Pandemic influenza: guidance on meeting the needs of those who are or may become vulnerable during the pandemic

Influenza (flu) pandemics are natural phenomena, which have occurred three times in the last century: the ‘Spanish flu’ of 1918/19, in which 20-40 million people worldwide died (with peak mortality rates in people aged 20-45), the ‘Asian flu’ of 1957/58 and the ‘Hong Kong flu’ of 1968/69. While the later pandemics were much less severe, they caused significant illness levels (mainly among young people and older people) and an estimated 1-4 million deaths each.

The World Health Organization announced a global pandemic of the H1N1 strain of swine flu on 11 June 2009. However, there is still uncertainty about the virus’ speed and pattern of spread and about its potential impact on the UK posing a challenge to healthcare planners and providers.

Pre-emptive, coordinated and robust plans that take account of this uncertainty will help to reduce the impact of the pandemic and hasten recovery of services. These plans for health services, local authorities and their partners incorporate business contingencies and changes to the provision of services. These changes will have an impact on the population served: many people are susceptible to changes in health and social care provision, and it is likely that these people will be even more vulnerable during the pandemic. These groups should be identified early in the planning stage so that their needs can be taken into account when developing local arrangements for the provision of health and social care in community settings.

For the purposes of this guidance, ‘vulnerable groups’ refers collectively to a wide range of people who face particular challenges in accessing mainstream public services, including health and social care.

However, in relation to pandemic flu, the term ‘vulnerable’ can be extended to mean anyone who is known to be vulnerable or may become vulnerable in the course of the pandemic.

1.2 Purpose

The purpose of this guidance is to emphasise the need for vulnerable groups to be taken account of in the pandemic flu plans drawn up by primary care organisations and their partners (NHS trusts, foundation trusts, local authorities and the third sector). The guidance is for England only.

All plans for the flu pandemic should be sensitive to the demographics of local populations, taking account of ethnic and cultural backgrounds and the geographical dispersion of residents. This is important to ensure adequate communications and access to services and treatment. In addition, the consideration of vulnerable groups and individuals within the population is essential to good pandemic flu plans.

In advance of the flu pandemic, primary care trust (PCT) pandemic planning committees and/or Local Resilience Forums (LRFs) should have:

• identified the individuals and groups who are potentially at risk of being unable to access care
• established their needs
• developed systems to ensure continuity of care.

Some groups - for example people with substance misuse problems, disabled people, children and older people - are already receiving specialist services, and efforts should be made to continue these for as long as possible during the pandemic. However, given the uncertainty about the effects of the pandemic, some flexibility in planning and responding is expected.

For identification of people at risk, please refer to Cabinet Office guidance Identifying people who are vulnerable in a crisis: Guidance for emergency planners and responders, available at www.cabinetoffice.gov.uk/media/161195/vulnerable_guidance.pdf

Guidance on information sharing is available on the UK resilience website on www.cabinetoffice.gov.uk/ukresilience/preparedness/informationsharing.aspx

This present guidance consists of general contingency advice for planners and is not intended to prescribe detailed operational procedures for responding to the flu pandemic. Instead, it provides a national approach, setting out key planning assumptions that can be used to inform the development of local plans.

For any one group of service users there may be a number of providers, and these partners must work together. Guidance that focuses on the provision of healthcare within community settings, Pandemic influenza: Guidance for primary care trusts and primary care professionals on the provision of healthcare in a community setting in England, is available to planners at www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_091993

The planning assumptions for this swine flu (H1N1) pandemic are available at DH website DH_102892. Swine flu specific information can be found at www.dh.gov.uk/en/publichealth/flu/swineflu/index.htm

General pandemic guidance can be found at www.dh.gov.uk/pandemicflu and includes the following:

