While public attention has been diverted by swine flu, the predicted heatwave this summer also poses a danger to life, particularly to older people
Primary care trusts face a challenge to prepare the health service for the flu pandemic. But another public health threat is looming.
If forecasts of a “barbecue summer” prove to be correct, PCTs’ heatwave plans will be put to the test.
The 2003 European heatwave resulted in more than 15,000 excess deaths in France alone and the very hot weather in 2006 led to 1,000 extra deaths in England and Wales in a two week period.
Unlike cold weather, there is little time to act when a heatwave strikes: deaths, principally among the vulnerable elderly, start within one or two days. This means preparedness is vitally important.
Last month, the Department of Health updated its heatwave plan, which sets out what NHS organisations can do in advance of hot weather. PCTs in particular are tasked with identifying potentially high risk people (such as the elderly who live alone) and including necessary changes to their care plans such as additional visits by staff; working with their families and informal carers to ensure awareness; and making requests to local authorities to find out if their living conditions during a heatwave would be tolerable.
Although some of these points are fleshed out in more depth in this year’s plan, the majority of them have been in the plan since 2004 - and therefore ought already to be in place.
The need is urgent: the risk to health is greater from a heatwave in the early part of the summer, when people have had less chance to adapt to higher temperatures.
But are PCTs getting to grips with the requirements for preparation? This year, strategic health authorities have been tasked with ensuring that local NHS organisations are planning appropriately.
In the North East, the SHA has already told other organisations to review their heatwave plans and to liaise with social care partners, although it has been unable to tell HSJ what its monitoring of these plans has shown.
But according to their websites, many PCTs appear to have heatwave plans that merely repeat DH guidance, with little indication of how it will be applied in their areas and who will be responsible for different parts of the plan.
And in some cases the 2008 plan is still to be updated. Even some PCTs along the south coast with large elderly populations have been unable to tell HSJ about their plans.
Faculty of Public Health president Alan Maryon-Davis says: “Theoretically it should all work very well. In practice it comes down to how many people are getting into a vulnerable state.”
Association of Directors of Public Health vice chair Chris Packham says PCTs have been helped by the pandemic flu plan - which requires them to identify a similar group of vulnerable people.
“We already have lists of vulnerable people and people who can contact them,” he says. “It is quite transferable.”
In London, lists are held by a number of bodies with the intention they should be brought together quickly in the event of a heatwave.
But public health officials are less clear about whether care plans are being adjusted in advance of a heatwave - one of the DH document’s demands.
Dr Packham was unable to say whether it was the case for his PCT, Nottingham City. In Birmingham East and North, head of business planning Dawn Roberts says staff are told to ensure care plans are adjusted for temperature, but this is not audited.
In London, clinicians have the information available to them to review care plans in the event of problems, says Mr Wapling.
NHS Confederation PCT Network director David Stout points out that many of those potentially at risk will not have care plans and some high risk people will not necessarily be in touch with the NHS on a very regular basis - making it less likely they will be on any list.
And there is scepticism that many homes are being assessed by local authorities to ensure they will be suitable in a heatwave: the plan says health workers should refer some high risk people for assessment under the housing, health and safety rating system. This could lead to funding for improvements to the home that could prevent heat related problems.
Mr Wapling says it is a useful mechanism but is unlikely to be happening on a large scale.
Community hospitals and acute trusts also need to ensure temperatures are kept low: this can be challenging for some where the buildings do not lend themselves to creating a cool environment.
In Birmingham, cool areas rather than rooms have had to be created. Professor Maryon-Davis warns that a severe heatwave could lead to elective surgery being cancelled. Mr Wapling says mental health patients in the community could be brought into hospital in the event of a heatwave.
Nursing and residential homes are likely to be important partners in preparation but Frank Ursell, chief executive of the Registered Nursing Homes Association, is unconvinced that PCTs are being proactive. He says preparedness may actually have declined over the past couple of years. He will be contacting his members and drawing their attention to the DH guidance, but points out that many homes do not belong to any association.
No one doubts that a severe heatwave will stretch the NHS’s resources, just as winter flu does. PCTs will face an enormous task, potentially having a large number of high risk people to monitor, in some cases needing to make contact with them daily.
This is likely to coincide with a time when many staff will have booked annual leave. Weekends will be a critical period when fewer staff will be on duty and GPs in particular may not be available.
And getting staff, local authorities, nursing homes and voluntary bodies to realise how quickly they need to react once temperatures rise may be the final hurdle.
French lessons: the 2003 heatwave
The 2003 European heatwave was described as having the highest death toll from a natural hazard in the region for 50 years: the Earth Policy Institute calculates that 52,000 people died as a result.
The effect on France was particularly dramatic with around 15,000 deaths and a resulting political storm. In England, the excess deaths were around 2,000. But the high death toll did prompt research into the factors affecting mortality and morbidity from heat:
- In France, a significant number of people who died were already in hospital or nursing homes; the ability of hospitals to provide cool areas may be important
- Many who died were elderly, living alone but not in regular contact with health services. The over-95s and women were at higher risk
- The heatwave saw extreme temperatures during the day - seven days of over 40C in some areas - but also unusually high night time temperatures and duration of heat. Air pollution - ozone - was also likely to have been a factor in the number of deaths
- The effects of the heatwave were probably exacerbated by it coming at a time when many French people took holiday, so public services could have been less able to cope. While this August shutdown does not occur to the same extent in the UK, staff holidays could still affect capacity
- Some groups who could be expected to suffer during a heatwave were much less affected, such as children and young babies
- The number of deaths in cities was high, possibly because cities can become much hotter than surrounding rural areas. But social isolation in cities could also be more widespread