is the HPA's funding, which has been cut in recent years, adequate for it to fulfil its own commitments? How deep does the planning go? Have the implications of a pandemic for frontline health services been fully assessed? While we have not had time in the course of this short inquiry to explore all the ramifications of health service contingency planning, we have identified some particular areas of concern.

HPA FUNDING

6.7. In the course of the Department of Health's review of arm's length bodies the HPA's funding has come under close scrutiny. It is clear that this has presented problems in the context of planning for an influenza pandemic. As Professor Troop said,

"We came under extreme scrutiny and had our budgets squeezed. That … does make planning for an influenza pandemic quite challenging. We do get small amounts of money for specific activities but most of this has been found by internal efficiencies, and while influenza is a priority of course all the other infectious diseases do not go away whilst we do this." (Q 98)

6.8. The Minister, in contrast, responded to a question on HPA funding by saying, "If you wanted to send us any information that you were particularly told that they would not be able to do, please do so. That is certainly not what we are feeling at all." She accepted that "there may well be room for certainly efficiency savings in terms of things like backroom staff or whatever", but argued that "the idea of that is to put more resources at the frontline, not to cut funding to organisations". This is a wholly unconvincing response in light of Professor Troop's comments, and particularly given that the HPA is not formally considered a "frontline" service under the arm's length body review process. (QQ 257-259)

INFORMATION GATHERING AND REPORTING

6.9. Given the inherent uncertainties of contingency planning, and in the case of a pandemic the particular uncertainties over the effects of the virus, the best treatments, outcomes for individual patients and so on, flexibility in applying and if necessary adapting contingency plans will be essential. This will require constant surveillance and the rapid interchange of information between frontline health services and the centre.

6.10. The Minister sought to provide reassurance on this point, drawing attention to the "very good information reporting systems" that have been tested in the context of severe winters and ordinary seasonal flu. More detail was provided by Dr Salisbury, who noted that information from a range of frontline services would be brought through a single "gateway" controlled by the HPA, who would in turn "be doing the epidemiological surveillance, and the modellers can be taking data and making projections on the pattern of the pandemic which will then allow informed policy decision-making". (Q 263)

6.11. A key contribution to this exchange of information should be made by the Royal College of General Practitioners (RCGP) influenza surveillance unit. However, Professor Mathers of the RCGP claimed that they had been unable to secure formal agreement from the Department that the unit would continue to receive support beyond April 2006. In the words of Professor Mathers, "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." In contrast, Dr Salisbury, of the Department of Health, said, "we have already been having discussions with the RCGP about their central surveillance scheme, including expanding the scheme to take in parts of the country which were not previously covered." We are unable to reconcile these apparently contradictory statements. (QQ 164, 265)

MANAGING RESOURCES AND MANPOWER

6.12. We have already noted that hospitals, GP surgeries, and other frontline health services, can expect significant absenteeism in the event of a pandemic, either as a direct result of illness or as a result of failures in public transport. Professor Menon, of the Intensive Care Society, estimated that Intensive Care Units could lose "20 to 50 percent of … nursing staff". Professor Mathers suggested that if those working in small general practices followed guidelines recommending voluntary quarantine for those with influenza-like symptoms, "very rapidly you are going to close down the practice". Dr Peter Bailey, of the Monkfield Medical Practice, noted that under pessimistic scenarios his practice, with a staff of around 20, might see "a greater than 1:4 probability … [of] the death of a team member." Ms Lynne Young, of the Royal College of Nurses, suggested that the Government should consider putting out a call to "recently retired nurses" or "nurses who have actually chosen to leave the profession"—though these would need training if called upon. (QQ 157, 176, p. 132, Q 165).

6.13. In response, the Government has ordered some 2.5 million doses of H5N1 vaccine, for distribution among key workers, including frontline healthcare workers. The vaccine may provide some protection against infection, though how much is far from certain. In addition, the Contingency Plan indicates that planners at local levels are expected to decide on issues such as the provision of protective equipment to staff, and the rostering of staff so as to minimise the spread of infection within health service premises (p. 51). However, we are unclear as to the measures in place either to reallocate staff among PCTs, or to call on extra staff, for instance the recently retired, to provide support in an emergency.

