By David Williams
17 September 2009
As public services in the UK brace themselves for a new surge of swine flu, what have we learnt from the first wave of the pandemic? David Williams talks to practitioners and policy makers on the front line
Nobody, least of all in government, expected a flu pandemic to feel quite like this. The contingency plans drawn up by public bodies before we had even heard of H1N1 swine flu set out a range of circumstances that resemble a society on the brink of disintegration: quarantine zones; police defending NHS property from looters; mass burials; and disruption to energy imports.
The reality of the past five months has mercifully been rather less dramatic. No sports events called off; not a single operation cancelled to free up beds. While any virus that has killed 75 and counting remains a serious public health emergency, it’s fair to say it’s all gone unsettlingly quiet.
There is a weird sense of anticlimax, like in a phoney war, and an expectation that something is about to happen mixed with the suspicion that it might not. The nation is ready to mobilise as soon as the balloon goes up. All that is lacking is the actual fight.
That could be upon us soon enough: the virus, which is expected to infect one in three people in the country before it has had its fill, is likely to come back for a second bite this autumn. The school holidays, widely credited with bringing the first wave to an end, are over. Children, the ‘super-spreaders’, are mingling once more. For the public sector, the question is: how ready is it possible to be?
A compelling early insight into how services can best respond to swine flu can be found in a report, published on September 8, by Birmingham City Council’s health overview and scrutiny committee. The story it tells is of the public sector continually finding itself wrong-footed.
Birmingham was, along with Glasgow and parts of London, one of the UK’s earliest swine flu hotspots. That alone caught authorities off-guard: the Department of Health had predicted the virus would spread fairly consistently across the UK, and only then after the World Health Organisation had reached its highest level of alert. But the Birmingham outbreak started a full month before the WHO declared a pandemic.
Still, in theory, the UK was one of the best-prepared countries on earth. The only problem was that the Department of Health had meticulously planned for an outbreak of bird flu. When swine flu came over from Mexico, authorities were working from a set of assumptions based on a different strain of the flu virus.
Jim McManus, Birmingham’s director of public health, was forced to adapt the city’s guidelines while the virus was taking root. He told Public Finance: ‘I don’t think the UK was as well prepared as it could have been. It was the willingness of people to rally round that made us most prepared.’ But some confusion was inevitable.
The most significant misunderstandings were around school closures – a vital element in the strategy to contain the pandemic. In many cases, head teachers assumed the Health Protection Agency would give them clear orders to shut down, but discovered the agency had no power to do so. As a result, some closures were delayed, making the containment less effective.
Welford Primary School, in Handsworth, was shut only four days after absence rates began to rise steeply. Different schools experiencing similar outbreaks reacted differently, further damaging public confidence in the government’s strategy. Some closed instantly. Others didn’t close at all.
Nationally, containment finished on July 2, by which time the virus was spreading freely in the population. Since then, doubts have been raised about just how appropriate and useful the response was.
Andy Hull, senior researcher at the Institute for Public Policy Research’s national security team, says containment was ineffective because authorities were closing schools but still allowing children to congregate at community centres such as mosques.
McManus adds: ‘We were trying to run a containment strategy when the virus was already circulating widely in the community. If you stay in containment and it’s not containing the virus, it means you spend an awful lot of time and energy swabbing people and administering anti-virals to everybody.’
The use of anti-viral drugs – chiefly Tamiflu – was the central plank of containment. Drugs were offered to all suspected and confirmed cases of swine flu, and all those who had been in close contact with them. Britain had huge reserves of Tamiflu from the very beginning of the pandemic, stockpiled in response to the bird flu scare of 2005/06. The drugs reduce symptoms and make the sufferer less infectious, and when outbreaks began, officials widely distributed them as a precautionary measure.
The most compelling criticism centres on consistency. In a letter to the British Medical Journal, Jacky Chambers, director of public health at Heart of Birmingham Primary Care Trust, savaged the apparently random deployment of Tamiflu. It had variously been offered to: entire schools; isolated classes; and children ‘within a metre’ of a pupil displaying symptoms. In some schools, Tamiflu was given to pupils listed as having any medical condition, including those wearing glasses.
Chambers also suggested that the use of Tamiflu, and by implication the wider containment strategy, was politically driven. Senior health sources say the Health Protection Agency was pushing to relax containment earlier, and that the decision to persist with it came from ministers on the Civil Contingencies Committee (also known as Cobra).