• Responding to pandemic influenza: The ethical framework for policy and planning.
• Pandemic influenza: Guidance on preparing acute hospitals in England.
• Planning for pandemic influenza in social care (DH website DH_0933380).
• Pandemic influenza: Guidance for ambulance services and their staff in England.
• Guidance for pandemic influenza: Infection control in hospitals and primary care settings.
• Pandemic influenza: Human resources guidance for the NHS.
• Pandemic influenza: Guidance on preparing mental health services in England.
• Pandemic influenza: Guidance on the delivery of and contract arrangements for primary care dentistry.
• Pandemic influenza: Guidance for dental practices.
• Pandemic influenza: Guidance on preparing maternity services.
• Pandemic influenza: Managing demand and capacity in health care organisations.
• Pandemic influenza: Guidance on planning for vulnerable groups.
• Pandemic influenza: Guidance on the management of death certification and cremation certification.
• Planning for a possible influenza pandemic: A framework for planners preparing to manage deaths (Home Office).
• Planning for a possible influenza pandemic: Registrar General’s guidance on death registration services for Registration Service Managers and Practitioners (Home Office/Identity and Passport Service).
• Supporting people with long-term conditions to self care: A guide to developing local strategies and good practice.
• NHS emergency planning guidance 2005.
• Strategic command arrangements for the NHS during a major incident.
• Psychosocial guidance for NHS staff.

1.3 Objectives

The main objectives of this guidance are to:

• prevent people who are or may become vulnerable from being discriminated against or excluded from care during the flu pandemic
• encourage the development of effective and resilient local response plans for the pandemic that take account of the needs of vulnerable people
• minimise the impact of the pandemic on vulnerable people who are known to health and social services
• minimise the impact of the pandemic on individuals who become vulnerable as a result of it
• promote partnership working and integration of local response plans, for example between social care services and primary care.

2 Planning assumptions

Anybody can become vulnerable as a result of circumstances or incidents, and it is likely that many people will become vulnerable during the flu pandemic.

Planners are used to working with people who have previously been identified as vulnerable. In planning for the pandemic, however, planners also need to be mindful of the potential for new groups of people to become vulnerable because of it.

The challenge for planners is to determine who these people are, and it may be helpful for them to undertake a risk assessment of the potential impact of the pandemic on the local population.

These can be found at www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_102892

2.2 Impact of pandemic flu

It is difficult to predict the precise impact that the present flu pandemic will have on the UK population. The effects of a pandemic depend on a number of factors, including the characteristics of the virus, the severity of the illness it causes and its clinical attack rate. However, the impact of the flu pandemic is likely to be sustained and intense, affecting the whole country. Health and social services will be under tremendous pressure, and will face an increased workload caused by patients with flu and complications arising from flu. H1N1 appears to be more contagious than ‘normal’ seasonal flu, as pre-existing immunity is low, and we are likely to see a significant increase in cases over the coming months. Although symptoms have generally proved mild, a small number of patients will develop more serious illness. Many of these people will have other underlying health conditions, such as heart or lung disease, that put them at increased risk. Based on what we know about seasonal flu and the current pandemic virus, the following groups of people have been identified as likely to be at greater risk of serious illness:

• people with chronic respiratory disease
• people with chronic heart disease
• people with chronic kidney disease
• people with chronic liver disease
• people with chronic neurological disease
• people with immunosuppression (whether caused by disease or treatment)
• people with diabetes mellitus
• people who have had medical treatment for asthma within the past three years,
• i.e. who have active asthma
• pregnant women
• people aged 65 years and older
• young children aged five years and under.

At the same time, there will be a depletion of the health and social care workforce and the pool of informal carers. Primary care services will need to deal with large numbers of people infected with influenza, and because of the parallel pressures on hospital services there will be more people with acute care needs who will have to be cared for within the community setting.

Most health and social care services will need to be delivered outside the hospital setting, as this will be reserved for those who are most seriously ill and most likely to benefit from hospital treatment. Flu patients who are unable to access secondary care will need to be cared for in their own homes or in a care home setting as far as possible, and care will have to be taken to them when required and as appropriate.

Flu patients who do not have access to accommodation may need to have emergency intermediate care arrangements made for them. Health services need to be aware of the potential impact of this, and plan for people who do not normally use and have not registered with health services approaching these services for the first time.

People should be encouraged to self-care and symptomatic patients should be advised to remain in their own homes as far as possible. This is generally agreed to be the most practical and effective way of slowing or limiting the spread of infection. If people have underlying health conditions, they should keep in touch with their GP or other health or social care professional. If these people are unwell, it is important that they access antivirals as soon as possible after they become symptomatic.

Access to antivirals and other treatment will be provided mainly via the web- and telephone-based National Pandemic Flu Service.

Communicating the messages of self-care, of the desirability of remaining at home if ill and of how to access treatment is pertinent to those identified as vulnerable. Such communication may be difficult, particularly since known vulnerable groups encompass a wide range of individuals, from differing demographic groups.

