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The use of good judgement during the discussion of controversial issues would be greatly appreciated.

Can the NHS cope with a pandemic?

by: SusanC

Mon Jan 15, 2007 at 10:48:28 AM EST


( - promoted by DemFromCT)

There has been too little discussion of what is going to happen in the UK in a pandemic.
SusanC :: Can the NHS cope with a pandemic?
For whatever reason.  Let me start at least this topic.  Please share your opinions, thoughts, experiences of the NHS, etc.  The purpose is to collect information and ideas, as well as to start brainstorming alternatives or at least parallel solutions to what the government is proposing.

The first line of defence appears to be the use of tamiflu, prescribed by phone consultations.  Would that work?

Read this report and comments http://www.newfluwik...

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tamiflu saving many cases now?
Hospital care saving many cases now,

when each hospital only has a few at a time, and the rest of the nation is not suffering a pandemic?

Pushing household preparedness for self-isolating to prevent infection seems to be the best option, to me.

Would it lower the peak of a wave, if nobody came out to get sick?

(I already commented in more detail on lugon's page, and CurEv., on the "delivery by tamiflu buddies" idea. Rambling starts now:)

I think the US may use the postal service to deliver some items, is that discussed at all in the UK?
(delivering medicines)http://www.nalc.org/...
(mail carriers noticing when someone inside may need help) http://www.nalc.org/...

...Ken Engstrom, National Association of Postmasters:
"On January 8, 2007, I attended a Mail Security Task Force (MSTF) meeting at Postal Headquarters.  The topic involved the USPS Pandemic Influenza Policy.  Information was shared on how this occurs and what actions will be taken if it does occur."...  (And that's all he wrote.)

Back to UK: http://www.medicalne... ..."Apr 2006, UK Plans For Pandemic Flu Don't Go Far Enough 

...the need to prepare for high death rates,

being open with the public,

and understanding population behaviour. Clear and appropriate accountability and communications are also needed, ...

...""Intensive care resources are unlikely to be able to meet the extra demand of an influenza pandemic, warns critical care specialist, Richard Marsh. Based on data from influenza patients admitted to hospital in Asia, he predicts that between four and five times the number of intensive care beds available in most general hospitals in the UK would be required to meet demand at the peak of the epidemic."(sic)

"Decisions will be difficult and will require an unprecedented degree of cooperation between everyone caring for these patients, he concludes.

In terms of primary care, preparation is key, says Anthony Harnden. It is not sufficient for practices to rely on government or primary care trust plans. Current guidance is voluminous and general practitioners are in danger of not being able to see the wood for the trees. He believes that practices should develop straightforward plans that are applicable to local circumstances."...


not to be flip, but...
The answer to the question of 'can agency x cope with a pandemic' will always be

no.

Only a populace of empowered and prepared individuals can do it.  At best, agencies can help, but they'll be bailing with a sieve.

I think it would help them focus better if they admit up front that they will do all that is possible and still fail , and move on to empowering all those individuals who will listen.  At least then a few of the 'passengers' on the government 'boat' may have their own life-preservers.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.


It seems like
the government did tell people a while back that they would try, but in the end you would be "on your own."  They caught nothing but crap from the "help us" crowd for admitting that they can't be/do everything to/for everyone every time.

Even when HHS Secretary Leavitt tried to advise people to stock up by purchasing more of what they normally buy, people tried (tried really hard in some cases) to twist his examples of buying extra tuna and powdered milk - as in calling it the "milk and tuna diet."  It was obvious that he was just trying to give a couple of examples of things that people might normally buy, but the nay sayers really came out of the woodwork to ridicule him for it.


[ Parent ]
Re: NHS coping with a pandemic?....It already can't cope without one!
I do not believe the NHS is in any way ready to cope with a pandemic.  I dont really believe that any staff member of the NHS really believes that the NHS is prepared to cope, either. Many of the paper plans from DH centre are admirable - but many bear little resemblance to the likely reality that we will have to face, if the next pandemic should be any worse than an 1968 experience - and even then I beleive it would struggle and badly.  Overall, this is for three over-riding reasons.  Shortage of money, restructuring of the NHS, and a general lack resources, even when the 'light' and unrealistic assumptions of the UK national plans are taken into account.  When you apply realistic assumptions, the picture deteriorates, rapidly.  When the UK is cited as one of the best planned nations, I shudder to think what the future has in store for us if H5N1 fulfils all of its terrible promise.

I am not sure where to begin on this, so shall try to be succint with my points, which are in no particular order.  Sorry - its going to be long.  Since it is all off the top of my head and wirtten in haste, I hope it wont ramble too much.

1.  The UK Pandemic Plans: These contain many completely unrealistic assumptions. These include:-

2. That there will be a single wave of infection before vaccinations are widely available.

3. That Tamiflu stocks will be sufficient to manage the situation between wave one and wave 2 (or 3, 4 etc. )

4. That vaccines will be widely available for use after wave 1 has come to an end. As we all know, due to manufacturing and other considerations, the pandemic will be over before vaccines are likely to be widely available for the population at large.  There is also an assumption of quite some months before wave 2 occurs.  No one knows if this will be the case or not, but there is no contingency considerations of what to do if wave 2 follows immediately on from wave 1, or if there are further waves in quick and rapid succession, and the degenerative effects on resources that this would have. 
All plans consider that there will be adequate time to recover, restock etc and that not only will the UK be able to pick itself up rapidly after the conclusion of a wave, but that all other countries who may supply essential goods will similarly be able to recover quickly - this is frankly, one of the most unlikely considerations IMO, and I do not think UK plans have adequately considered the vulnerability of essential supply lines.

5. That the pandemic will attack the traditional age range of persons i.e those over 65 and the very young. Whilst there are (in most plans) a caveat that the at risk groups for treatment and vaccination will be finalised when the precise epidemiology is known.  If H5N1 gives rise to the next pandemic then on its current form, as far as I can see, no-one has adequately factored in the preferntial loss from the workforce of young adults, even if temporarily.

6. That plans expect that only 3% of cases will require hospitalisation, and, that the average time off sick will be 5 days.  Nothing we have seen indicates that those succumbing to H5N1 recover this quickly - never mind factoring in extended time off work to care for sick family members.  This will have massive effects on staffing levels, never mind any other aspect of essential service continuity.

Cant think of anything else on assumptions just now, but other FW members, feel free to add to this list.  Then we get to specific areas of weakness in the NHS/ DH plans and current circumstances.

Communication: Like every aspect of government, the UK management structure is so large and cumbersome that the left arm rarely knows what the right arm is doind, yet expects everyone involved to 'just know' what is going on and planned.  The senior beraucrats do (roughly), so they imagine that everyone else in the system does too.  Internal communication is vitally important, and sadly lacking.

Plans have been developed in Whitehall and the Department of Health and the special commitee in the Cabinet Office. Like many plans, The UK pandemic plans do not necessarily bear any resemblance to the reality of availability of resources at a local level. It appears to be only now that certain practical considerations are being thought through, giving rise to the UK Buddy Plan (Congratulations - a apractical solution) However, plans are also only any good if the individuals who have to carry them out understand them, know exactly what is expected of them, and what resources they will or will not have at thier disposal.  I have not seen or heard much to fill me with confidence that this is occuring - or if it is, that it is going on at anything like the speed that is necessary for the UK and the NHS to be ready and cope.

Hospital trusts and PCTs have been asked to designate individuals to draw up local plans based on the DH framework.  However, it is extremely patchy as to how developed these local plans are. Many planners still seem to be woefully misinformed about what they are planning for in terms of H5N1 characterisitics (susrvival in the environment), disinfection measures etc etc.  Normal flu rules are being applied.  H5N1 isnt a normal virus.

Planning failures: The above issues are due (IMHO) in no small part to the fact that the DH base planning assumptions (built into their instructions for planning) are woefully optomistic, unrealistic and worse (see above). The base assumption is to plan for a 1968 style pandemic, and to consider if the plans are resilient enough to withstand a 1918 style pandemic: - as the initial direction requested planners to consider only a 1968 level of pandemic becuase that is all the UK NHS can possibly cope with, (although the directions have been changed,and planners have been requested to update their plans,) the base assumptions that were made at stage one have (more often than not) not been altered.  What this means in practical terms is that most plans assume an instantly avialable vaccine in mass quantities; that the estimates of the numbers and percentages of infected persons who are likely to require hospitalisation are LAUGHABLE based on present H5N1 experience, and are probaly some 5% of the likely reality; and therefore estimates of the amount of IV drips, needles, consumables for hospital care have been woefully underestimated. 

There appears to be (from my discussions with public health officials) little direction and communication from centre - and in the main,  planners are waiting for a lead from centre as to what they should do next. 

At the next level, the NHS Primary care system and the average GP have had little, if any, useful information - no plans are being made at this level as they have not been asked to do so, nor have GPs or local surgeries been given any direction as to what may have to be coped with in the event of a sever pandemic.  The overall assumption is that difficult cases of flu or those individuals suffering complications will simply be able to be referred to hospital.  Little thoght therefore seems to be being given to the consideration of what to do if/when hospitals are overwhelmed, Tamiflu is unavailable (or worse, not useful if resistance develops.