Whether there was a hint of macho ministerial muscle flexing at work, or if the apparent over-reaction was simply about doing everything to stem the spread of the virus for as long as possible, is known only to those who sat at the table.
As the UK moved from containment to ‘treatment’ measures, the role of local authorities became increasingly vital. According to McManus, it was Birmingham City Council’s many lines of communication with residents that made a fight on the ground against swine flu viable. The council quickly put together a publicity campaign, with adverts on the side of buses and broadcasts on giant video screens in the city centre. There was also a push directed at non-English speakers, using local radio stations and training sessions with community leaders.
Across the country, the simple, clear messages in the government’s leaflet and poster campaign might have been undermined by some confusion in the messages going out. In the worst example, pregnant women were advised first to stay in, then to carry on as normal, and finally to stay in if they felt worried. A more recent example risks discrediting the message through sheer ludicrousness: the sight of Cabinet members teaching children how to sneeze will be of more use to satirists than to the cause of public health.
The National Pandemic Flu Service, launched on July 23, opened up the government to more substantial criticism. The DoH’s 2007 guidelines describe a phone and online service, to disseminate information and distribute anti-virals, much like the one provided. But it assumed the service would be operational before the virus arrived in the country.
In fact, plans for the service were still at development stage when the pandemic struck, and it was not able to launch until the peak of the first phase. By that point, three months after the first confirmed cases of the illness in the UK, there were 100,000 new diagnoses in a week.
Nevertheless, when the government’s overall response to the first wave is evaluated, it will be difficult to be wholly critical. Social order was maintained, drugs were available to those who needed them, public services continued as normal and the population was generally well informed about the threat.
Lessons are being learned, and plans for the second wave are better, clearer, comprehensive and more tailored to H1N1. In Birmingham, the council has commissioned an educational DVD package for schools, with films for pupils and staff. Head teachers whose schools were affected by early outbreaks are now acting as mentors. There are also plans to pool resources such as catering staff, or even to integrate classes from different schools, to keep them open.
But, nationally, big question marks remain over some essential services. It is unclear just how prepared GPs are for high levels of staff absence coupled with unprecedented demand for services. The British Medical Association’s pandemic flu lead, Peter Holden, says that across the country, preparation by practices has been patchy because PCTs have been unwilling to give them extra money to draw up and test plans.
‘What we’re beginning to feel is that a cheeseparing government is relying as always on goodwill and professionalism to do the right thing,’ he says. ‘That’s one thing, but you can’t rely on that when cash has to be laid out in order to do something.’
A deal has been struck to pay GPs £5.25 per job for each vaccination they carry out, but they are still angry that no extra money has been guaranteed for overtime. Nevertheless, Holden says these squabbles are exceptional. In a rare relinquishing of autonomy, GPs have agreed that if necessary primary care trusts should take command and control of their labour and resources – although the exact circumstances that would trigger this are uncertain.
‘What we’re finding is that medical politics is suspended for this,’ says Holden. ‘There is a huge co-operative effort going on.’
By contrast, the pandemic has exposed fissures between social care providers and commissioners. Frank Ursell, chief executive of the Registered Nursing Homes Association, is concerned that barely any of his members are in contact with local authorities at a strategic level – even though they provide a vital service to some of society’s most vulnerable people, and deal with flu outbreaks annually.
‘I’m happy to sit on the local resilience team, I’m just waiting for the invitation,’ he says. ‘There is still a grand canyon between public commissioning and private provision. Our experience is not being recognised by councils or PCTs.’
There is no cover-all plan to keep private nursing homes operational. But Ursell is confident that, while the larger homes will have their own contingency plans, the smaller ones will be able to remain operational thanks to their flexible staff, many of whom work part-time.
What worries him more is the vaccine, due for essential health employees by the end of October. ‘The secretary of state has made sweeping statements about frontline workers – but we have not been told whether we will get it,’ he says. Inoculating doctors and nurses at the earliest opportunity is absolutely vital, whoever they work for, as health workers could end up carrying the virus right to the bedside of sick people who are least able to defend themselves against it.
The vaccine is the one issue that is essential to the public sector’s drive against swine flu this winter. A successful vaccination programme will make the difference between a few hundred fatal cases and the 19,000 deaths currently thought to be the worst-case scenario.