6.14. In addition, many of our witnesses argued that if frontline services were to cope with a pandemic certain core day-to-day services would have to be set aside. Ms Helen Young, Director of Nursing at NHS Direct, noted that if contingency plans came into effect, "we would be unable to continue with what we call the core business, the business that we currently do." Professor Menon was equally pragmatic with regard to hospital beds and operating facilities: "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." The RCGP argued that "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." (QQ 168, 177, p. 55)

6.15. Ms Winterton, however, offered no guarantees:

"What is important is that at the moment we establish the relationships between GPs and those they would be working most closely with in the event of a pandemic, so that it is quite clear what would happen and who is doing what. I can understand that some people would say, 'We want to know everything now', but quite honestly we have to give out the information depending on the circumstances of the moment." (Q 260)

STRUCTURAL REFORM

6.16. Health Services, particularly Primary Care Trusts, continue to undergo radical reform. The effects of this upon preparedness clearly varies widely between regions and individual PCTs. Professor Mathers described the effect of reorganisation as a "planning blight … it is very difficult for PCTs actually to focus down on one particular topic, such as the flu pandemic." Mrs Jan Hutchinson, of NHS Alliance, while noting that "we may see new primary care trusts coming into existence round about this time next year", and that this might "not be a good time to have new organisations coming into existence," was reassured by the stability provided by the HPA. Ms Lynne Young was much less sanguine: "We are hearing from our nurse members every day about what utter chaos and confusion there is in primary care trusts at the present time." (QQ 162, 98, 185)

6.17. Ms Winterton rejected any suggestion that health service reform should be scaled down in view of the threat of a pandemic: "As we have said already, one has very little idea as to, if a pandemic did strike, when exactly it would be, in how many years' time it might be. It would be a slightly curious proposition to say that we could never do anything to the NHS in case this upset planning and took people's minds off the job." Ms Winterton did not give any indication as to whether the Government's position on health service reform might be reviewed if the state of pandemic alert was raised further. (Q 254)

RAPID DIAGNOSIS AND TREATMENT

6.18. In the event of a pandemic, the first line of defence for those infected will be antiviral drugs. The Government's stockpile of 14.6 million courses of oseltamivir will be complete by September 2006, and will (subject to the issues we have already raised concerning prophylaxis) be sufficient to treat 25 percent of the population. If a pandemic were to occur before September 2006, of course, the stockpile would be incomplete, and there would be a serious risk that health services would simply run out of antivirals. In such circumstances, or if the 14.6 million courses themselves turned out to be inadequate, decisions on rationing would have to be taken. Drawing attention to this possibility, Dr Jarvis of the British Medical Association argued that "under no circumstances can we let individual GPs and nurses on the frontline have to make decisions of that magnitude; it needs to come from the centre." We agree. (Q 197)

6.19. However, even once the stockpile is complete, and assuming it is adequate, the diagnosis of up to a million new cases of influenza a day and the rapid distribution of drugs (which, to be effective, have to be taken within 24-48 hours of the onset of symptoms) will be a huge challenge. We have already drawn attention to the potential burden on general practices—alternatives to attendance at GPs' surgeries will be needed.

6.20. We draw some comfort from the evidence of Ms Helen Young, of NHS Direct, whose telephone operators already triage callers by reference to standard algorithms, starting with the "worst case scenario" and working backwards. Ms Young assured us that the service already had "algorithms available for a potential flu pandemic". These would distinguish between those capable of "self-care" and those in need of personal consultations.
(QQ 173-174)

6.21. However, there is still much to be done in this area. Ms Winterton emphasised that part of the Government's communications strategy would be to encourage people "to look out for symptoms in themselves and their families" (Q 262). But self-diagnosis is inevitably problematic, however good public information may be. Dr Salisbury appeared to imply that in the event of a pandemic "false positives" would have to be tolerated:

"the public will be receiving information that not only tells them what sort of things to look out for in terms of flu-like symptoms but tells them what to do about it and also tells them where they can get more advice. Much harder is telling them about everything else which is not influenza. During the times when you do not have a pandemic, clearly you are going to have to take great note of people who think they have got pandemic flu to see what they have got. At the time of the pandemic, most people with flu-like symptoms will have influenza." (Q 269)

6.22. If rapid diagnosis is to be feasible, the availability of a simple, "dipstick" test for influenza would be invaluable. No such test for H5N1 exists at present; Professor Zambon, of the HPA, confirmed that research into such a test was a priority, but it was unlikely to be available in the next six to twelve months. We note in this context that among the projects being supported by the HPA is that of Professor Helen Lee, of Cambridge University, who in October was awarded the Lord Lloyd of Kilgerran award for her contribution to the application of technology to diagnostic development, with particular reference to the third world. Rapid and affordable diagnostic tests will be especially important to such countries in the event of a pandemic.
(QQ 117-118)

6.23. There is still the question of how antiviral drugs would be supplied to those patients, particularly those quarantining themselves at home. The Government appear to be examining possible mechanisms for this. Dr Harper noted that in the event of self-diagnosis "we would look at Primary Care Trust level to have in place arrangements to get the antiviral to the people who needed them. That is the sort of consideration we are looking at right now." Similar considerations would also apply to the availability of oxygen and antibiotics to treat secondary infections. (Q 262)

Emergency and local services

6.24. We have also explored the extent to which emergency and local services are prepared for a pandemic. Under the Civil Contingencies Act 2004, "Category 1 responders" (e.g. emergency services, health services, local authorities) are required to put in place emergency plans, to co-operate with other responders, to provide information to the public and businesses, and so on. At regional level the response to a pandemic or any other emergency is led by Regional Resilience Forums, based on police areas, which bring together Category 1 responders and other organisations such as utilities or transport companies. Such Forums are required to be in place from November 2005.