Finances: Due to financial restrictions, (The NHS is in severe cash shortages at the moment, especially in the South East)many hospitals are running on minimal resources, let alone being in any position to build strategic reserves of such consumable, but essential goods - even to cope with these very low infection and hospitalisation rates. Many hospitals do not have enough of these items for present day to day usage.  Given that, almost without exception, these goods are made in the far east and imported, the lead time for manufacture is quite long.  Importer/ suppliers are also running on JIT prinicples, and hold minimal safety stock reserves.  Therefore it must be considered likely that the basics of provision of these essential items for hospital care will fall over very quickly indeed - there is no slack in the system anywhere, and there is no additional funding or provisioning being made available to build pandemic reserves. 
To the contrary, the NHS and all trusts, especially those in the red, must balance their books.  Despite the political imperatives, this has meant staffing cut backs across the board - including reductions in beds, nurses and doctors.  Some major hosptials are facing closure, on the back of white paper reports that seek to cut costs by passing more and more responsiblility for care and recuperation to primary care and the GPs surgery.  In fact, given the problems of MRSA and C. Difficile infections at present, there is a significant drive to get patients out of hospital as fast as possible. Hospitals are increasingly becoming surgical units with extremely rapid discharge of patients.  Nothing in the NHS is geared for prolonged critical care, and there is already a national shortage of ICU beds.

Medicines supply: in an effort to reduce prscribing budgets and reduce wastage, PCTs only have allowed for single month long scripts of chronic care medicines.  Pharmaceutical supply lines do not generally cater for more than a six week safety stock reserve, if that.  GPs will be overwhelmed very rapidly caring for patients in a severe pandemic - so they need to be issuing 3 monthly scripts for essential meds for life threatening conditions - now - to allow supply lines to restock for essential meds such as asthma medications, cardiovascular medications, Insulin, thyroxine etc etc.  Whilst it may be painful, except for the most severe patients, NSAIDs etc could be gone without if needs ve - so they dont need to do this across the board, so the cost implication need not be massive.  However, for a list of 'essentials' they could easily get issuing 3 month scripts NOW.  It could save a lot of lives, and it can be expected that manufacturing plants will be fully tied up with production of antibioitcs and similar (assuming raw materials can be obtained) for the pandemic duration.

NHS actions: The NHS dress rehearsals for 'coping' with a pandemic all entail practice for mass vaccination campaigns.  On the face of it this would be fine if we had large volumes of pandemic vaccine in the wings ready for the outbreak of pandemic flu - but as all readers here will know by now, there will not be a vaccine for the population at large for at least the first wave, and I believe that realistically, any later pandemic waves will have been and gone before any such vaccine can be widely avialable.  There is no back up plan for what to do in the absence of a vaccine, nor what to do if Tamiflu resistance should emerge, or, what to do when the stockpile runs out.  (more on this later.  Where are the contingency plans involving local GP surgeries setting up filed hospitals?  If the average hsopital stay of a surviving patient is a month or longer, they are going to be needed and fast.  Every surgery should be planning how they would manage if a severe pandemic hits.  But becuase no such direction has come from centre, nothing is being done - they are so overworked already, that without such direction, no action will be taken.  To put togehter such plans in the midst of a pandemic is going to be way too late.

Surgeries have not yet been asked to take measure like stocking up on surgical gloves, consideration of removal of carpets (could harbour virus) and a 1001 other practical considerations to protect themselves and their patinets who may visit the surgery.  Or at least, I have not seen anything addressing this issues, so if I am wrong I will happily eat humble pie and be corrected.

You have probably all got rather bored of reading this by now, but perhaps this will get the ball rolling!  Will add more as it occurs to me...


the biggest folly is the tamiflu-led response
thank you, you have indeed started the ball rolling.

I'm just going to take this one element for now, and summarise the issues around the assumption that we can use tamiflu as the first line response to widespread pandemic illness

The plans rest on the assumption that we have enough tamiflu to treat 25% of the population, and that telephone lines will be set up, so that people who are infected can send a 'buddy' to a local pharmacy or other distribution point to collect the medicine.  The aim is to make the drug available within 12 hours of onset of symptoms.

What are the fallacies inherent in this set of proposals?

  1. 25% is the lowest limit of all estimates for clinical attack rate for a pandemic.  Indeed, recent government communications already indicate they think a 35% attack rate is more likely.

  2. 'enough for 25%' only means enough in seasonal flu doses, ie one packet per person at 75mg twice daily for 5 days.  Both animal studies and experience from Vietnam (and other places) tell us that with H5N1, the viral load is many times higher and the duration of viral replication is far longer than seasonal flu, such that it is very likely that twice the dose for twice the duration (Eik De Clercq, Professor of Microbiology and Immunology, Rega Institute for Medical Research, Belgium, Paris Anti-Avian flu conference, Institut Pasteur, June 2006, reported here) will be needed for adequate treatment. ie 4 packet per patient.  If you look at the following chart, 5 days of treatment is obviously not enough.

    Instead of there being enough drugs for everyone who catches the virus, we are facing possibly enough drugs for only 1 in 5-6 patients, assuming perfect diagnosis, distribution, efficacy, etc.

    ie before the following issues are included in the equation

  3. widespread inadequate treatment is likely to result in resistance, a known problem with tamiflu

  4. then there is the issue of inability to make an accurate diagnosis.  According to Herman Kosasih of NAMRU-2 in Indonesia (reported here at 22:07) clinical distinction between avian and seasonal flu was difficult before Day 5, with onset of respiratory difficulties. 

  5. distribution failures and/or mis-match of need and allocation will cause further wastage

  6. the system is open to abuse and widespread fraud, as per my comments yesterday

  7. all, of course, assuming that the phone lines will stay open. 

  8. and that you can get through within < 12 hours of onset of symptoms.  Those who have various experiences dealing with the ingenious ways that GP practices use to ensure compliance of the 48 hour target in 'normal' times might very well question how likely that is going to happen.

  9. Given there is no tamiflu set aside for prophylaxis for contacts (rightly so IMO), can we expect people to willingly nurse their sick family members?  We can tell them till we are hoarse that they are already exposed, but many will still be afraid of catching the virus, so there will be pressure to admit patients, whether beds are available or not.

  10. There doesn't seem to be any provision to protect healthcare workers or essential personnel either.

  11. This whole process will instill in people (citizens and professionals alike) blind faith in one drug.  When the drug is no longer available via the phone prescription route, as is certain to happen either cos we've run out or to stamp out abuse, the panic will be extreme, and mayhem will reign in hospitals.

To bet everything on one drug is pure folly.  To bet everything on one drug that we do not have enough of, that we cannot give to those who need it in time, that is likely to lose efficacy as time goes on, that is more likely to cause divisiveness than co-operation, is totally irresponsible. 

The consequences of (the almost certain) failure of this policy will be catastrophic.





All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Tamiflu resistance
Given that it appears that two different Tamiflu resistance markers are now being identified in humans in the one instance (Egypt) and birds in the other - and in a strain known to be capable of infecting humans (Russia, Quinghai), do we have any indication of what level of UK stockpile exists for the other antiviral drugs eg amantadine etc?

I sincerely hope that given these developments the NHS plan is being urgently reassessed (and all subsequent impacts)re: what to do in the absence of Tamiflu sensitivity (which will still probably be used regardless)and therefore the impacts on the numbers of persons with serious disease that will require hospitalisation etc, even based on the current UK assumptions.

This simply confirms that a new set of planning assumptions are needed under a 'worst case scenario'.  These must include full viral resistance to Tamiflu at the start of a pandemic, as this is looking increasingly like it is a highly possible scenario.

Given the present data on development of resistance, I would suggest that even if Tamiflu resistance is not initally fixed in a pandemic strain, it will emerge within  a first pandemic wave extremely quickly. 

UK planners must reassess their plans.


[ Parent ]
clarification on tamiflu resistance marker
There was one marker found in 2 Egyptian patients N294S.  Both died, but we don't have any information on clinical drug resistance, as opposed to laboratory assays.

I haven't seen any mention of finding them in birds.  If anyone has that, please post. 

There was one case in Vietnam in 2005 where there were 2 tamiflu-resistant markers, N294S and H274Y, but the patient recovered with standard doses of tamiflu, ie the virus in that case was clinically sensitive to tamiflu.

There were 2 additional cases of H274Y in Vietnam where the patients died.  The virus load clearly was not falling significantly in those patients, which meant true clinical resistance.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
H274Y isolated from swans in Astrakhan
To clarify, it seems the H274Y mutation has been identified in avian isolates from swans in Astrakhan, although they are samples from 2005: I am not sure when the sequences were actualy released.  However, this does indicate that there is at least some H274Y circulating in an avian reservoir, but this does not necessarily mean that it is fixed or still in the viral reservoir.  However, risks of this are increased.

Influenza A virus (A/swan/Astrakhan/1/2005(H5N1))
http://tinyurl.com/2...

A/swan/Astrakhan/Russia/Nov-2/2005(H5N1)
http://tinyurl.com/3...