‘The acceptance rate might be a lot lower than we hope for,’ warns John Oxford, professor of virology at Queen Mary University. ‘The danger is people will be too complacent. There is a lack of appreciation that this virus is moving in, and can cause problems. It’s a question of duty and honour for doctors and nurses that they will be expected to set an example.’
Oxford says a take-up rate of 75% to 80% among health staff should be enough to convince the public that the vaccine is safe and worthwhile. The precedents are not encouraging, however.
First, there is a possibility that the swine flu vaccine will require two doses – not everyone that has the first will bother returning for the second. Second, seasonal flu vaccine take-up rates only top 75% among over-65s, who are the one group who appear to have some natural immunity to swine flu. Among younger at-risk groups, such as those with asthma, that percentage languishes in the 40s.
A perceived over-reaction of authorities earlier in the year, coupled with the low mortality rate so far, can only make for complacency. Worse, the scare around the measles-mumps-rubella (MMR) vaccine for children indicates a readiness to buy into myths about medicine in the face of evidence and strong messages to the contrary from government. Vaccine-phobes might dredge up the disastrous US inoculation programme against another swine flu outbreak in 1976, which killed more than the virus did.
Although swine flu has so far been milder than expected, future surprises might not be so pleasant. Oxford fears the virus will spare us this year but return in 2010, mutated just enough to start killing pensioners, who usually make up 80% of the victims of a flu pandemic. ‘The thing about phoney wars is they tend to turn into the real thing,’ he says.
There is still a huge task ahead for the public sector. The chief medical officer, Sir Liam Donaldson, might tell us we are ‘tantalisingly close’ to beating swine flu, but services have barely been challenged yet. Current assumptions are that public bodies should plan for 8% of staff to be absent at any one time – but the Chartered Institute of Personnel and Development this month instructed its members to be ready for 50%.
Predicting the course of the pandemic is impossible when we still do not know why swine flu has hit the UK harder than the rest of Europe. Pandemics consistently defy expectation, and the response will have to remain under constant revision. If the past six months have taught us anything, it’s that the ‘unknown unknowns’ will provide the biggest challenges.
17 September 2009
As public services in the UK brace themselves for a new surge of swine flu, what have we learnt from the first wave of the pandemic? David Williams talks to practitioners and policy makers on the front line
Nobody, least of all in government, expected a flu pandemic to feel quite like this. The contingency plans drawn up by public bodies before we had even heard of H1N1 swine flu set out a range of circumstances that resemble a society on the brink of disintegration: quarantine zones; police defending NHS property from looters; mass burials; and disruption to energy imports.
The reality of the past five months has mercifully been rather less dramatic. No sports events called off; not a single operation cancelled to free up beds. While any virus that has killed 75 and counting remains a serious public health emergency, it’s fair to say it’s all gone unsettlingly quiet.
There is a weird sense of anticlimax, like in a phoney war, and an expectation that something is about to happen mixed with the suspicion that it might not. The nation is ready to mobilise as soon as the balloon goes up. All that is lacking is the actual fight.
That could be upon us soon enough: the virus, which is expected to infect one in three people in the country before it has had its fill, is likely to come back for a second bite this autumn. The school holidays, widely credited with bringing the first wave to an end, are over. Children, the ‘super-spreaders’, are mingling once more. For the public sector, the question is: how ready is it possible to be?
A compelling early insight into how services can best respond to swine flu can be found in a report, published on September 8, by Birmingham City Council’s health overview and scrutiny committee. The story it tells is of the public sector continually finding itself wrong-footed.
Birmingham was, along with Glasgow and parts of London, one of the UK’s earliest swine flu hotspots. That alone caught authorities off-guard: the Department of Health had predicted the virus would spread fairly consistently across the UK, and only then after the World Health Organisation had reached its highest level of alert. But the Birmingham outbreak started a full month before the WHO declared a pandemic.
Still, in theory, the UK was one of the best-prepared countries on earth. The only problem was that the Department of Health had meticulously planned for an outbreak of bird flu. When swine flu came over from Mexico, authorities were working from a set of assumptions based on a different strain of the flu virus.
Jim McManus, Birmingham’s director of public health, was forced to adapt the city’s guidelines while the virus was taking root. He told Public Finance: ‘I don’t think the UK was as well prepared as it could have been. It was the willingness of people to rally round that made us most prepared.’ But some confusion was inevitable.