6.25. Both Deputy Chief Constable Alan Goodwin, of the Association of Chief Police Officers and Mr Philip Selwood, of the Ambulance Services Association, offered reassurance that these arrangements are indeed falling into place, and that there is what Mr Goodwin called "very close liaison at all levels". Mr Goodwin also told us that he was "confident that within every regional and local resilience forum there have been very detailed discussions around the national pandemic flu plan and also some very large scale exercises at the local level to test the plan". (QQ 327-328)

6.26. The role of the forum is preparation. Mr Zyg Kowalczyk, of the London Resilience Team, described what would happen once a pandemic or another emergency actually occurred. The Civil Contingencies Committee at the Cabinet Office (COBRA) would at this point activate Regional Civil Contingencies Committees, which would in turn co-ordinate regional responses to a crisis. These would in effect be the same as the Forums—there would be "a change of name and a change of function but most of the personnel around the table will be the same." It is not, however, clear to us what would happen if a quarter or a third of these personnel fell ill. (Q 334)

6.27. The major challenge that the emergency services, like health services, will face in the event of a pandemic, will be to maintain core services while losing, in Mr Goodwin's words, "25 to 40 percent of the workforce". Demands on the emergency services would also inevitably increase, with ambulances answering increased numbers of 999 calls, police having to protect stocks of antiviral drugs, and so on. Mr Goodwin confirmed that arrangements for reallocating police resources between regions were "well tried and tested", and that there was "the potential for military assistance". Mr Selwood said that the ambulance service had had "dialogue with private ambulance services". (QQ 315-316, 337)

6.28. As for local authorities, which are obliged by statute to contribute to Regional Resilience Forums, and which, in the event of a pandemic, would have a major role, and whose key public services, from waste disposal to social services to mortuaries, would be under considerable strain, we had considerable difficulty in securing any evidence. The Local Government Association declined to give evidence, and although we did ultimately talk to the London Regional Resilience Forum, they were of course unable to speak for local government across the country. We find the lack of evidence from this sector a matter of great concern.

The private sector

6.29. Like local government, representatives of the business community were reluctant to come forward to give evidence. In the event, we were grateful to Professor Jim Norton, of the Institute of Directors (IOD), Mr Kevin Hawkins, of the British Retail Consortium (BRC) and Mr Alan Lacey, of J Sainsbury plc, for their willingness to talk to us. Their evidence was probably the most alarming that we heard in the course of our inquiry.

6.30. Professor Norton, for instance, highlighted a survey conducted by the IOD which showed that only 50 percent of member companies had contingency plans in place—the lack of planning was particularly marked among smaller companies. This was compounded by the lack of resilience in a whole range of services that are critical to business, partly as a result of the fact that "for very good economic reasons and very good business reasons, we have taken much of the slack out of our systems in many sectors". He warned of the vulnerability of the electricity network, mobile phone networks, and so on, whose collapse could rapidly lead to "cascades of failure". (QQ 347, 352)

The "shortage of qualified heavy goods vehicle drivers", on whom the entire food distribution network, from farmers to distribution centres to shops, depends; in the event of a pandemic the possibility of recruiting qualified drivers to replace those falling ill would be "very remote";

The impact on the large numbers of mostly part-time staff who actually put food on supermarket shelves;

The possibility of panic buying. (QQ 352-354)

6.32. Attempts to plan for such contingencies have not had much encouragement from the Government. In answer to a series of questions, our witnesses made it clear that they had received no guidance from the Department of Health, the HPA or local government, and that there had been no discussion between Regional Resilience Forums and the major retailers about maintaining food supplies in the event of pandemic. The only meeting with Government of which Mr Hawkins was aware had been arranged at the request of the BRC, and had been attended by Defra officials working on disease control, rather than business continuity. He pleaded for more proactivity from Government: "We seem to have to take the initiative every time in order to get answers to questions … one would have thought it would have been in their own interests to initiate an early dialogue with the key parties within that supply chain." (QQ 367-373)

Communications and leadership

6.33. There has been considerable media coverage of avian and pandemic influenza in recent months, much of it ill-informed and alarmist. An effective and proactive communications strategy will be essential in the event of a pandemic in order to provide reassurance and advice to the public. The Government have already made a good start in this area, with the circulation of guidance, including useful background material on pandemic influenza, to general practices.