Re the N294S mutations, I have not been able to verify the following, but have read reports that NAMRU-3 also sequenced virus from blood samples taken before treatment was initiated in the two Egypt patients.  These samples also contained this N294S mutation, and therefore (if accurate) it can be considered fairly conclusive that the mutation did not arise as a consequence of Tamiflu treatment, but was in the virus at the time of infection.  If anywone can verify this it would be useful.


[ Parent ]
Brittle vs Resiliant
From what I have read (mostly BBC and flu-related articles coming in on my web-alerts) the public health system of the United Kingdom is no better and in some cases worse off than the public health system in the US.

Both have become thin and brittle over time from a lack of public and financial support and from stagnancy in vision and methods. 

In reviewing some articles recently on the vulnerability of the the electric power grid in the US and Canada, I say the system described as having grown old and brittle from lack of upkeep and improvements over many decades. 

I think this same statement can be made for the public health systems.  Would it be correct to say the the UK is more heavily dependent on its public health system?  If, as I believe, it is so, then it is in even more trouble than the US.

One of the other support pillars of every major pandemic preparedness plan is public cooperation (not just acquiesance, but participation in some form.)  Again from what I have seen of the UK plans, this is true here as well, yet I don't think they have had even the minimal level of citizen engagement that the US has had.  Are UK citizens that much more ready to hear and obey?  I doubt it.  I hope the Buddy Plan is a start of that discussion.  Because other than being able to identify who is getting sick, funneling them into a phone center for triage, and maybe identifying someone who is willing to help not only their buddy but others, I don't think tamiflu is a real answer (due to both shortage and questionable effectiveness.)

Building back up the public health system, giving it a little bit in the way of emergency reserves, engaging the public in frank discussion and actively encouraging them to prepare (both for self-reliant living and for in-home pandemic flu treatment) would be the top of my list of suggestions for the UK (as it is right down the line here at home.)

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


citizen engagement needs leadership
I don't think they have had even the minimal level of citizen engagement that the US has had.

From my own participation in the US process, citizen engagement happens only because of tremendous political will from the top.

How many of us have tried to tell our friends and no one will listen?

This is a difficult and complex subject.  With the best will from the top, lots of resources, and multiple stakeholders actively participating, it is still excruciatingly slow, again as attested by the US NPI consultation process.

Until the leadership at the very top realises the severe systemic hazards of even a moderate pandemic, and takes active steps to address this problem as primarily a national security issue first and a public health issue secondarily, no country will escape the catastrophes brought on by the domino effect of multiple simultaneous global failures accompanied by a sick, hungry, bereaved, and angry population.




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
path forward
so what's the path forward?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
"The NHS can barely cope as it is! Poor NHS!"
that's all my old school chum had time to say, when I sent the thread and an invite. ;-)

Even if the overall plan is lacking
the "buddy plan" is brilliant.  It's a great way to get people thinking about the realities of PF and how bad it could really get.  I think it takes a personal connection to bring it home to people. 

As for the Phone-in Tamiflu idea, it's not great but certainly far more workable than relying on the current system to handle patient surge.  Yes there will be issues, mis-diagnosis, Tamiflu given for seasonal flu, etc.  But it beats filling up already overcrowded hospitals and doctor's offices with very sick patients. 

Of course, that assumes the gov't has enough to go around...


the problem is using this as the LEAD intervention, though
The only benefit would be the one that you mentioned that people would start thinking about it.  I doubt it, though.  I think it is more likely to breed complacency and closure, what I called the 'blind faith in one drug'.

There is of course nothing inherently worse in this way of dispensing tamiflu than any other. 

The problem is using this in place of other preparations such as non-pharmaceutical interventions such as early school closure, or vigorous dissemination of correct information.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
absolutely true
too many are relying on Tamiflu or some other miracle to get us through.  As far as schools go, I don't know how it works there and if the NHS would have any say/influence over school closures?  My understanding is it's be like the CDC ordering schools to close - they can make recommendations, but certain things are out of their control. 

[ Parent ]
the problem is insufficient leverage at the leadership level
certain things are out of their control

The problem is in the command/control structure.  In the UK, the Department of Health is the lead agency 'co-ordinating' the entire pandemic response.  Follow this link http://www.dh.gov.uk... and you will find this bio:

Professor Lindsey Davies was appointed as National Director of Pandemic Influenza Preparedness in April 2006. She is also a senior doctor within the Department of Health.

Note that not only was she appointed in April 2006, her post was only created in April 2006, as part of the Department of Health.

Now, I've met Prof Davies on occasion, and she seems competent enough.  But how does one 'co-ordinate' the national pandemic response unless someone has authority over what you are supposed to co-ordinate?

In the context of HIV/AIDS, I learnt a very valuable public health policy lesson from a senior analyst in Chatham House in London.  He said, "If you want to predict whether a country is able to control or reverse the HIV problem, look at who is leading the initiative.  Anybody who has a job with the word 'health' in it ain't gonna do it."

What he meant was you need someone above the level of Health Minister.  For example, the Thai Prime Minister famously went on national TV to promote the use of condoms, and Thailand is one of the more successful countries in the control of AIDS. 

Political will, and therefore the ability to command and utilize appropriate resources, at a sufficiently high level is essential.

That rule applies similarly to pandemic influenza, multiplied many times over, because pandemic flu is likely to result in rapid, widespread, and simultaneous global breakdowns.  Pandemic flu is not just a health and medical problem, it contains as major components issues above and beyond that, at the level of critical infrastructure, national security, and strategic considerations, which will not be resolved by solving the health problem alone.

This is, very simply, a question of leverage.  How can someone who is a departmental employee (ie not even head of the Health Department, let alone Health Minister or above) lead such a national response?  With the best will in the world, she cannot. 

Yes, there are people in various departments doing pandemic planning.  But piecemeal and haphazard activities are not the same as a national response.  Right now, we have some sort of a health/medical response. 

A truly national pandemic response for the UK does not exist, because the institutional structure that makes it possible has not been put in place yet.




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Katrina certainly demonstrated here
that without a "czar" who can call the shots across multiple agencies, you end up with a cluster f(**.  What is needed is one crisis head who perhaps only can institue powers under a limited set of circumstances.  That, or convincing all agency heads about the crisis and what it all means and coordinating all of them.  I haven't seen any countries who have been able to do that either. 

[ Parent ]
when will new version of UK plan come out? (says this week)


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

Will it include the words 'your kiss goodbye backside?' n/t


[ Parent ]
Health focus is part of the problem
SusanC has made a whole range of very pertinent points.  I would like to broaden the discussion slightly now, to take in the bigger picture outside the immediate issues of health and NHS in a pandemic.

Because the whole issue of pandemic planning has not had the political championing from the top, as SusanC has said, there is insufficient clout to get things done and co-ordinated across the board - I would not disagree with a word she has said.  However, the issues raised by this lack of central leadership and co-ordination go far deeper than this.

When you take a look at national resilience planning, it has had two primary areas of focus, neither of which are joined together.

On the one had we have the UK NHS plan, all health focussed.  On the other we have a business continuity focus, within which comes management of essential services etc.  The latter aspect of planning has been jointly led by the Treasury, the institutions, and the FSA.  But each ahs been looked at in isolation form each other.

Looking at the coninuity aspect for a moment: the fundamental flaw in this area of planning (and IMHO from where the lack of direction for UK citizens to stock up on essential goods comes from) is that the govt and whitehall only consult with big buisiness.  They are the only organisations with sufficient size to free up the manpower resources to run scenario planning, consider resilience impacts etc.  They are also sufficiently large that in such scenario planning exercises, they can conintue operating with a great shortfall of staff.  All well and good, exercises are run, and individual corporations look to their identified weaknesses and seek to bolster them, so that their operations can continue.

The catch is that 80% of the UK population are employed by SMEs (small/ medium sized enterprises).  However, these SMEs only produce, on the face of it, 20%ish of the national revenues - hence in government consultations, the impacts of a pandemic are considered to be most profound in the 20% of big buisness.  Yet it is these SMEs that run on the tightest of margins, and have little financial resilience to withstand a pandemic event - they will be the first to fold under financial and severe manpower pressures.  So what do we have then?  Very significant proportions of the population rapidly unemployed and without an income - with knock on economic effects that will make the Great Depression of the 1920s seem like a picnic.  This aspect of pandemic planning seems to have escaped govt planners, as far as I can tell.

Now add to this the fact that food production and producers, are, primarily SMEs. It is they that supply the supermarkets with goods for onwards sale.  This is true of food producers across the EU.  Take 30 - 50% of their manpower out, and they will fold both financially and in terms of production capabilities very quickly.  SME producers will be similarly affected no matter which EU country they are based in.  So, if their operations falter in a first pandemic wave, who is going to take up the slack in the inter pandemic wave period and be there to amintian food production in waves 2 or 3, especially as we probably sTILL wont have any meaningful quantities of vaccines at this time?  If food production is massively hampered here and in every other country, how long will it be before there is insufficient supplies to be available for export beyond a countries borders?  Not long I think.