Ensuring access to the National Pandemic Flu Service and other support for vulnerable people is also an issue, as some people may not have access to or be able to use a telephone or the internet, may not understand the National Pandemic Flu Service’s processes or may not have a friend to collect antivirals on their behalf. So the emphasis should be on building and developing support networks at a local level as soon as possible. Suggested sources of support include friends, family, informal carers, and health and social care staff in addition to third sector organisations.

The number for the National Pandemic Flu Service is 0800 1 513100, and the web address is www.direct.gov.uk/pandemicflu

These messages form part of the Department of Health’s overall communications strategy for the flu pandemic. This is explained in more detail in chapter 6.

3.1 Business continuity plans

The aim of business continuity plans should be to maintain normal services for as long as possible and then activate a proportionate response to any emergency situation. PCTs, mental health trusts, social services and third sector organisations should have decided already which of their services are considered core or essential, and which could be scaled down or delivered differently as the pandemic gathers momentum. Pandemic plans will need to be flexible to meet the changing demands of the current swine flu situation.

Business continuity plans should have been tested, reviewed and updated regularly to ensure they are robust, and PCTs, social services and their partners should have consistent local policies on ways of working. Current guidance from the Cabinet Office on business continuity is available at www.cabinetoffice.gov.uk/ukresilience

With regard to vulnerable people, business continuity issues fall into two main categories:

• continuity of existing services for known vulnerable people
• advance planning for a possible increase in demand for services.

Working practices should be made flexible during the pandemic in order to maximise the use of available resources to meet any increase in demand for services.

3.2 Identifying and assessing needs of vulnerable individuals

Some people may experience difficulties in accessing and using health and social services in general. Particular consideration needs to be given to such people in planning for the flu pandemic so that a safe and appropriate response can be given to their needs. Providers of care should now be working to ensure that all people covered by a local health economy have access to the services they need or may need.

The process of identifying and assessing the needs of vulnerable people entails obtaining and sharing information about people, including obtaining a list of partner organisations and other contacts that can be used to gather relevant information as the pandemic proceeds. Planners should make the best use of available surveillance data, employing established data-sharing arrangements to ensure consistent communication across organisations.

Health and social care professionals (such as community matrons and social workers/care managers) who are in contact with vulnerable people are a good source of information about an individual’s specific health and social care needs. It is good practice to ensure that an individual’s care plan takes account of business continuity issues. Details of an individual’s next of kin, medicines taken, known allergies, etc, may be useful in the event of any emergency, including a pandemic.

3.3 Assessing needs of vulnerable groups

A health needs assessment of a sub-population or population group is a useful approach. Public health specialists can advise on how to undertake such assessments, and there is plenty of material published on how to conduct one. A good example is the National Institute for Health and Clinical Excellence’s Health needs assessment: A practical guide (available at www.nice.org.uk/aboutnice/whoweare/aboutthehda/ hdapublications/hda_publications.jsp?0=210). Health needs mapping is a specific form of health needs assessment that has been used to design and improve services for hard-to-reach populations, for example South Asian communities. Information can be ascertained from routinely collected data, and for vulnerable groups can be supplemented from other sources such as the Health Poverty Index (www.hpi.org.uk), neighbourhood renewal programmes, Sure Start programmes and community projects.

3.4 Integrated planning and partnership work

Ensuring that the needs of vulnerable people are addressed in flu plans requires partnership working with relevant stakeholders in order to facilitate continuing access to services.

PCT pandemic committees or LRFs are responsible for developing the register of vulnerable groups, including the identification of existing and potential vulnerable groups, an assessment of their needs during the pandemic and a description of the ways in which care will continue to be provided. This information should be held, tested and updated regularly by PCTs or LRFs as part of business continuity planning. It is the responsibility of partner organisations to inform their PCTs who the vulnerable people are within its local health community. Such information should be accompanied by estimates of overall numbers and information as to where these groups are located, for example a particular housing area or hospital.

Third sector organisations and volunteers may be able to support the response to the pandemic at a local level by:

• communicating information and advice
• making links with isolated people
• supporting people by facilitating the collection of antivirals on their behalf
• putting in place ‘good neighbour’ schemes and initiatives to develop community resilience.