6.34. However, other examples of Government efforts to communicate with the public on health issues are less reassuring. Mr Hawkins cited two. When the Sudan 1 scare broke out, the Food Standards Agency (FSA) on the one hand said there was only a "small risk to human health", and on the other said that the public should not eat products containing Sudan 1, but should return them all to retailers. And then in the autumn when concerns over avian influenza were heightened, the FSA "simply put out a statement saying that chicken was perfectly safe to eat on its website", when they needed "something which is a lot more proactive, especially in the context of tabloid headlines". (QQ 351, 349)

6.35. The need to give clear, unambiguous messages is tied up with a broader issue of Government leadership. Although contingency planning is co-ordinated by the Cabinet Office through COBRA, the Cabinet Office role is largely administrative. On policy individual departments lead as appropriate—in the case of pandemic influenza, the Department of Health leads, and in fact the Cabinet Office declined to give evidence to our inquiry.

6.36. But in the case of a possible influenza pandemic, an emergency that would affect every branch of social life—hospitals and schools, the transport system, food supplies and prisons—there must be some doubt over whether the Health Department is capable of communicating effectively with all those involved in contingency planning. The food retailers have regular channels of communication to Defra, the police to the Home Office, and so on. It does not appear that all these channels of communication are yet being used effectively or consistently.

6.37. Mr Hawkins emphasised that "What we learned during foot and mouth … is that there needs to be one simple message communicated by all the relevant government departments and it needs to be repeated and repeated and repeated". A related point was made by Dr David Nabarro, the Senior UN System Co-ordinator for Avian and Human Influenza, who argued that within governments there was "a necessity to take the responsibility for preparedness planning above the level of the Minister of Health versus the Minister of Agriculture versus the Minister of Interior versus the Defence Minister and to have an over-arching ministerial responsibility … it is very hard to get different government departments and ministers to work together in a joined-up way on contingencies unless they are encouraged to do so by the highest authority in the country." (QQ 349, 311)

6.38. It was striking that at the same time on 1 November as we discussed United Kingdom preparedness with Ms Winterton, Minister of State at the Department of Health, in Washington President Bush was announcing a $7.1 billion programme of action and research on influenza. This vividly demonstrated what Dr Nabarro called "the political dimension, the kind of thing we saw today which is quite courageous from the US President, where a senior figure steps out and gives additional political cover to the ministers of health or the ministers of finance." (Q 302)

CONCLUSIONS

6.39. The Government's Contingency Plan is an excellent top-level account of the United Kingdom health service response to a pandemic, but an enormous amount of work remains to be done at lower levels. We therefore recommend:

That cuts in HPA funding be reviewed and if necessary reversed, to ensure that the HPA's ability to provide leadership to the health service response is not compromised;

That the Government review the resilience of systems for supplying information from frontline health services to the centre, and in particular that they ensure that funding for the Royal College of General Practitioners' surveillance service is extended;

That the Government provide advice to PCTs and general practices on the mechanisms for reviewing and if necessary suspending performance targets in the event of a pandemic—such advice is needed now if frontline health services are to develop robust and well-informed contingency plans;

That mechanisms for storing, prescribing and distributing antiviral drugs be urgently reviewed; and that the availability of antibiotics, oxygen and other supplies be examined and if necessary reinforced.

6.40. We commend the work of the emergency services in developing contingency plans. However, despite the duties imposed on local authorities by the Civil Contingencies Act 2004 to develop contingency plans and participate in Regional Resilience Forums, we are not convinced that local government is yet fully aware of the implications of an influenza pandemic. We urge the Government to provide clear and unambiguous direction and guidance in this area.

6.41. We are alarmed at the risk of serious disruption to food supplies, and at the lack of contact between the Government and the major food retailers. The Government urgently needs to address the resilience of food distribution networks.

6.42. All departments of Government need to work together in preparing for a possible pandemic, but we do not believe the Department of Health can provide strong enough leadership to achieve this. We therefore support the view of Dr David Nabarro that the importance of pandemic influenza contingency planning should be underlined at the highest level within Government. The development and implementation of contingency plans should be the responsibility of a Cabinet-level Minister for contingency and disaster planning, located within the Cabinet Office.

6.43. In the event of a pandemic a clear message and direction from all branches of Government will be critical, and we recommend that the Government develop and publicise a strategy for proactive dissemination of key information and advice, using all forms of national and local media.