So when we then consider that the DEFRA report considers that whilst the UK is only 70% self sufficient in terms of food production, we still have 'food security'on the basis of imports. I would suggest that this will rapidly become utter nonsense in a pandemic, as our 'security' relies on supplying countries being able to make up the 30% shortfall.  Each country will look after thier own intersts first. That includes us.  So how bad does it have to be before the UK (or any other EU country) suffers a 30% reduction in food production capability?  How quickly could this be recovered (food production is a long term thing - if you dont harvest fast enough, a years corp can be lost.  If livestock die, it takes years to rebuild herds etc etc)

It is from this blase UK assumption that all will be well, and economic and other recovery after wave one will be rapid, that the UK has (IMHO) dismissed US style plans to get everyone to stock up on essential goods. This has been allowed to persist throughout UK plans simply because there is not a centralised co-ordinating lead to look at every inter-realtionship of UK infrastructure - health and health management has been the key and core driving force behind all planning.  Private industry (read big buisness) run scenario plans and say that they, as an idividual organsiation, can cope (on very weak assumptions too - see earlier posts), and thus the end conclusion is that the UK as a whole can cope.  How far back have they checked their supply lines  - I can answer that this has not been done thoroughly, becuase the SME suppliers have not carried out any continuity planning nor impact assesments to back up their (usually poorly informed)statements that supplies would be maintained.  Think about it - securing Supermarket supply contracts is a highly competeive game, and part of it is being able to guarantee conintued supply of goods within very short lead time.  If one organsiation says they cannot there are atleast 20 similar organsiations in the queue that will say that they can.  Therefore when one of the big groups asks a supplier, 'in a pandemic will you be able to maintain supply' what do you think they will say?  Having been working with many such organsiations, I can categorically state that they have not yet carried out full or proper conintuity planning or impact assessments, and instead have the somewhat naive view that somehow, they will just cope.  No one seems to be considering a period of longer than afew months.  If we get a rapid succession of waves we are most certainly sunk.  I am dubious about their abilities to survive a single wave.

I would like to see the farming union running similar detailed scenario plans, alongside those of Tesco et al and see just how resilient the UK actually is in terms of essential goods i.e food etc.

There are a host of good whitehall led resilience planning sites that businesses of all shapes and size can review, and advice can be follwoed.  But where has been the government led, and media led call to action?  There has not been one.  And as the media has been silent, most SMEs (who are working flat out jsut to survive) have wrongly assumed that there is no issue - it is all a storm in a teacup.

As a Stategic Marketeer (as well as a first degree in science)I can think of a host of things that businesses can do, now, to make sure they survive a pandemic = keep people employed = keep the economy turning = minimising the long term damage from a pandemic. Lets pick an example that everyone jsut says - well they will besunk e.g. Restaurants - well perhaps they can turn their food production capabilities to supply offices that do not have their own/ adequate facilities, and where staff are udnergoing a lock in.  Overspill hopsitals will have persons who need feeding, without kitchen facilities.  The internet can be used for remote ordering and home delivery.  Any or all of these may not make any restaurant owner rich, but it may keep him in buisness.  But to achieve this sort of thing, restaurants need to planning and negoitating this sort of agreement, at least in principle, NOW. They need to be building internet sites.  They need to be looking for local produce and supplies in case national transport networks and imports break down.

Instead, most probably in an effort to keep the economy stable, these issues are not bing championed by Government nor whitehall- SME organsiations are simply no more aware of the issues surrounding a pandemic and pandemic risks than any of our friends and neighbours are when we try to talk to them about indiviudal preparations - and they no more accepting either.

This all, at the end of the day, dovetails back to the original question posed in this thread - Can the NHS cope in a pandemic.  I would respectfully suggest we may want to broaden this to:-

Can the UK cope in a pandemic? I think that the answer is a very resounding NO.  I really hope I am wrong, but I think that these issues outlined here have not been recognised by the powers that be becuase they are looking for impacts in the wrong places, or perhaps are not considering impacts in all of the places that they need to i.e SME impacts.

For all our sakes, I hope that this changes soon.

Apolgies if this takes the subject too far off topic, but again, I hope that it may stimulate food for thought by those who may be better informed than I.


well put, flumonitor!
No, you didn't take if off topic.  It is exactly the debate needs to go - can an NHS-led response stave off the multi-system gridlock that is likely to happen in a pandemic?

Can the UK survive a pandemic without "a centralised co-ordinating lead to look at every inter-realtionship of UK infrastructure", as you rightly pointed out?

In addition, I want to add a remark to the supply chain problem:

"Therefore when one of the big groups asks a supplier, 'in a pandemic will you be able to maintain supply' what do you think they will say?"

I think a lot of them will say they are prepared, even if they're not. 

Think about it, if one of your biggest customers wants to know whether you will be solvent and functioning in a pandemic, would you want them to know that you are not prepared?  Why risk losing a big customer NOW?  A lot of SME's function on the principle of 'first things first', and often the 'first things' are whatever allow them to survive from month to month and not beyond that.

Instead of just asking whether suppliers are prepared, businesses need to assume they are not, and build in redundancies and alternate sources as a matter of continuing good practice.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Next step that is needed: Finish quantifying the problem with SMEs
I dont think we can come to the end solutions to these problems without further work, carried out quickly, to quantify the impacts.

As stated in my original comment, the issue I see is that national resilience planing has focussed solely on big business.

Winter willow and similar exercises have looked, mostly, at the ability of big buisness to withstand a pandemic and maintain operations.

What needs to happen is for similar exercises to be carried out with each of the major UK SME organisations, perhaps led by the Small Business Service at the DTI.  Then the findings of such an exercise can be fed back into the outputs of the bigger planning exercises that have already happened.

If similar exercises can be carried out asap by the SBS in conjuncition with the Federation of Small Buisnesses, the Federation of Private Businesses, The National Farmers Union, the road haulage associations etc the problems that will exist at SME level can be quantified.  Then when the full measure of the impacts have been assessed, solutions can be found - policies made - to address the problems.

The catch here is that most SMEs cannot give sufficient time to do this - so the govt is going to have to find the money to PAY SMEs to take part - and pay them over the odds so that they can replace individuals on temporary contracts.  As I know from bitter experience, if you take one senior person out of an SMEs day to day ops,  for a period (this is going to be needed over a reasonably long time i.e 6 months or so) you need 2 extremely qualified people to replace that person, and even then there may be some longer term impacts on the business that need to be compensated for.  So its going to cost the govt money - but in the scale of things, not really all that much.

Combined with the obvious issues of needing centralised co-ordination, I see this as one of the biggest areas that needs addressing as fast as possible.  As far as I am aware, it isn't happening.  Only when this step has been completed do I beleive that it is likely that the UK govt will start leading the clairon call for SMEs, and therefore the country at large, to prepare.


[ Parent ]
SME's: Ontario Chamber of Commerce action
http://www.newfluwik...

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
Who should be treated?
There is another fact that needs to be considered properly by TPTB, that is falling through the net for a lack of leadership and co-ordination, and its a debate that needs to be held in the media - now, before a pandmeic arrives.

It is not certain that H5N1 will give rise to a pandemic, but with each passing day and human infection, it appears increasingly probable.

We know that the vaccine sums do not add up.  There are so many subclades circulating, each with the potential to cause human infection, and guessing which strain might lead to a pandemic is difficult.  Susan C has already outlined clearly above why the UK national stockpile will be grossly insufficuent.  Prophylactic use of Tamiflu for health and essential workers will be needed to keep essential services running until it can be said that any pre-pandemic vaccine confers any immunity.  If the answer is no, most of these supplies could be tied up in this way, until the first production runs of an effective vaccine can be completed. This of course assumes that the virus remains Tamiflu sensitive.

Then of course, we have the fundamental issues of global manufacturing capacity.  For a normal vaccine global capacity is presently soemwhere in the region of 350million doses annually of trivalent vaccine. If you made the vaccine to include 3 differing substrains of H5N1 it will not go very far.  If you make all capacity monovalent, and there is sufficient adjuvant efficacy this can probably stretch (given current data on vaccine amounts required to get an adequate immune response) to 450m doses, in 12 months, 24/7 days production around the clock. Globally.

Therefore the prospect that the UK could manage to manufacture sufficient vaccine for all its population, and withold any UK production output to other countries is not realistic.  The virus will continue its mutations and evolutions, and an H5N1 vaccine (like all other vaccines,) will have to repearedly be refined and updated.  There will never be a time within the pandemic itself, that every person in the UK could be vaccinated for physical reasons, discounting any issues of political will, money etc. 

Therefore we need to be debating now who treatment and vaccination should be prioritised to. UK plans continually look at vacination of the young, the elderly and those with pre-existing medical conditions. 

As harsh as it may be, this is where holistic, including ecominic considerations, aside from emotional ones need to come into play.

On present form, we can expect that those under 40 will be hardest hit.  The 18 - 40 age group is the generation presently working to fund our social systems, pensions etc.  If we get a 50% attack rate, and in a worse case scenario, mortality rates are maintained at say 50% in the absence of effective treatment, we are talking about the UK losing 25% of our revenue producing population.  Extend that the the children and then you can easily see we are talking about losing this proportion of our economic drivers, not just for 2 generations, but for four.  If the elderly are not hit equally then the hope of maintaining anything like the sort of social welfare system that currently exists is gone for the next 50 years or longer.

Besides the emotive reasons of wanting to protect our children, and the practical considerations of keeping the wheels of society turning during a pandemic, proper consideration needs to be given to these factors and a proper, and public debate needs to be held.