The most significant misunderstandings were around school closures – a vital element in the strategy to contain the pandemic. In many cases, head teachers assumed the Health Protection Agency would give them clear orders to shut down, but discovered the agency had no power to do so. As a result, some closures were delayed, making the containment less effective.
Welford Primary School, in Handsworth, was shut only four days after absence rates began to rise steeply. Different schools experiencing similar outbreaks reacted differently, further damaging public confidence in the government’s strategy. Some closed instantly. Others didn’t close at all.
Nationally, containment finished on July 2, by which time the virus was spreading freely in the population. Since then, doubts have been raised about just how appropriate and useful the response was.
Andy Hull, senior researcher at the Institute for Public Policy Research’s national security team, says containment was ineffective because authorities were closing schools but still allowing children to congregate at community centres such as mosques.
McManus adds: ‘We were trying to run a containment strategy when the virus was already circulating widely in the community. If you stay in containment and it’s not containing the virus, it means you spend an awful lot of time and energy swabbing people and administering anti-virals to everybody.’
The use of anti-viral drugs – chiefly Tamiflu – was the central plank of containment. Drugs were offered to all suspected and confirmed cases of swine flu, and all those who had been in close contact with them. Britain had huge reserves of Tamiflu from the very beginning of the pandemic, stockpiled in response to the bird flu scare of 2005/06. The drugs reduce symptoms and make the sufferer less infectious, and when outbreaks began, officials widely distributed them as a precautionary measure.
The most compelling criticism centres on consistency. In a letter to the British Medical Journal, Jacky Chambers, director of public health at Heart of Birmingham Primary Care Trust, savaged the apparently random deployment of Tamiflu. It had variously been offered to: entire schools; isolated classes; and children ‘within a metre’ of a pupil displaying symptoms. In some schools, Tamiflu was given to pupils listed as having any medical condition, including those wearing glasses.
Chambers also suggested that the use of Tamiflu, and by implication the wider containment strategy, was politically driven. Senior health sources say the Health Protection Agency was pushing to relax containment earlier, and that the decision to persist with it came from ministers on the Civil Contingencies Committee (also known as Cobra).
Whether there was a hint of macho ministerial muscle flexing at work, or if the apparent over-reaction was simply about doing everything to stem the spread of the virus for as long as possible, is known only to those who sat at the table.
As the UK moved from containment to ‘treatment’ measures, the role of local authorities became increasingly vital. According to McManus, it was Birmingham City Council’s many lines of communication with residents that made a fight on the ground against swine flu viable. The council quickly put together a publicity campaign, with adverts on the side of buses and broadcasts on giant video screens in the city centre. There was also a push directed at non-English speakers, using local radio stations and training sessions with community leaders.
Across the country, the simple, clear messages in the government’s leaflet and poster campaign might have been undermined by some confusion in the messages going out. In the worst example, pregnant women were advised first to stay in, then to carry on as normal, and finally to stay in if they felt worried. A more recent example risks discrediting the message through sheer ludicrousness: the sight of Cabinet members teaching children how to sneeze will be of more use to satirists than to the cause of public health.
The National Pandemic Flu Service, launched on July 23, opened up the government to more substantial criticism. The DoH’s 2007 guidelines describe a phone and online service, to disseminate information and distribute anti-virals, much like the one provided. But it assumed the service would be operational before the virus arrived in the country.
In fact, plans for the service were still at development stage when the pandemic struck, and it was not able to launch until the peak of the first phase. By that point, three months after the first confirmed cases of the illness in the UK, there were 100,000 new diagnoses in a week.
Nevertheless, when the government’s overall response to the first wave is evaluated, it will be difficult to be wholly critical. Social order was maintained, drugs were available to those who needed them, public services continued as normal and the population was generally well informed about the threat.
Lessons are being learned, and plans for the second wave are better, clearer, comprehensive and more tailored to H1N1. In Birmingham, the council has commissioned an educational DVD package for schools, with films for pupils and staff. Head teachers whose schools were affected by early outbreaks are now acting as mentors. There are also plans to pool resources such as catering staff, or even to integrate classes from different schools, to keep them open.
