Good planning and preparation cannot remove the pressure of swine flu but it does put the NHS in the best possible position to respond, says Michael Caley

The West Midlands became one of the major epicentres of activity during the first wave of Influenza H1N1v.  Learning the lessons from this response has motivated all the NHS organisations and partners in the region to prepare for future waves in the coming months.

Although all NHS organisations in the region had pandemic flu plans prior to H1N1v, many did not fully take into account the plans of NHS partners.

Our experience of significant and rapid increases in demand for NHS services in the first wave has highlighted the need for plans within a local health economy to be aligned and complementary. Organisations are now working together to prepare joined up winter pressure plans that aim to tackle usual demand plus that created by flu.

It is this kind of integrated approach to tackling the anticipated arrival of another wave of flu that the NHS in West Midlands is now developing.

Last winter the ambulance service became overwhelmed quickly as demand increased. A coordinated and systematic approach to reducing demand for non-urgent ambulances across local health resilience fora is now being encouraged and may prove to be a critical factor in maintaining capacity.

Recognising rising pressures

During the first wave, the speed of the surge in demand for frontline services was unprecedented, putting significant pressures on community and secondary care. Primary care trusts and acute hospitals managed exceptionally well in coping with this demand with well established emergency response and management arrangements being deployed in Birmingham and the Black Country, one of the first swine flu hotspots in the country.

New tools and dashboards have now been developed by local health economies to be able to detect where pressure is building up in the system. Using softer intelligence together with dashboards allows organisations to be proactive about demand management so they do not find themselves in a situation where staff and usual services are stretched unnecessarily.

Command, control and coordination

In anticipation of needing to activate formal command, control and coordination processes to manage demand and equalise pressure throughout health economies, local health resilience fora leads have started preparing and rehearsing these arrangements. This not only involves reviewing plans and structures but more importantly making sure that all the chief executives in an area appreciate the role, remit and value of local health resilience fora commanders. 

The SHA has also been having weekly preparedness meetings since July and has clarified methods of working and the strategic priorities for likely scenarios over the winter. 

The role of command, control and coordination may involve the prioritisation of services and suspension of some performance targets if demand affects the ability of the NHS to deliver usual services.

The importance of having a framework to allow consistent decision making within the region to make these processes transparent has been highlighted by many organisations to avoid variations in response during a time of maximum demand.

The development of a dedicated strategic operations centre at the SHA has been invaluable in driving forward the many workstreams that are required to manage the threat from pandemic swine flu.

The centre has 12 permanent and dedicated staff including public health, operations, intelligence, capacity management, communications and administrative staff in addition to the flu directors.  It has the benefit of acting as a single point of contact and information at regional level for all organisations and has prevented multiple, uncoordinated messages being disseminated.  Local health resilience fora are also now starting to operationalise their own operations centres to support activity at more local levels.

In addition to the centre acting as a single voice for operational aspects of the response, a health advice cell has also been convened. This cell mainly considers issues that have health protection and infection control implications and includes representatives from the Health Protection Agency, the NHS and communications. 

The cell allows advice to be compiled in a uniform manner and to ensure that this advice does not contradict information provided by other organisations.

Critical care

In order to ensure that the region’s critical care services had the ability to respond to the potential demands of pandemic flu the West Midlands Critical Care Network was engaged early on about the vital role that critical care may play. 

Excellent engagement of senior clinical staff has enabled the West Midlands to carry out a full audit and assessment, exceeding the requirements of the DH, on all the critical care units in the region.

By early and thorough engagement and a huge amount of work in the acute trusts our units are already working on up-skilling staff and a significant number of recently decommissioned ventilators have been refurbished and brought back into operation months sooner than would have been possible had they been purchased via usual routes. 

Significantly, the planned launch of a regional paediatric critical care retrieval service has been brought forward by several months and is now in operation to support paediatric capacity.

Stress tests

Four one-day “stress test” exercises have been held in each of the local health resilience fora areas which were designed to test the robustness of plans from each of the local health economies in response to a series of scenarios of pressure on NHS services. 

The NHS in the West Midlands has also completed Exercise Peak Practice, a national exercise facilitated by the Health Protection Agency, designed to help SHAs assure themselves of the level of preparedness within their region. 

These exercises provided an environment where all the NHS organisations as well as local partners could meet and discuss their plans for coping this winter. There has since been a marked acceleration in the level of activity and engagement between organisations within LHRFs as the exercises served to highlight both the strengths of plans and identify work still to be done. 

All these exercises served to underline the commitment of all NHS organisations in the West Midlands to ensuring resilience in the system and its leadership role when faced with another wave of flu in addition to usual winter pressures

Handling the media

The media attention given to the flu activity in the West Midlands during the first wave was significant. The regional communications team dealt with over 150 media enquiries, wrote daily press briefings and fronted spokespeople for around 50 radio and television interviews. In May, the team hosted a regional media emergency forum to brief the regional media on the current and likely future state of the pandemic and the NHS response and state of preparedness.

Frank and honest discussions were had about what pressures the NHS may come under, how this would be managed and the role the media could play in assisting the health service response.

Since this forum was held the media messages and reports regarding H1N1v and the NHS response have been almost entirely positive.

Paid for advertising in print media and on buses has been used to disseminate public health messages and advice on using the NHS appropriately in times of pressure. A pack of information and toolkit aimed at schools experiencing outbreaks and potential closure was developed by one PCT for use across the region. 

The second wave of H1N1v, while continuing to be mild for the majority, could still present very significant operational issues for the NHS and social care this winter. Last winter’s cold temperatures and high rate of Norovirus infection put several acute trusts in the region under great strain. The demand from swine flu could dwarf these pressures. This is why the West Midlands is putting flu preparedness at the top of its agenda and ensuring that resilience of essential services can be assured.

Key priorities

  • Ensure decisive and strong leadership within organisations and health economies
  • Establish a local operations centre
  • Develop data dashboards
  • Revise flu and business continuity plans in light of emerging situation and likely scenarios
  • Ensure organisations are dovetailing plans within health economy
  • Engagement of critical care network
  • Preparing emergency response and command, control and coordination processes
  • Proactively engage local media

What command, control and coordination isn’t about

  • Just about the “big bang” outbreak or surge
  • Detailed command of resources or operational response in localities
  • Another tier of bureaucracy

What command, control and coordination is about

  • Defensible consistency of prioritisation
  • Practical criteria for mutual aid
  • Joined-up communications strategy
  • Mechanisms for shared intelligence and shared situational assessment
  • Determining the level of escalation of response according to the situation and predetermined triggers
  • Keeping ahead of the situation (“what if”)
  • Co-ordinated response on key capacity constraints
  • Shared strategy and clear policy on key risk areas