In the eye of the storm

GP Dr John Howarth describes how he faced the unthinkable – coordinating the response after a compete wipeout of health services in his area.

It rains a lot in Cockermouth. But on last November the fells around the market town of Cockermouth received one third of their annual rainfall (over 12 inches) in just 24 hours - a national record.

The resulting floods in Cockermouth affected 880 houses and 190 businesses. Thousands of people were evacuated and 10 of the 11 bridges were damaged or destroyed.

Health services for 15,000 patients came to a sudden full stop as GP premises and pharmacies were severely flooded, leaving patients at risk of disease and those with long-term problems with no support.

Rapid response

Right from the start we were determined that we would do everything possible to avoid further excess morbidity or mortality.

The PCT had built an extensive network of clinical leaders through practice-based commissioning in the previous two years, and this system of clinical leadership was resilient in response to the floods.

Our business continuity plans (for what they were worth) were washed down the river together with all our equipment, but the first of 13 whole team meetings occurred within four hours of the flood. This meeting was attended by up to 70 people, including GPs, the director of public health, practice and district nurses, therapists, receptionists, cleaners, town pharmacists, social workers, practice managers, and Red Cross volunteers.

We started simply by projecting all the key headings for recovery using PowerPoint onto the wall e.g. accommodation recovery, IT systems, telecom systems, pharmacy services, public health risks, and an overall risk log. The resulting recovery plan was written together and owned by us all.

We identified the following key priorities:

1. Avoiding diarrhoeal disease - the sewage works were flooded

2. Preventing severe respiratory illness from crowding in church halls and reception centres

3. Re-establishing normal health services for long term conditions asap especially the re-establishment of pharmacy services and systems

4. Boosting psychological support

As a local GP and someone who had experience in disaster medicine and public health having worked in 11 wars in the 1990s, I co-ordinated the public health effort.

What we did

Working together we identified all at-risk vulnerable patients and proactively contacted them e.g. those with chronic respiratory disease, those in palliative care and the frail elderly.

We established heightened surveillance for diarrhoea cases – every case in the first four weeks was notified to myself and investigated by an infection control nurse

We gave out information on hand hygiene and diarrhoea prevention to rescue workers and vaccinated 1000+ at-risk people in reception centres and 350 rescue workers against swine flu and seasonal flu in the first week.

We rapidly rebuilt GP telephone and IT systems (within 24 hours) and re-established pharmacy services (within 48 hours). The GP surgeries moved up to the community hospital and went from 29 consulting rooms to four, and 16 telephone lines to a single handset, but we provided extended GP opening 24 hours for first day then 8am-8pm every day for the next two weeks including weekends.

We also rapidly established additional counselling services including drop in services in the church and school halls and widely distributed public health information for those returning to their flooded homes and businesses and placed health information posters widely around towns, village notice boards, local supermarkets etc – local children distributed them.

The combination of strong co-ordination between public health and primary care and ‘co-design' - using the key resource (our team) to manage the risk - we managed to avoid further excess deaths, illness and hospital admissions following the floods.

What has changed

There were many positive and sustainable benefits to come out of this response. Cockermouth is a national integrated care pilot and primary care was already beginning to take a population view. The floods accelerated this process.

In a dramatic way it introduced the wider primary care team to public health, looking at the community not just in terms of needs but also as assets to mobilise and enable.

Our team was great but the response of the civil groups and organisations in the town was inspirational - local churches together toured the town with shopping trolleys full of bacon sandwiches and had a network of over 200 volunteers to help distribute food and clothing. A mosque in Bradford saw the floods on TV and sent the churches in Cockermouth £5000 to help.

Now a network of ‘street angels' is being developed – community activists looking after a designated part of the town. People are talking to each other, connections are being made between groups and leaders and champions have emerged. This changes people from passive victims receiving help to empowered individuals and groups in charge of their recovery.

We now have a different and better view of how we should serve our population. We should work much more with the skills and assets of our communities rather than looking on them in terms of needs or problems. We should know what these assets are (map them) then help them connect to each other and to us - the organisations involved in health delivery.

Of course we should continue to give high quality individual care to our patients, but perhaps we should begin to have a different relationship with the community we serve. Through mobilising the assets within the community and co-opting them towards improving health we have a fighting chance of coping with the massive demographic and economic challenges ahead.

Dr John Howarth is a GP in Cockermouth and clinical director for NHS Cumbria

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