IMHO this all suggests that treatment needs to be directed to the under 40s, whichever type we talk about to protect our future and our countries future as much as our childrens future.  In the UKs currently self interested mindset, how many will understand that they may be denied vaccine, antiviral drugs, hospitalisation for the sake of our children if this debate has not been held?  Worse still, is if the policy does not consider this forward thinking - we, the citizens of the UK, could reap the consequences for generations to come.

Japan is airing this debate now - individuals versus the future of the nation.  We should, on this one, be taking a leaf out of their book.  For as long as the UK govt and whitehall cling to the belief that 'they have it covered' in terms of Tamiflu stockpiles and stated plans to get 'everyone' vaccinated, these debates are not being had.  Wake up and smell the roses!


Apologies
I do apoloise for my typo's.  Have not been able to find a spellchecker at the new wiki, and my brain works faster than my fingers do!

Health focus: collateral damage
There is another NHS focus point to consider.

We all readily acknowledge that in a pandemic, hospitals will be overwhelmed.  Background health emergencies such as heart attacks, accidents etc will not go away during the pandemic period, but in fact, more probably they will increase under the burden of fear, distress, & grief at the prevailing circumstances. 

However, there is another factor that I have metioned elsewhere before that concerns me very greatly.  The UK has not called on its population to stock up on essential medications.  I believe the reasons are very simple:- The way the NHS is funded is such that each GP is given an annual budget to pay for hospitalisations and referrals, staffing of surgeries, building costs and prescription of medicines.  Some years ago, the data showed that there was considerable wastage of medicines arising from people having adverse reactions or other issues with treatment.  Therefore a policy was introduced that instead of issuing patients with multiple prescriptions, scripts should only cover a single month.  Therefore, without centrally led NHS direction to do so, GP surgeries will not change this, even for essential meds for long term chronic conditions. 

Let us assume that production and supply lines could be maintained during a pandemic wave.  Could the distribution network though? How will GP surgeries cope when they are overwhelmed with sick flu patients? They wont, and they will start to issue longer term scripts.

However, the chances of the pharma sector being able to maintain supplies, uninterrupted, throughout a pandemic are (I belive) highly questionable.

To get round certain regulatory restrictions, Pharma production is a truly globalised business.  Raw materials will be manufactured mostly at a central location/ country(and not necessarily the same one), sent to another country for pressing into tablets or encapsulating or being put into a special delivery system, and then sent for blister packing and boxing, quite probably in the country in which the drug is intended to be sold.  Some drugs have a very long lead time and complex production processes.  Factories make not just one drug, but many - placing production equipment on rotation.  Make more of one, you have to cut back on production of another.  It is JIT manufacture at its finest, with not too much margin for error.  Whilst the global pharmas will have looked at continuity planning, I cannot see that such a stretched system will manage cope and not fall over, which could lead to all manner of drug shortages in the short term, if longer term prescribing ONLY happens in a pandemic.

In ever increasing drives to increase returns to shareholders, safety stock reserves are kept to the minimum possible to maintain uninterrupted supply.  A surge in demand for one drug leads to problems in supply of another.  If people dont get critical meds, they will be surging to the hospitals as the background rate of serious cardiovascular and other events goes through the roof.

Then we have the issues of the generic suppliers. I beleive that a very significant proportion (the vast majority) of UK medicines usage is in fact, generic prescriptions. A very significant proportion of these generics are made overseas (India), and UK manufacturers are often small.  If we suddenly envisage a global pattern of everyone rushing to ther medicines suppliers to stock up, even if we think that at a UK domestic level many of these factors have been taken into account, how will the system cope with this globalised surge? It wont.

If we believe that our UK big pharma production issues have been adequately addressed, how confdident can we be of maintaining generic supplies from overseas? How resilient are thier businesses? 

In this thread we have considered the UK as an island (which of course it is!)and so are national planners everywhere.  For key and critical issues like this, a global co-ordination is required, and quite possibly governments are going to need to fund or support the smaller manufacturers to increase their raw material supply, their safety stock reserves etc etc.  Not all medicines producers are rich, and generics manufacture is highly competitve, with profitability being squeezed from the margins.  There is little financial slack here.

I really hope that someone can tell me this gloabl consideration of these issues are being done.  At least in the US, stocking up on meds forms part of the national call to action for pandemic preparedness. If its not happening, then whoever you are, and wherever you live, stock up on your chronic illness meds now.


Solution to the above problem: UK
Under the heading of finding solutions, rather than simply identifying the problems here is my take on what needs to be done here.

The solution required is fairly obvious - move to get 3 month prescriptions issued asap across the UK for essential and chronic meds. This requires the DH to instruct the NHS and GPs to modify repeat prescribing practices in some disease conditions.

1. Supply.

Give the pharma sector (or most importantly the major UK wholeslaers i.e Unichem, AAH etc) advance notice of which repeat medications are being placed on 3 month scripts so that they can increase thier orders to their pharma suppliers, who in turn can move to increase production in a pre-pandemic period.  They are going to need at least 3 months notice to plan for modifying production rotas or outsourcing to contract manufacturers - remember that to increase production of drug a may result in a lower production of drug b - other meds may be 'bumped' off the production rota.  This needs addressing, and timetabling into production requirements

2. Fianances.

Health budgets are annualised.  Therefore it should be feasible to increase repeat script volumes to 3 monthly repeats ONLY for certain chronic conditions without massively impacting overall financial resources required to increase medicines stocks in patients hands - just some of the money earmearked for this within the NHS will need advancing to PCTs a little bit earlier - it will be a cash flow issue.

3. Stagger introduction in a prioritised manner

If this process is staggered i.e look at conditions a,b,c in month 1, then move to conditions d, e, f etc. the impacts on the supply chain and financial resources can be spread over time.

4. Prioritise medical conditions.

DH planners need to draw up a list of medical conditions where chronic conditions require ongoing prescriptions that without which, there will be increased human morbidity and mortality in a pandemic.  Examples will be asthma meds, heart meds - only the DH has access to the national data that shows what conditions most frequerntly end up in A&E and hospital, which needs to be considered for prioritisation to occur.

5. Profile which patients should be eligible for 3 month scrips, and notify PCTs.

Identify patients from each priority chronic disease area who are

1. On repeat medications
2. Have been settled and established on such medications for 6 months or more (i.e are tolerating/ responding to their treatment regimen)
3. Maintain existing health review protocols to make sure patients continue to respond to their current treatment regimen, as normal.

There will be some very small added medicines wastage, but it will be minimal versus the alternative in a pandemic.  Problems outlined above.


[ Parent ]
time for some political activism? how?
We believe, with details, that even if Professor Lindsey Davies does her best (which she most likely will given the importance of the subject), it won't be enough at all.

We want this to go to the top.  Or to someone who sits by the side, near the top.

Who should we contact and how?

DemFromCT has mentioned a triangle between politicians, mass media and netizens.  Maybe netizens can create awareness in journalists, so that politicians in turn have to pay attention to issues.

Is that the way to go in Europe, and namely in the UK?

What would be some effective ways to do that regarding the UK?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


Since SusanC is right when she targets parents
as the group with the most to lose, then a politician with school age kids might be most receptive.

[ Parent ]
or, their spouse? n/t


[ Parent ]
I was thinking the same ;-) n/t


[ Parent ]
The ministerial committee on influenza pandemic planning are:-
http://www.pm.gov.uk...
page 52 has influenza pandemic as MISC 32

Secretary of state for health (chair) (Rt Hon Patricia Hewitt MP)

Secretary of state for International development (Hilary Benn MP)

Secretary of state for environment, food + rural affairs (David Miliband)

Minister of state, department of trade and industry (Malcolm Wicks)

Minister of state, home office (Tony McNulty)

Minister of state, department of Health (Rosie Winterton)

Minister of state, department of Culture, media + sport (Sue Street)

Minister of state, department of education and skills (Jim Knight)

Minister of state, communities and local government (Phil Woolas)

Minister of state, ministy of defence (Rt Hon Des Browne MP)

Minister of state, department for transport (Dr Stephen Ladyman MP)

Economic Secretary to the treasury (Ivan Lewis MP)

Paliamentary under secretary of state, foreign and commonwealth office (?)

Parliamentary secretary, cabinet  office (Ed Miliband)

Parliamentary under secretary of state, Morthern Ireland Office (Paul Goggins)

Parliamentary under secretary of state, department for work and pensions (Lord Hunt of Kings Heath)

Parliamentary under secretary of state, Scotland office (David Cairns MP)

Parliamentary under secretary of state, Wales office (Nick Ainger MP)

Take your pick.

http://www.pm.gov.uk...

Citizens to take centre stage in Whitehall2 January 2007

Ordinary people will have the chance to directly influence government decisions as part of a major policy review starting this month.

Members of the public will be consulted in a "deliberative forum" that will put them in the shoes of decision makers in government. Cabinet Office Ministers Pat McFadden and Ed Miliband will support them throughout the process.

The February meetings will see 100 delegates study official papers currently under discussion, and then consider the same dilemmas which Ministers face on a daily basis before making their final decisions.


