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On 16 July, Andy Burnham, Secretary of State for Health, announced that the National Pandemic Flu Service will be activated in the next few days. This latest step in the government's ongoing response to the global H1N1 outbreak highlights a number of important points about how planning assumptions and emergency preparedness evolve into an actual response.
By Jennifer Cole, Head of Emergency Management, RUSI
When considered in the context of national security and resilience, pandemic flu occupies a remarkably unique position. It sits at the top of the National Risk Register, publicly identified for nearly a year before it arrived as a threat the Government considered to be very likely to happen and, more importantly, to have a severe impact on the UK when it did. As a result, the relationship between emergency planning and preparedness - between resilience, response and recovery - is more finely balanced here than it is likely to be in any other case barring, perhaps, the bigger picture of climate change. Uniquely, over the past few months we have been able to consider, assess and modify our plans at the same time as we actually respond to the situation.
Breathing space between phases
The slow build has provided not only a breathing space between the planning phase and the response phase but also an overlap of the two that would simply not be possible for a terrorist attack, a flood event or a major industrial accident - the threats that sit second, third and fourth on the National Risk Register. Terrorist attacks and industrial accidents begin and end in seconds; flood waters rise less instantaneously but nonetheless more quickly than the five weeks that have elapsed since 11 June, when the WHO officially announced the pandemic, and the three weeks since 2 July, when the UK moved from the containment to the treatment phase.
The way the pandemic has unfolded is akin to watching a terrorist attack in which the protagonists are identified at the outset of their journey, their final destination is relatively easy to predict, the weapons they are choosing to use are known, their target has been identified and there is time to muster the emergency services to react; although they cannot be stopped. The planning that has been done so far may not cover all the bases, but as their plot unfolds, gaps in preparedness become clearer and planning may be adjusted accordingly. This is the position we find ourselves in with pandemic flu.
Over the coming months, we will learn a lot from the way the response is handled. The first lesson relates to the importance of planning. The WHO has long since identified the UK as being extremely well prepared to deal with pandemic flu and this is now paying huge dividends. During the containment phase, the exponential increase in cases we are seeing now was slowed down by three to four weeks, according to Department of Health estimations. Without initial plans in place for how emerging cases would be recorded, swabbed, isolated and treated, we might have seen the current number of cases occur within days of the first. The information - intelligence in security terms – that this has enabled us to build up on the disease must not be underestimated. It has moved us a month closer to a vaccine and has prevented us from wasting Tamiflu stockpiles on patients who need nothing more than Paracetemol.
Burden of treatment
This breathing space has, however, come at a price. During the protracted containment phase, the burden of treatment has fallen squarely on the shoulders of GPs and the out-of-hours helplines they utilise. In light of this, it is easy to criticise the decision not to activate the National Pandemic Flu Service earlier, but to do so would have been an over-reaction. Implementing the service brings with it a huge price tag (approximately £250 million) and it is as, its name implies, a national endeavour.
Until now, only some areas of the country (London, the Midlands and some regions of Scotland) have seen significant numbers of cases. Others, such as Kent, have been virtually unaffected. The affected regions have been under strain but in any emergency some strain is inevitable. The importance is to ensure it is well-managed and kept to as short a time period as possible.
Over the past few years, comprehensive pandemic flu planning has been cascaded down from the Department of Health to Strategic Health Authorities and Primary Care Trusts, and from there to GPs and hospitals, as well as through information in bulletins from the Chief Medical Officer. It is not the case that everyone has taken that planning as seriously as they might but if some GPs have not considered that during a pandemic their surgery and out-of-hours service may receive a significant increase in the number of calls and that they may be required to do more home visits than would usually be the case, the fault does not lie with the initial planning assumptions. The fault is more likely to lie with a failure in the communication channels, and this should certainly be reassessed. We should also remember however that despite the strain they have been under, GPs have coped. Those who have needed treatment, and Tamiflu, and hospitalisation, have received it. Those who have died have not done so because the system has failed them; they have died because in a flu pandemic it is inevitable that there will be victims.
Where more work may need to be done in future, however, concerns the terminology that is used. It does not seem to have been well-enough understood by the public or the media that the 'containment' phase was not a time during which pandemic flu could be made to go away, or be cured. It was simply a holding phase, a slowing down of the spread of the infection - understanding this brings with it an understanding that the Government did not 'fail' to contain the disease. Neither did they 'fail' to activate the National Pandemic Flu Service early enough; they have waited until cases reached high numbers in all areas of the UK, and until the volume of calls genuinely threatened to swamp the usual channels - not just when they were at a level that required some healthcare professionals to work some overtime. Before 16 July, activating the national service would have involved setting it up in regions which, simply, did not need it.
For the same reason, it is only at this stage that we need a full-time Director-level lead dedicated to flu preparedness and resilience. Up until now, there has not been the volume of work to warrant the position. This does not, of course, mean that no-one had considered the need for it: three senior civil servants have been tasked with flu preparedness and response, in addition to their other roles: Professor Lindsey Davies has been National Director of Pandemic Influenza Preparedness since April 2006, Ian Dalton was appointed as National Director for NHS Flu Resilience in May 2009 and Ron Taylor was named National Director for Social Care Flu Resilience in July of this year. In addition, there has been a pandemic flu lead in all Primary Care Trusts for more than a year.
Overall, however, these have been minor issues to overcome and having the time and space to assess each one individually has allowed us to perform an ‘OODA’ loop of observe, orientate, decide, act, and to observe the impact of those actions before beginning again: to turn slowly and steadily rather than spiraling out of control. It should enable emergency planners to hear Department of Health warnings about possible disruption to 'just-in-time' supply chains with time to pull off the shelf the lessons learned from the 2000 fuel protests. It should enable business continuity managers to ask whether they have sufficiently considered not only how they will deal with staff shortages, particularly when the likelihood is that the temping agencies that would usually plug the gap will be similarly depleted and therefore unavailable. It should remind us of the process of emergency planning and the importance of testing those plans in the most realistic scenarios possible. As a result, it should make emergency plans for all future scenarios stronger.
The views expressed above are the author's own, and do not necessarily reflect those of RUSI.