3.3 Assessing needs of vulnerable groups

A health needs assessment of a sub-population or population group is a useful approach. Public health specialists can advise on how to undertake such assessments, and there is plenty of material published on how to conduct one. A good example is the National Institute for Health and Clinical Excellence’s Health needs assessment: A practical guide (available at www.nice.org.uk/aboutnice/whoweare/aboutthehda/ hdapublications/hda_publications.jsp?0=210). Health needs mapping is a specific form of health needs assessment that has been used to design and improve services for hard-to-reach populations, for example South Asian communities. Information can be ascertained from routinely collected data, and for vulnerable groups can be supplemented from other sources such as the Health Poverty Index (www.hpi.org.uk), neighbourhood renewal programmes, Sure Start programmes and community projects.

3.4 Integrated planning and partnership work

Ensuring that the needs of vulnerable people are addressed in flu plans requires partnership working with relevant stakeholders in order to facilitate continuing access to services.

PCT pandemic committees or LRFs are responsible for developing the register of vulnerable groups, including the identification of existing and potential vulnerable groups, an assessment of their needs during the pandemic and a description of the ways in which care will continue to be provided. This information should be held, tested and updated regularly by PCTs or LRFs as part of business continuity planning. It is the responsibility of partner organisations to inform their PCTs who the vulnerable people are within its local health community. Such information should be accompanied by estimates of overall numbers and information as to where these groups are located, for example a particular housing area or hospital.

Third sector organisations and volunteers may be able to support the response to the pandemic at a local level by:

• communicating information and advice
• making links with isolated people
• supporting people by facilitating the collection of antivirals on their behalf
• putting in place ‘good neighbour’ schemes and initiatives to develop community resilience.

3.5 Principles of staffing and training for health, social care and third sector organisations

Previous pandemics have seen total illness levels of 25-35% of the total population. So that our plans are as robust as possible, we have based them on current swine flu (H1N1) illness rates of 30% of the population. Based on this figure, the workforce could be reduced by 12% at the pandemic’s peak.

Absence due to influenza infection is likely to average seven to ten working days. In addition, a proportion of staff will be absent due to the need to care for an infected relative, due to bereavement or other psychosocial impacts, because of practical difficulties in getting to work, or as a result of problems organising childcare. However, sufficient human resources will still need to be available to run essential social and health services, so maximising the use of available staffing levels should be a key focus for flu pandemic preparedness. A register should be developed to establish the skill mix of individual staff and to identify staff with skills and experience in physical healthcare.

In order to reduce the impact of the pandemic on staffing levels, all organisations should consider the steps needed to ensure that employees who are ill or think they are ill with flu are positively encouraged not to come into work. This may involve reviewing current personnel policies. Organisations will also need to have arrangements in place for handling staff who become ill with flu-like symptoms while at work. Once staff have recovered from pandemic flu, it may be appropriate to utilise their skills to look after patients with pandemic flu, provided the health and safety needs of such staff are taken into account.

A workforce that is well-informed and trained is likely to be able to manage the additional pressures and challenges arising during the pandemic. Primary care organisations, mental health trusts and social services should consult the following guidance for further information on training of staff:

• Pandemic influenza: Guidance for primary care trusts and primary care professionals on the provision of healthcare in a community setting in England.
• Planning for pandemic influenza in social care.
• Pandemic influenza: Guidance on preparing mental health services in England.
• Guidance for pandemic influenza: Infection control in hospitals and primary care settings.
• Pandemic influenza: Human resources guidance for the NHS.
• Swine flu specific information at www.dh.gov.uk/en/publichealth/flu/swineflu/index.htm

PCT pandemic influenza committees or LRFs should develop a risk assessment grid or framework that shows the likelihood of particular events occurring set against the degree of impact they would have. This could include scenarios with different levels of staff absence, timings for closing areas and deploying staff. These scenarios should be tested as soon as possible.

Volunteers and staff in third sector organisations also need to be trained. LRFs or PCT pandemic flu committees should ensure that training in infection control and pandemic flu is cascaded to third sector organisations and faith communities and then updated regularly.

3.6 Recovery phase

A single-wave pandemic profile with a sharp peak provides the most prudent basis for planning. However, second or subsequent waves have occurred in some previous pandemics, often weeks or months after the first wave. While the chief priority at the end of the first wave will be to develop recovery plans and restore health and social services to their original capacities, plans must assume the need for some regrouping in anticipation of future waves. Second or subsequent waves may be more or less severe than the first wave. The Department of Health will issue guidance to inform health plans following its review of the first wave.