[ Parent ]
who are these 'members of the public'
and how will they be selected?



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
ahhhh, that's the £64000 question n/t


[ Parent ]
1000 petitions, 100 members - does this mean it's done (with 10%)?


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
99 of the members are mps, mps wives and civil servants n/t


[ Parent ]
is that a statement of fact
or are you being rhetorical?

Sorry, can't tell, on a blog!  ;-)



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
just and educated guess ;-) n/t


[ Parent ]
there's a pdf file linked to at the bottom of the page
but i can't understand if it's really related :-?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
It's where I got the names from - see page 52 n/t


[ Parent ]
this job is for newshounds ;)
I seriously wouldn't know how to go about this.  I mean, look for say 5 people in the list and maybe politely contact them?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
I've started collecting details about the key players
Who's married, who's got kids and roughly how old etc, and what sort of people they are. Might take a day or two to complete.

[ Parent ]
i guess we need to get ourselves some real activists ;)


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
need to get ourselves some citizens, then?
From http://www.pm.gov.uk...

The Downing Street "e-petition" service which since its launch in November has seen over 1,000 petitions posted on the site and more than 150,000 signatures

But The February meetings will see 100 delegates study official papers currently under discussion, and then consider the same dilemmas which Ministers face on a daily basis before making their final decisions.  So does this mean the agenda is set already?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
I suspect the pandemic thing is not on the current agenda
but they may choose their 'citizens' from people who have shown an interest. I'm not sure we could get a very large petition going though.

[ Parent ]
yep, the agenda
is TB's survival, right now!



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
don't take that for granted
they could decide they will take their kids out of school at the same time as refusing to close schools....

remember that one?



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
True, but you have to narrow the field of politicians down some how.
And we could point out that the public hate double standards - eg Ruth Kelly and public school for her kid.

[ Parent ]
the discussion should be very basic - assume "sin-less-ness"


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
Media alerts
I would sugest that the best way forward is to see if we can, privately, speak to key UK media.  Alert them to the key points identified in this thread. Give them specific questions to ask about the points that have been raised here and ask them to go to TPTB for answers.

If the questions are specific and factual enough, the media wont accept a 'there, there, we have everything covered' response from official spokespersons, they will want hard factual responses.  Then they may start to cover the issues in the press (assuming that authorisation is not required for BF pieces to be run under the interests of national security) - and if not, the asking of questions behind the scenes by authoratative media just might get them to look more closely for the answers, and start to consider the issues.

Our other option to consider is to approach MPs and perhaps the authors of the house of lords report, and get them to ask the questions in parliamentary debate.  As long as the right questions are asked, the issues will get looked at.  That is the primary achievement we need to be targetting, because if the answers are not good enough, policies will then be made to address the problems - or so I beleive.  The political stakes need to be raised to elevate the importance of the topic and get the Prime Minister/ Cabinet office to lead and coordinate a response. This is the only way I can think of to achieve that outcome.  General awareness is too low for an e-petition, unless it were one of medical and scientific experts, along with crisis planning etc etc.  In a sense though we have already had this when a number of critical expert reports having been published in recent times - and dont appear to ahve changed all that much - so I am less optomistic about such an approach.

Let us hope that the media and news hounds read this thread and start the process by themselves.  There are enough hard facts in there to get them started, and they are intelligent people who are well practiced at what they do.


[ Parent ]
how would they look into this?
Let us hope that the media and news hounds read this thread and start the process by themselves.  There are enough hard facts in there to get them started, and they are intelligent people who are well practiced at what they do.

How would they look into this?

I mean, should we send the link to this thread to their emails, or what?

My guess is we need to know the journalist to know what he/she will be interested in, and then try to open the open-able door.

Speaking only for myself, there are issues I simply don't have energy to respond to.  So maybe it's the same with other people.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
For media
If we look at past UK new reports (there is a good archive of articles here at FW) and see who has authored them, yes - I would just send a link to this thread.  Request them to read it, with contact e-mail addresses to people that they can ask questions of to clarify what we mean in our writings here if needed.  Apart from that we have an editors contact list from the Pandemic awareness week - chnage the message and resend would do it. 

It will only take one good reporter from one of the leading rags to write a good article and stir the debate, for the other majors to follow.

Politicians will be a bit more homework, but they all have email addresses that are freely avaialable.  We could just email everyone in the list above in the ministerial committee, but someone needs to compose the letter.  I will try and find the directory that exists - alternatively its a case of doing a search individual by individual.


[ Parent ]
MSM is over-rated IMO
What you write here, what all of us write here gets a lot of exposure too.  Check this out http://blogs.salon.c...

Halfway down the page:

Experts Debate UK Preparedness for Flu Pandemic: In another appreciation of complexity and the absurd expectation that simplistic plans will cope with complex problems, the regulars of the flu wiki discuss why the UK is unprepared for a flu pandemic, and what would be needed to make it better prepared ....

Plus media bosses have their own agenda making them less versatile than blogs these days.  What's more, wiki's, forums, and blogs are interactive.  Notice how Davos is using Web 2.0 technology as well. 

So any news, opinion, debate, that we can aggregate will attract more.  But we need to make it grow.  We need to write more UK-related diaries. 

One thing, though, online attention span is short.  So it is better to split up complex topics into different but clearly titled diaries,

btw This was how it worked in the US.  How on earth did you think I got invited into US pandemic policymaking, if not partly cos of what I write, and partly cos of our audience access?



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Reasons I didn't want to post on this thread
If the pandemic is anything other than very mild, the simple answer to the question is NO. But I don't know how to go about making any changes. I'm not a part of the system and I can't see a way in.

Unlike America that has had meetings where you can at least prod officials into thinking harder about a pandemic, the UK hasn't done anything interactive.

The press isn't interested and the official pandemic plans still seem at the 'once upon a time' stage (ie fairy stories that have a happy ending).

There aren't enough of us to start a campaign, even if we round up all the Brits on other flubie web sites. We don't add up to much of a pressure group.

We could sent e-mails but they'd have to be very, very persuasive, even assuming they'd be read.

We can identify people who might be influenced and thus make a difference, but I can't see how we can persuade them through remote contact. It's hard enough to persuade loving relatives that you're not bonkers, even when you point out all the facts you can remember and you're looking them in the eye.

I don't want to pour water on our enthusiasm but I'm totally at a loss as to how we generate some interest. And no, I'm not dressing up as Wonder Woman and climbing Big Ben ;-)


Better to try what we can than do nothing at all
It isn't a perfect approach, but it is, frankly all that PR companies do except that they start and follow up with phonecalls, and then see journalists for a face to face briefing.

All we need (which we have mostly already) is to write up a single page press release, supported by a Q&A which can be sent.  Cold, hard and factual, and referenced well.  Ideally with a quote or two from someone authoratative (and include a one para appendix about who they are.  Then we have to hope it is taken up. The catch for us all is time - but surely it should be possilbe for us to each take one single reporter from each of the main broadsheets and do the whole a-Z with them.  Divide and conquor!

Thyen we know we have done all that we can, and we wait and hope.


[ Parent ]
and I agree with you in principle
But we need to make sure we make the best use of our efforts.

I certainly think we need to time any activity with some event that gives us a boost - eg Winter Willow (phase 1 or 2) or an upswing in tv interest due to deaths.

Alternatively the contact needs to be more personal - MP surgery for example or a chat with an area branch of UK Resilliance.


[ Parent ]
parents
What are the Parents' Associations?

Just conduct a survey with a simple question: What if "number" of people were to die - would you take children out of school?  If many yeses, then publish - resend.

Dunno.  I really looks like we have no muscle.  Who could we contact that does?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
We need a champion on the inside of the system
I would strongly advocate trying to link into the main media - 4 journalists or so and to find a political champion.  Someone who shares our concerns.  They can only share these if they are aware of the issues however.

Therefore who fits a profile of

1. Science or medical background or training
2.  Has a family with children somewhere between 0 - 30 (might have grandchildren)
3. Has an existing level of understanding of current pandemic plans and may sit/ have sat on some aspect of a special commitee.
4. Someone who is not afraid to speak out and to ask questions.

Anyone fit the bill?


[ Parent ]
maybe Mark Henderson?
http://www.timesonli...

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
As good a person as any to start with


[ Parent ]
We can do it right here IMHO
I'm not a part of the system and I can't see a way in.

I'm not even a US citizen but I'm being invited to their Pandemic Vaccine Prioritization National Stakeholder Meeting next week, for example.  It's become an ongoing process, not a one-off event that I thought my initial presentation at the National Academies of Sciences might be.  How do you think that happens? 

I can think of several elements:

  1. Commitment - aka Working hard.  IMO there is no escaping that. 

  2. Building credibility and accountability. That was the major reason why I went public.  If we want tptb to take us seriously, if we want to work with professionals, we need the same standards of integrity and accountability.  It doesn't mean everyone has to do what I do, but it does mean checking facts before posting, softening the most speculative of your thoughts, admitting you are wrong when you are, and so on.

  3. Be a resource, not a burden.  Aim at finding solutions, not blame.  Remember that this is uncharted territory for everyone.  If you found it challenging to think about this stuff, it is the same for whoever sits in the policy chair as well, multiplied many times over.