But, nationally, big question marks remain over some essential services. It is unclear just how prepared GPs are for high levels of staff absence coupled with unprecedented demand for services. The British Medical Association’s pandemic flu lead, Peter Holden, says that across the country, preparation by practices has been patchy because PCTs have been unwilling to give them extra money to draw up and test plans.
‘What we’re beginning to feel is that a cheeseparing government is relying as always on goodwill and professionalism to do the right thing,’ he says. ‘That’s one thing, but you can’t rely on that when cash has to be laid out in order to do something.’
A deal has been struck to pay GPs £5.25 per job for each vaccination they carry out, but they are still angry that no extra money has been guaranteed for overtime. Nevertheless, Holden says these squabbles are exceptional. In a rare relinquishing of autonomy, GPs have agreed that if necessary primary care trusts should take command and control of their labour and resources – although the exact circumstances that would trigger this are uncertain.
‘What we’re finding is that medical politics is suspended for this,’ says Holden. ‘There is a huge co-operative effort going on.’
By contrast, the pandemic has exposed fissures between social care providers and commissioners. Frank Ursell, chief executive of the Registered Nursing Homes Association, is concerned that barely any of his members are in contact with local authorities at a strategic level – even though they provide a vital service to some of society’s most vulnerable people, and deal with flu outbreaks annually.
‘I’m happy to sit on the local resilience team, I’m just waiting for the invitation,’ he says. ‘There is still a grand canyon between public commissioning and private provision. Our experience is not being recognised by councils or PCTs.’
There is no cover-all plan to keep private nursing homes operational. But Ursell is confident that, while the larger homes will have their own contingency plans, the smaller ones will be able to remain operational thanks to their flexible staff, many of whom work part-time.
What worries him more is the vaccine, due for essential health employees by the end of October. ‘The secretary of state has made sweeping statements about frontline workers – but we have not been told whether we will get it,’ he says. Inoculating doctors and nurses at the earliest opportunity is absolutely vital, whoever they work for, as health workers could end up carrying the virus right to the bedside of sick people who are least able to defend themselves against it.
The vaccine is the one issue that is essential to the public sector’s drive against swine flu this winter. A successful vaccination programme will make the difference between a few hundred fatal cases and the 19,000 deaths currently thought to be the worst-case scenario.
‘The acceptance rate might be a lot lower than we hope for,’ warns John Oxford, professor of virology at Queen Mary University. ‘The danger is people will be too complacent. There is a lack of appreciation that this virus is moving in, and can cause problems. It’s a question of duty and honour for doctors and nurses that they will be expected to set an example.’
Oxford says a take-up rate of 75% to 80% among health staff should be enough to convince the public that the vaccine is safe and worthwhile. The precedents are not encouraging, however.
First, there is a possibility that the swine flu vaccine will require two doses – not everyone that has the first will bother returning for the second. Second, seasonal flu vaccine take-up rates only top 75% among over-65s, who are the one group who appear to have some natural immunity to swine flu. Among younger at-risk groups, such as those with asthma, that percentage languishes in the 40s.
A perceived over-reaction of authorities earlier in the year, coupled with the low mortality rate so far, can only make for complacency. Worse, the scare around the measles-mumps-rubella (MMR) vaccine for children indicates a readiness to buy into myths about medicine in the face of evidence and strong messages to the contrary from government. Vaccine-phobes might dredge up the disastrous US inoculation programme against another swine flu outbreak in 1976, which killed more than the virus did.
Although swine flu has so far been milder than expected, future surprises might not be so pleasant. Oxford fears the virus will spare us this year but return in 2010, mutated just enough to start killing pensioners, who usually make up 80% of the victims of a flu pandemic. ‘The thing about phoney wars is they tend to turn into the real thing,’ he says.
There is still a huge task ahead for the public sector. The chief medical officer, Sir Liam Donaldson, might tell us we are ‘tantalisingly close’ to beating swine flu, but services have barely been challenged yet. Current assumptions are that public bodies should plan for 8% of staff to be absent at any one time – but the Chartered Institute of Personnel and Development this month instructed its members to be ready for 50%.
Predicting the course of the pandemic is impossible when we still do not know why swine flu has hit the UK harder than the rest of Europe. Pandemics consistently defy expectation, and the response will have to remain under constant revision. If the past six months have taught us anything, it’s that the ‘unknown unknowns’ will provide the biggest challenges.