As the threat of further waves subsides, England will move into the recovery phase. Although the objective is to return to pre-pandemic levels of functioning as soon as possible, the pace of recovery will depend on a number of factors, including demand for services, backlogs, supply difficulties, and staff and organisational fatigue. A gradual return to normality should be anticipated, and expectations shaped accordingly. Local resilience plans should have robust strategies in place in order to prevent the needs of individuals being forgotten as services are being rebuilt.

4 Partnership working

4.1 Working together

The public sector includes health and social services provided by PCTs, local authorities, mental health trusts, hospitals, and foundation and other specialist health trusts.

PCTs are responsible for assessing local risk and for commissioning, supporting and monitoring the development of integrated health response plans. They are also responsible for developing arrangements to maintain and support patients in a community setting and for ensuring that health plans take account of the needs of different sub-populations who may require specific planning, including vulnerable people. Local authorities are responsible for the assessment of needs of people who appear to have a need for community care services. Services or support to meet those assessed needs can be provided in a variety of ways.

If they have not already done so, PCTs and local authorities should seek as a matter of urgency to engage the third sector and other stakeholders in pandemic flu planning for vulnerable people. A joint approach to self-care should be developed, and vulnerable people should be supported to remain in their own homes (or another community/ residential setting) during the pandemic.

Social care services are aware of, and are in regular contact with, vulnerable people whose health and social care needs mean that they are more seriously affected by pandemic flu. Local authorities often have established links to other groups (for example liaison officers for travelling communities), ensuring that appropriate support and information is provided to reduce vulnerability.

Community pharmacies also have an important role to play in supporting and educating informal carers, promoting self-care and providing advice and information to vulnerable people. They can be a first point of contact for those who do not usually use primary care services.

Pandemic flu partnership working should build on existing local links and partnerships. Where possible, PCTs, local authorities and the third sector should work together in seeking out and building on links to vulnerable and isolated communities, with the involvement of carers’ groups, refugee and asylum seeker support services, street homeless outreach services and resettlement services, and substance misuse teams, among others.

Provision for vulnerable people should already have been planned and commenced (where possible), and pre-pandemic relationships and procedures should already have been tested. This provision should be part of the flexible, integrated planning process for pandemic flu and should be developed jointly by health and social care agencies.

Many third sector organisations are involved in the provision of services to vulnerable people, and act as support networks for their members. The MS Society, for example, supports a number of people with MS who are members. The third sector can support a number of known vulnerable groups such as older people, children with additional support needs, people with mental health problems, people with long-term conditions, and minority ethnic and traveller communities.

Third sector organisations offer a range of services that can be tailored to meet the needs of vulnerable people during the flu pandemic. Such services include telephone advice and helplines, assisting those experiencing stress, providing social support to help people remain in a community setting, helping people to find appropriate emergency accommodation if homeless, and supplementing healthcare resources. The third sector should be represented on PCT pandemic flu committees or LRFs.

Third sector organisations should develop business continuity plans in order to continue providing their services during the pandemic. These plans should seek to mobilise the capacity and skills of all staff and there should be business contingency plans to cover staff absences. Staff should also be provided with training in infection control measures for pandemic flu. Development and testing of business continuity plans is essential, as it is likely that any disruption to the provision of services by the third sector will impact negatively on service users.

4.2 The role of volunteers and faith communities

Volunteers (from faith groups, community networks and small third sector organisations) provide a proportion of health and social care to vulnerable people. Volunteers are regularly involved in delivering food; undertaking domestic chores and other tasks; and providing companionship to older people, people with disabilities and other vulnerable individuals in their neighbourhood. These services will be crucial during the flu pandemic. Volunteers could help with the collection of antivirals and the delivery of essential supplies to vulnerable people.

Local flu plans should include provisions to ensure that volunteers who will be continuing to support others in their local communities have adequate briefing, training, skills and personal protection. Faith-based and community-based organisations should be encouraged to develop plans for the provision of services and supplies during a pandemic.

Communities and Local Government has produced helpful guidance for faith communities. Faith communities and pandemic flu: Guidance for faith communities and local influenza pandemic committees is available at www.communities.gov.uk/publications/communities/influenzapandemic

5 Access to antivirals

This chapter aims to remind planners of the objectives of the National Pandemic Flu Service including its public-facing components, the likelihood that not all people will be able to follow the standard antiviral access process, and the alternative options available to access antiviral treatment. PCTs will need to plan how they will support people to access antivirals through the standard pathway as well as through alternative routes.