  4. Having a sizeable constituency. aka building a substantial UK community here.  How does one do that?  In this context, probably by providing as many resources for anyone who lives and works in the UK as possible.  This is related to #2 as well.  Why should people come and read your rants unless there is meat on the bone everytime they come?  Being inclusive, accepting  and respecting that people can choose to respond in different ways to a pandemic, is also important.

  5. tptb reaching a point in the policy process when realize they can't do it alone.  which in my estimate is just about beginning.  ;-)

     



    All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Finding solutions
Susan C - All points above heartily agreed.  Identifying the problems rarely produces results in any walk of life, what is needed are proposed solutions to each of these problems.

Whilst we cannot have a full picture on everything that is going on behind the scenes, perhaps now we are getting at the weaknesses of UK planning, we could start a thread where solutions are proposed - what could/ should be done.

Perhaps we could summarise

1. Problem identification - ongoing in this thread

2. Propose solution options

3. Consider the advantages vs. disadvantages of each option considering factors in a wholistic manner i.e. human impacts, economic impacts, practability (i.e is it doable? what resources would be needed to achieve such an outcome? Are they available?)

We may not cover every aspect of each option, but if we debate things in this manner we can perhaps be more of a resource for TPTB - do some of their thinking for them, or at least 'plant some seeds' of ideas that may grow?


[ Parent ]
we also need to look at strengths
Just as an example, I recall reading a paper (or a set of papers) about a group of citizens being guided to "lose weight together".  Apparently, just one health-care person was enough to dinamize a group of 20-40 people who then proceeded to help each other with meals, walks and conversation ... and sensible goals too.  [Sounds like Flu Wiki to me ;)]  [I want to find the link to that.]

The point being that there is already a social network that works in "normal times".  There are GP associations, neighbourhood associations, and so on.  Those would be the sensible venues for community preparedness.

Survivors look at their strengths, too.

So we could really have a sub-portal much like the Caribean.  We need help on that.  [Oh, no, one more thing to start and leave unfinished! ;(]

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
we need to look at the Caribean - there's a subportal in the making
It's right in the "subjects" box (on your left column):  http://newfluwiki2.c...

So we could both have several diaries and a common "entry point".  I don't know if it can get better than that.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
some links
- http://www.ukresilie... ... further links to school closure impact!
- http://www.ft.com/cm...  Clive Cookson
- http://www.continuit...

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

Simulation findings back points made earlier
Well, the good news is that at least some aspects of what has been highlighted above ARE being looked at.

The attached news report is well worth reading in full, and highlights the pint about drug supply I was trying to make albeit, limited to vaccine issues and tamiflu production.  However, the findings in relation to these drugs can be magnified to include ALL drugs.

At least movement may begin now.

Is Britain prepared for the Big One? (No)
Last Updated: 12:01am GMT 09/01/2007

'War games' have exposed serious flaws in government plans for fighting a deadly influenza pandemic, reports Roger Highfield

Snip

However, a report now circulating among ministers underlines how the UK's supply of drugs and vaccines is dependent on an all too fragile international supply chain.

That was the conclusion of participants in a "war game" in which national preparations were put to the test by civil servants, the pharmaceutical industry, emergency planners and regulatory agencies.

One participant commented: "There is a myth about the UK being self-sufficient in its supply chain so we can somehow manufacture things here, close off our borders and all will be fine. This is absolutely not the case."
snip

They tested how Britain would cope with a "moderately severe" scenario for a theoretical pandemic of "Sumatra Flu" beginning in December 2006 The scenario envisaged 21 million UK cases in two waves of outbreaks and a death rate of up to 2.5 per cent. (My comment - and this is the finding with a CFR THIS low)

By the time almost 20 million of the UK's population had developed full symptoms, there had been 485,000 deaths. "The economy was now depressed with an expected loss of £41 billion," added the report.

snip

Although coping with the surge in demand would be very difficult, the good news is that Britain has a large capacity to make flu vaccines using eggs, the tried and tested (and very old-fashioned) method. But in the simulation the BPI quickly realised that the country lacks a supplier of disease-free, fertilised eggs, which have to be imported from America.

If the Americans were faced with demands at home, self-preservation would take over, even when it came to an ally like Britain.

"It would be critical therefore to allow the supply chain to function effectively during a pandemic to ensure egg-based vaccines could be manufactured," said the report.

"The Government may need to consider financial support for creating production capacity for those vaccines most likely to be rapidly produced during a crisis." Speeding the scale-up of new ways to make vaccines - for instance, using cells - is also critical.

snip

The first line of defence will be the antiviral drug Tamiflu. Here again, the UK is dependent on an international supply chain because the key ingredient is shikimic acid, derived from an exotic spice harvested from native trees in China. Once again, the pandemic would disrupt the Tamiflu supply chain.

Current government policy is to use antivirals for treatment only and not for prophylaxis, but the war game found that GPs and pharmacists were worried that "key health workers need to feel protected, otherwise there will be increased absenteeism".

As well as seeing health workers flee their posts, the simulation assumed that 30 per cent of the workforce within the supply chain would be incapacitated through illness.

Unsurprisingly, the report calls for more joined-up thinking. Inconsistencies in pandemic flu planning between national and local health organisations could undermine public confidence, and the simulation revealed disagreements over whether to distribute Tamiflu through "flu centres" as opposed to pharmacies.

Pharmaceutical wholesaler representatives also admitted there had been few discussions with the Government about how to get antivirals to where they would be needed. The report suggests supermarkets, post offices, and couriers should distribute the drugs.  (My comment - which measn there have been few discussions about any other essential meds in the supply chain)

snip

The bottom line is that industry and bureaucrats need to work more closely together, said Dr Samuels, "not just on flu medicines but also ensure the supply of essential non-flu medicines during a pandemic."

Roger Highfield is a member of the BFF

http://www.telegraph... 


corrected link to above
Sorry.  Hopefully this works better http://www.tiny.cc/a...



Global phama planning
Having examined the Global Pharmaceutical planning assumptions for business continuity over at FT (Hat tip), most are reasonable and of note in terms of this discussion, as I wonder how many of these were derived from the above exercise. 

The points of note are that it is unclear to what extent the generic manufacturers and importers were represented in the above exercise.  Given that the focus was vaccines and tamiflu, the probable answer is not at all.  Therefore, whatever conclusions were reached here for these drugs will not be mirrored for a wide range of other drugs that are accounted for by generic suply.  The picture for these medications is liable to be far worse, and within the planning assumptions there is no consideration of the impacts of global surge demand caused by a pandemic.  This is very concerning.

For full Global Pharmaceutical Industry BC guidelines tiny.cc/3gVVa

Planning Assumptions used in this document: (remember that any plan is only as good and as accurate as the assumptions upon which the plan is based!)

Current estimates of the impact of an influenza pandemic vary. Reasonable planning assumptions include:

If avian influenza adapts fully to humans, the disease will spread worldwide in a few weeks

The pandemic will circle the globe in 2-3 waves, recurring after 4-6 months (This recovery period is questionable - no one knows and with international travel may be far less)

25% of the population will become ill in the first wave, decreasing in subsequent waves

Creating a peak absentee rate between 30-50% (about 20% are ill at the same time, and the remainder are absent due to care giving and other personal reasons)

A fatality rate of 3-5% of those who are ill, resulting in about 1% mortality across the entire population (seems extremely low given current circumstances - It would be far better if planning seperately considered a scenario with an overall mortality of at least 10% given the present situation with H5N1)

Most commercial flights will be grounded during the first wave

Although restricting cross-border travel (car, train, bus, air) for a period may not be particularly effective at preventing the spread of a pandemic virus it should be
assumed for planning purposes that restrictions will be introduced

Cargo transport will be restricted to land and sea, except for critical supplies (e.g. vaccines)

Cargo transport of certain goods (e.g. food) will be restricted or forbidden (The Pharma industry will have gained these assumptions after wide consultation with the major powers that be. This assumption therefore has massive implications on UK food security - please see posts above)

Given the highly infectious nature of pandemic viruses, existing healthcare systems and infrastructure will be overwhelmed

Vaccines against the exact pandemic strain will not be available until 4 - 6 months after the first wave arrives (My comments: but this assumption makes no allowance for how long it will take to manufacture vaccine once it has been developed, and assumes the UK can get hold of adequate egg supply! This assumption should read at least one year for the population at large, and even then vaccine will only be likely to be available in limited quantities)

In the next 1 - 2 years, most governments will not have sufficient stockpiles of antiviral agents to treat those infected.

In light of this added information, the point about an urgent requirement of 3 month script issuing in the UK as soon as possible from NOW is underlined further.


Take part in Patricia Hewitt webchat - on the No10 website
http://www.gnn.gov.u...

Next week you'll have the chance to quiz the Health Secretary about the future of the UK's public services.

The webchat is the first in a series addressing the big issues included in the Government's Policy Review.

It will take place on Thursday February 8, from 1045 GMT , and last for about an hour. High-quality public services are crucial for the strength and health of this country. They provide the platform on which we achieve our ambitions for our families, communities and society.

Over the last decade, major investment in public services has been coupled with far-reaching reform to build public services around the needs of the patient, the pupil and the citizen. The result has been greatly improved, more responsive and accessible services for the public through an increased variety of providers and greater responsibility at local levels.

