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Race against time to plug gaps in pandemic planning

Back in January, the BMA and the RCGP released a 61-page document, urging GPs to prepare for a flu pandemic that could strike at any time and kill tens of thousands of people in the UK.

By Steve Nowottny

Back in January, the BMA and the RCGP released a 61-page document, urging GPs to prepare for a flu pandemic that could strike at any time and kill tens of thousands of people in the UK.

Few expected it to be put to the test quite so quickly.

Less than six months later, though, and swine flu has brought the prospect of a pandemic from just off the horizon to very much the here and now.

It may not have caused the devastation some predicted, but the outbreak has shown up stark variations in levels of preparation in different areas of the country – by both GPs and primary care organsiations.

With many scientists convinced a second, more deadly, wave of the illness could be on the way in the autumn, GP leaders say it is now a race against time to ensure gaps exposed in the system are plugged.

The first two weeks of the outbreak has seen many examples of GPs working in harmony with PCOs and HPA experts.

But they have also seen chaos on the ground in some areas, with arguments raging over lack of equipment, contradictory guidance and general lack of planning .

Within days of the outbreak, practices in Birmingham had run out of swabs and had been told to buy their own face masks.

NHS Coventry initially instructed GPs to drive to the local hospital themselves to deliver swabs for analysis.

But it wasn't just NHS managers who were unprepared.

GPs across the country were inundated with calls, struggling to separate potential cases from a stream of worried well. And while many had put plans in place for dealing with a pandemic, a significant minority did not.

PCOs approached by Pulse that had requested GPs submit pandemic plans reported not all had done so - 20% of practices in Calderdale and 15% in Hertfordshire, for instance.

In other areas, trusts had asked only that practices incorporate something on pandemic preparations into wider business continuity planning, but not all practices had business continuity plans – four out of 32 in Bury, for instance.

Pulse's survey of more than 200 GPs also suggested that, if anything, these figures understated the problem. A third of those who responded said their practice had no flu plan in place, while just 23% felt their practice was ‘sufficiently prepared'.

In some areas, trusts put up a wall of silence over their own and their local practices' preparations.

NHS East Lancashire was tightlipped in response to six detailed questions on key areas of preparation such as availability of swabs and facemasks – questions GPs were desperate to get answers to.

It said only: ‘The PCT and GPs are prepared and in a state of readiness should the need arise.'

Yet both PCOs and GPs were supposed to have had plans in place by the end of March, and GPC chair Dr Laurence Buckman says the time has come for all GPs to act.

‘Some GPs are ready, some less so,' he says. ‘Many PCTs did nothing after being given Government instruction to get on with local planning.

‘We gave a warning this was necessary months ago, and a lot of practices got on with it, and some didn't.

‘A lot more have got on with it now they've suddenly realised how critical it is, and I think there's a lot more going on right now, but it is important every practice is ready.'

‘This crisis is a wake-up call,' says Dr George Ferris, head of the medical division of the Medical and Dental Defence Union of Scotland. He adds: ‘Even if the current swine flu outbreak fails to develop into a major pandemic, it should serve as an urgent reminder that practices must have specific contingency plans for such an event.'

On the ground, GP readiness is often dependent on how ready the PCO has been. As Dr John Canning, secretary of Cleveland LMC, puts it: ‘This is a two way onus. It's a see-saw. It takes two to make this work.'

His local PCT, he says, has been ‘way ahead of the game', offering £1,000 to incentivise practices to complete pandemic flu planning as part of a LES agreement. As a result, he says, every practice in the area has a contingency booklet in place.

But Dr Russell Walshaw, secretary of East Yorkshire and North Lincolnshire LMCs, has seen his local trusts take a very different tack.

‘We're not aware of this £1,000 being paid to anybody,' he says. ‘I'm disappointed the PCTs haven't engaged with the LMC.

‘The masks, gloves, aprons should have been supplied – but this appears not to have happened. We're being asked to buy them ourselves.'

Other LMCs argue that despite shortfalls in PCO planning, a potential pandemic calls for a suspension of normal negotiations and all hands on deck.

Dr Douglas Moederle-Lumb, chief executive of two Yorkshire LMCs, says: ‘I've not heard anything about resourcing for planning. In this instance though we tried to decide what needs to be done, rather than having a conversation about resources first, because it's in all our interests that we decide what needs to be done.'

He adds: ‘GPs have been aware of national guidance for some time. But it's very difficult to translate national guidance into local importance.'

A key part of GPs' pandemic planning is ‘buddying up', where neighbouring practices organise themselves into geographical clusters to ensure mutual support in the event of a pandemic.

These buddying-up groups were also supposed to have been identified by the end of March.

But Pulse's survey found 60% of practices had no such arrangements in place.

Dr Simon Stockley, a GP in Eaglescliffe, Teeside, helped devise the ‘buddying up' scheme as part of a regional flu plan, and in January saw it rolled out nationally as part of the RCGP-BMA guidance.

Under the system practices should form geographical clusters covering a total population of between 22-25,000 patients or 11-14 whole-time-equivalent GPs, and make plans to share staff, services and on-call rotas as necessary.

‘It's been very successful and small practices were protected' says Dr Stockley.

‘If you thought about these things when you didn't have a problem, it will benefit you when you do. You want to be able to know who your friends are.'

In some of the less-prepared areas, as managers and clinicans alike start to get to grips with the potential for a full-scale pandemic, real progress is being made.

In Islington, where GPs had been left scrambling for information, Dr Paddy Glackin reports the situation much improved after initial fury at lack of communication from PCT managers.

‘The situation there changed dramatically towards the end off the week,' he says. ‘The PCT has been doing OK.'

Dr Maureen Baker, the RCGP's lead on pandemic planning, says it's impossible to predict if – or when – a full-blown pandemic could erupt, but warns planning now is ‘critically important'.

‘We just don't know,' she says. ‘We don't even know if we're going to have a wave now. But it's much better to be prepared.'

‘If people don't do anything now and things start to ramp up, they'll have lost this valuable time.'

Dr Buckman is similarly forthright: ‘There is a serious risk we will see wave two which will be much more severe than wave one. Practices must not relax, but must get on with it now.

‘Don't wait and see whether it'll be worse in September, you've got to be ready now. And ready means prepared – that you've got all your disposables and protective gear.'

His final comment would not have rung so true just a few months ago: ‘There will be a flu pandemic, it's only a matter of time.'

RCGP vice-chair at centre of outbreak

Dr Clare Gerada, RCGP vice-chair and a GP in south east London, found herself at the centre of the swine flu outbreak when six pupils at Alleyn's School in Dulwich were confirmed to have contracted the virus.

‘I was called by the local PCT medical director on Bank Holiday Monday to help out. Within two hours we had called all 15 of our partners back from wherever they were in the country to help at Alleyn's school and run the out-of-hours centre.

The normal rate of calls is about 30 an hour, but when I was there it was 300 calls. Thanks to our networks, we were able to recruit enough GPs and respond to patient fears.

GPs performed incredibly well under huge pressure. We dealt with 700 anxious families, answered hundreds of calls and worked with health authorities to update their advice. All of this on a bank holiday, too.

Despite the numbers of doctors we were able to recruit at short notice – there weren't enough. Also, our PCTs did not hold details of doctors, nurses, pharmacist and Healthcare Assistants' telephone numbers – and they must do.

Our telephonic system couldn't meet the demand and we urgently need to think about using more modern technology such as social networking sites to disseminate information to the worried public.

We need to learn that in the eye of the storm things don't always go to plan.

Finally it wasn't Tamiflu and facemasks we ran out of, it was phone lines, people, cars and rooms.'

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