5.1 Objectives of the National Pandemic Flu Service

The key objectives of the National Pandemic Flu Service are to:

• enable people to access antivirals within the desired timeframe without leaving their homes by using an online or telephone assessment and antiviral authorisation service
• reduce the burden on frontline primary care services as far as possible by providing a separate route for people to assessment and then collection of antivirals.

5.2 Components of the National Pandemic Flu Service

The National Pandemic Flu Service comprises the following elements:

●web- and telephone-based services for the assessment of a patient’s symptoms

●the authorisation of antivirals where appropriate

●antiviral collection points for the issue of antivirals.

An essential part of the response will be to ensure that there is a system for distributing antivirals rapidly to all those who need them, while reducing the pressure on primary care services when required. The National Pandemic Flu Service will enable people with symptoms to be assessed quickly via the telephone or online, whereon a ‘flu friend’ can collect their antiviral medicines from a local collection point so that they can start treatment. Antiviral medicines from the national stockpile are free of charge.

5.3 Patient pathway

The standard patient pathway as at July 2009 is as follows:

Symptomatic individuals or their flu friends will use the website or ring the dedicated telephone line. They will be asked for identification details and taken through a clinical algorithm (questions about their symptoms) to determine whether an antiviral is required.

If it is, a unique authorisation number will be generated. The flu friend will take this number (together with an identification document for the symptomatic person) to an antiviral collection point. The flu friend will also need to take proof of their own identity. The flu friend must show their own ID as well as that of the patient. Accepted ID includes one of the following:

• utility bill
• passport
• credit or debit card
• driving licence
• NHS card.

At the Antiviral Collection Point (ACP) the authorisation number and identification information will be checked to ensure that they match the information provided when the patient’s symptoms were assessed (assuming use of the web or telephone service).

The ACP will reconfirm certain details with the flu friend to ensure that the correct antiviral is provided in the correct dose. The flu friend will also be given a leaflet on self-care for the patient. This will include advice from the Medicines and Healthcare products Regulatory Agency on what to do if they suffer an adverse reaction to the antiviral.

Local planning needs to take account of the fact that some people will not use, or will not be able to use, the National Pandemic Flu Service as intended. For example:

• all children under one year old will need to be assessed by a GP or healthcare professional, although their antivirals (Tamiflu® solution) will still be collected from an ACP
• some people will be unable to access or use the telephone or web service
• some people won’t have a flu friend to assist them
• vulnerable people might contact their GP or walk-in centre if they have regular contact with them already
• some people will turn up at an ACP and need to be assessed
• some people will be assessed as needing antivirals but will have no one who is able to go to the ACP for them.

How a PCT responds to these various people will depend on the needs of its local population as well as on the availability and capacity of healthcare professionals.

It is important that health and social care organisations plan for people to receive help to access antivirals, and this should then be communicated to staff, so staff are aware of the different options available to assist individuals, if issues about access to treatment arise. This should also be communicated as part of PCTs’ partnership working plans.

6 Communications

The national pandemic flu communications strategy aims to provide accurate, timely and consistent advice to the public. There has been a mass media campaign of national TV, radio and print advertising, a national door drop and media briefings. National telephone and web information lines have also been launched. Public information is additionally available at www.direct.gov.uk and www.nhs.uk. Information for NHS and social care staff is available at www.dh.gov.uk. All of these channels will continue to be regularly updated to reflect the changing situation.

Embedding good respiratory and hand hygiene behaviours is essential. This is the first line of defence against the spread of the pandemic and is an ongoing message throughout all our campaigns.

The Department of Health is engaging with stakeholder organisations representing groups of people who may need additional support to access the National Pandemic Flu Service. This engagement will culminate in the delivery of communications relevant to these groups using stakeholder channels and outreach networks.

Local healthcare communications are the responsibility of PCTs. Effective internal and external communications will be vital in responding to the flu pandemic. Local communications plans that reflect national activities should be developed in conjunction with local stakeholders. These will include all areas of the NHS, pharmacies, social services and the voluntary sector.

We will continue to engage with staff through regional health and social care workshops, features in relevant publications and staff-facing briefing presentations.