But just as the expectations of the public rightly continue to grow, so our public services must continue to improve. No one believes that the level of service and choice that was acceptable, for example, in the days of food rationing 60 years ago is sufficient at a time of 24-hour opening and almost infinite variety in the shops.

http://www.pm.gov.uk

http://www.pm.gov.uk...

What would be the best questions to ask? I'd be interested why they seem to have no intention to involve the public in any pandemic plans and where the planned hygiene campaign went to.


reminder for interested UK peeps
Take part in Patricia Hewitt webchat - on the No10 website
Thursday February 8, from 1045 GMT

See parent post for details


[ Parent ]
Recent events in the UK illustrate the lack of cohesion in plans
I think that it is now fair to say that recent announcements by both the FSA and DEFRA illustrate how the lack of leadership from the top has produced disjointed plans and management of the H5N1 threat, and ultimately, the pandemic threat.

A failure to grasp just how tenacious this virus is, and infectious - even in its current avian form has led to a series of blunders that have quite possibly led to the UK infection in the first place.  No-one at present is asking why DEFRA have not been carrying out site visits to inspect bio-security measures and examine the routes of passage of commercial poultry at such large industrial plants, to make sure that practices are sage and secure.  Even given this, the lack of thought with regard to giving import licences to a country with confirmed infection underlines that the degree of the hazard is either not properly understood, or that commercial considerations are paramount.

This has then been followed by a stream of inaccurate, potentially risky information from the FSA once it was thought that infected meat may have entered the food chain.  The FSA initially claimed that there was no risk from consuming infected meat, whithout majoring on the potential risks of preparing infected meat and the need for increased hygeine measures.  A processing plant on site has been permitted to send processed cooked meat back to Hungary - given the high temperatures used in such processing, remaining infection is unlikely.  However, what additional biosecurity measures have been used to ensure that transport vehicles are not contaminated? If the infetion has passed into wildlife this is not only necessary, but could in fact be a cause of transporting virus elsewhere within the UK on tyres and similar.

If this sort of behaviour and misinformation is representative of the situation in the UK, and if it also extends to other areas of planning, we are in trouble indeed.  The only positive gain from this experience is that the UK govt and its lack of control and thought in these areas is steadily being exposed.  This may lead to greater political will from the top to address the problems, and a greater willingness by the media to both investigate the facts and report on them, which in turn may help to ensure that UK pandemic plans and preparation advice is brought into line with that of the US.

Let us hope. 


hope is not a plan, a plan is not preparedness ;-(


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
FSA Treasury continuity exercise report
A report on business continuity planning was posted over at FT which provides an interesting insight into the minds of UK planners.

For the full report visit

http://www.workplace...

However, some excerpts of note:

...In late 2006 the UK Financial Services Authority (that FSA as opposed to the Food Standards Agency) ran a 6 week exercise based on a Pandemic hitting the UK. It concentrated just on the first wave and in exercise simulated time lasted 22 sequential weeks. The findings just published, revealed comparatively good resistance, but weak points in areas such as Crisis management and HR. If you are interested here in very brief form, is how the exercise rolled out (based on Health Protection Authority (HPA) predictions):

Exercise Week 1 - WHO declare phase 4. First confirmed cases in Thailand.
Exercise Week 2 - First cases in UK about 3-6 weeks after Thailand. Massive demands by now on Internet Banking. Many flights cancelled and schools closed etc.
Exercise Week 3 - WHO phase 6 reached 10 weeks after simulated start. Flu now widespread in UK. Panic buying etc. ATMs run out. Hospitals overwhelmed. Massive financial crime waves. Home working proves not to work. Large scale gatherings stopped. Bad weather makes things worse. 36% absenteeism.
Exercise Week 4 - Flu peaks in UK 50% absenteeism. Now 18 weeks into simulated time.
Exercise Week 5 - Peak continues. Does not worsen. 19 weeks into simulated time.
Exercise Week 6 - Week 22 reached. Things just start to improve. Recovery starts.

snip

...There is some guidance from public health officials that indicates it is desirable for all organisations to perhaps consider the implications for their operations of an epidemic or pandemic that might develop in several "waves" over several months. The patterns of prior serious influenza outbreaks suggest that, if an "avian flu" outbreak does occur, each wave might persist over a period of six to eight weeks.

Historic patterns also suggest that, over the course of such an outbreak, staff absences due to illness might be in a range of 20% to 50% (although absenteeism due to illness on any given day would be less - perhaps in a 15% to 25% range).

If staff absences due to the need to care for ill family members and from fear of contagion are taken into consideration, however, the absenteeism rate might increase significantly - with some estimates anticipating a 60%+ level.

Public health officials also cannot reliably estimate the amount of warning that organisations might have that an easily communicable strain of "avian flu" had developed before a serious outbreak directly affects the organisations' operations.

While some scenarios suppose that an outbreak would occur first `overseas' (quoting from a US report) in a manner that provides organisations with several weeks' warning before it spreads to U.S. operations, it is quite possible that the actual warning period for an outbreak could be very brief indeed. Consider:
A serious "avian flu" outbreak could erupt in waves over weeks or even months, with some waves appearing to be mild only to be followed by others that are much more severe. Even after a particular wave appears to subside, follow-up waves could develop after safeguards are relaxed. As a result, Business Continuity (BC) plans that address discrete events that might affect organisations for limited time periods may prove inadequate for the longer-term impact of an "avian flu" outbreak.

During an "avian flu" outbreak, organisations may have to deal with unprecedented absenteeism for weeks at a time, from illness, family demands or fear of contagion. Personnel absences may become so widespread that existing succession plans may prove inadequate to have sufficient personnel available to maintain even critical operations.
An "avian flu" outbreak is likely to simultaneously affect multiple regions of the country and the globe. As a result, the backup facilities that have been established by many organisations - even remote sites hundreds of miles distant from primary facilities - may be just as affected by the outbreak as the primary locations they are intended to back up.

Disruptions could spread to other key infrastructures, such as power, transportation, telecommunications, water systems, police, fire, NHS including emergency medical services. Moreover, basic retail services might also be disrupted. In effect, parts of the UK Critical National Infrastructure (CNI) could be jeopardised.

These types of problems might make it very difficult for employees to function effectively at work. Further, since corporate business continuity strategies often rely heavily on the availability of public sector emergency service providers, disruptions in these services from high absenteeism could present significant challenges to corporate plans.....

It is clear from these excerpts that the full scale of disruption that is anticipated or deemed possible IS understood.

It is also clear from the further writings in this article that considerations of continuity ARE limited to larger and global organisations.

What is also clear is that little or not thought is being given to the effect on SMEs and the subsequent effects on the approximately 12 million persons employed in the UK by SMEs and their families who may depend on their income from such organisations.  Whilst it is recognised that essential services may be vulnerable, there seems to be little thought on the impacts of such failures on day to day life, and much less how society at large would withstand such an event over a protracted period.

Further, it would appear that Level 4 status is the trigger for any action by government and corporations, and by the above statements, it is indicated that there will be 10 weeks between declaration of this level and a full blown pandemic.  This is inadequate time to prepare, and it is also recognised that the transition between level 4 - 6 may occur in a much shorter timeframe.

As per my previous posts, aside and apart from medical considerations, this aspect of planning and preparation is the most vulnerable area for the UK, in my opinion.  Given that these factors DO appear to be recognised I find it incomprehensible that no action is being taken by governments and the media to encourage society at large to consider and prepare for such an eventuality.  If there is anyone who reads this who is privvy to the rationale for why individuals and SMEs are not being asked to plan for these eventualities, please would they share the logic?  If the UK govt considers that in the eventuality that there are disruptions to power, water and food supply that they have adequate plans in place to address these problems, please could they share the detail of the national plans of these?  If individual corporations working in the areas of power, water and food suply are required to be responsible for this area of planning, please can government oblige these organisations to publish their national plans, and those of any organisation that is taking a lead to ensure national coordination of the relevant sector plans?  This will allow scrutiny of the resilience of these plans by individuals and business organsiations, who will then be in a far better position to assess the impacts on their business continuity.

In the absence of such public scrutiny, the only assumption and conclusion can be that no national plans exist. 

If this is the case, then I hope that the winter willow exercise (or these posts) have highlighted these issues and that measures are taken to start to address these problems quickly. soon. 


NHS
As someone who is dependent on Thyroxine I went to my G.P. yesterday and suggested he write a prescription for three months instead of 28 days.

He cannot do it as the practice gets so much hassle from the officials.

"But it is essentisl!"  "It is so necessary to my health that I get free prescriptions!"  "Surely there must be a list of exemptions for severe and incurable conditions?"

NO! I came away with 28 days supply.  How can I SIP for 12 weeks?

Unless I apply for the prescription a week or so early each time?

Plan to go on a long holiday so need an earlier prescription?

Order stuff off the internet? Risk fake medicine!

I do not fancy doing what people in the early 20h century did which was to eat the raw minced thyroid gland! Yew!

This situation will affect anyone who needs oxygen, asthma inhalers, heart medicine, insulin etc. etc.


[ Parent ]
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