Pandemic Flu: A Scottish framework for responding to an influenza pandemic

10 MAINTAINING BUSINESS CONTINUITY - THE SCOTLAND WIDE RESPONSE

10.1 Aims

Contingency planning for a range of disruptive risks is a key business activity. Maintaining adequate staffing levels is also critical to every organisation's ability to maintain its essential functions. A major infectious disease outbreak such as an influenza pandemic will place considerable pressure on all organisations and most individuals. Although business continuity plans made for other disruptive challenges provide a solid base, contingency arrangements for an influenza pandemic need to recognise the unique nature of some of its characteristics, particularly its likely duration and the fact that higher levels of absence are likely to be a major factor.

During a pandemic, the Scottish Government's overall aim will be to encourage those who are well to carry on as normal for as long as possible, whilst taking basic precautions to protect themselves from infection and to lessen the risk of spreading influenza to others. However, absence is likely to be significantly higher than normal across all sectors, especially if the virus affects those of working age more than other groups. Uncertainty surrounding the actual impact of the pandemic virus will continue until it emerges, so plans to mitigate the effects of absence need to be capable of coping with a range of potential levels.

10.1.1 Factors leading to possibly high levels of staff absence

Over the course of a pandemic, staff are likely to be absent from work for a combination of reasons including personal illness, the need to look after family members who are ill, bereavement, fear of infection, the impact of public health measures such as school closures and other factors such as possible transport difficulties. Levels of absence may vary due to the size and nature of a workplace, the kind of activity that takes place there and the composition of the workforce.

As part of its role of co-ordinating the preparations for a possible influenza pandemic, the Police and Community Safety Directorate has issued advice to assist business continuity planning comprising:

' Guidance on contingency planning for a possible influenza pandemic' www.scotland.gov.uk/Resource/Doc/924/0040587.pdf

' Introductory advice to staff on planning for pandemic influenza' www.scotland.gov.uk/Resource/Doc/1094/0041751.pdf

10.2 Key assumptions

The following key assumptions, which are based on a uniform attack rate across all age groups, should assist in impact assessments and developing contingency plans. As the attack rate may not be uniform across all age groups, plans need to retain flexibility to adapt as information emerges.

• Up to 50% of the workforce may require time off at some stage over the entire period of the pandemic with individuals absent for a period of seven to ten working days. Absence should follow the pandemic profile with an expectation that it will build to a peak lasting for 2-3 weeks when between 15% and 20% of staff may be absent and then decline.
• Additional staff absences are likely to result from other illnesses, taking time off to provide care for dependents, family bereavement, other psychosocial impacts, fear of infection and/or practical difficulties in getting to work.
• The Scottish Government may advise schools, nurseries and childcare settings in an area to close in order to reduce the spread of infection among children. Any such advice would probably be to close for a few - probably 2-3 - weeks, but closures may be extended if the pandemic remains in the area.
• Modelling suggests that small organisational units (5 to 15 staff) or small teams within larger organisational units are likely to suffer higher percentages of absence - up to 30-35% over a 2-3 week peak period.

10.3 Dealing with staff absences

Each organisation needs to estimate the level of staff absence and its potential impact on its own activities in the period leading up to and during an influenza pandemic. The actual impact will depend to some extent on the composition of the workforce, the environments in which people work and the extents to which the absence of even small numbers of highly specialist staff might constitute a material risk. In order to derive estimates for the total numbers likely to be absent, employers should consider the demographics of their work teams, including the percentage who have childcare or other family care responsibilities, normal absence levels and options for home or remote working.

10.3.1 Protection in an occupational setting

In a pandemic setting, employers still have a duty to provide a safe place of work for their workers and are required to maintain safe working systems and implement protective measures based on local risk assessments. The risk assessment should consider whether the employee's work activity increases the risk of exposure beyond that of community acquired exposure and what proportionate control containment and protection measures, may be available. Most of the general principles for infection control in hospitals and other settings (see section 9.4) can be equally effective if applied in the general workplace.

Consultation and jointly conducted risk assessments by employers and staff and their trades unions or representatives, combined with documented procedures during the planning phase can help ensure that employees are well educated and informed. Joint risk assessments can also assist in identifying and exploring any subjective perceptions of risk, the opportunities for more flexible working arrangements and training requirements to help cover staff absences. Identifying those staff with co-morbid conditions or other factors that may put them at higher risk may also allow proportionate individual precautions.

Making temporary changes to working practices, e.g. to reduce close face-to-face contact, providing physical barriers to transmission, enhancing cleaning regimes, ensuring that the necessary protective equipment is available, having hand washing, waste disposal and other hygiene facilities in place and actively promoting these and other similar measures, can help encourage and maintain attendance at work during the response phase.

Any employee who reports feeling unwell with influenza-like symptoms should be positively encouraged to stay at home until their symptoms resolve. Staff who develop influenza-like illness at work should be sent home. Non-punitive personnel policies and reassurances should emphasise and support those aims. Follow-up contact with absent employees, the provision of occupational health advice and other similar measures indicated in the Health and Safety Executive's existing guidance can help minimise other absences and encourage return to work as soon as possible. Making best use of recovered staff should also be an important aspect of planning.

Further guidance for employers is available on the HSE website www.hse.gov.uk/biosafety/diseases/influenza.pdf

10.4 Dealing with a large number of deaths

The projected scale of excess deaths during a pandemic in Scotland could range from 5,100 to the reasonable worst case of 63,700. Local services are likely to be severely challenged, particularly at the upper end of the scale. Clearly business continuity will be the front line response. Similarly in terms of handling fatalities, the main emphasis of the local response will be to minimise the potential for delays to funerals, burials and cremations. At the same time planning must: recognise the need to handle the dead with dignity and respect; take account of differing faith, religious and cultural backgrounds; and, minimise distress to families.

Should the scale of deaths be at the upper end of the planning assumptions, local services will need to work differently. Business continuity planning should consider critical posts and the need for staff to work flexibly. As a consequence staff training will also be a critical consideration for Local Authorities and businesses.

Regardless of how well developed and robust local planning and preparations are these are unlikely to be successful during a pandemic without the active support of individuals, families and communities. Local Authorities will want to reassure their communities that every reasonable preparation has been made for high volumes of additional deaths and to consider how to manage the potential demands for advice, support and other needs before, during and after a pandemic.

During the early stages, local services will probably not know the precise scale of deaths in their area - although projections may become available - so plans need to be flexible and adaptable. Local service providers should aim to maintain current processes for as long as that is possible, but as numbers of additional deaths increase, those may soon become unsustainable. When that becomes the case, local services are likely to need to work differently and ways in which deaths are certified and funerals, burials and cremations arranged are likely to change.

Due to the possibility of fatality rates being too high for current systems to cope with, the Strategic Co-ordinating Groups ( SCGs) in Scotland have been asked to take on the responsibility for producing local multi-agency plans and response options for managing excess deaths. This should be done in conjunction with the police, procurator fiscal, registrar, funeral industry, Local Authorities, NHS Boards, community/faith leaders and family support groups. Planning by the SCGs should consider arrangements for additional mortuary capacity, internment arrangements and give due consideration to diverse faith, religious and ethnic requirements. The Police and Community Safety Directorate has prepared a report on options for additional storage for the SCGs. " Probable Pandemic Influenza Deaths in Scotland" will be distributed to SCGs to aid planning for their area and assist in selection of suitable temporary body storage facilities.

The Police and Community Safety Directorate has commissioned an audit of mortuary capacity which looks at options to provide additional storage within Scottish NHS hospital mortuaries in the event of mass fatalities occurring during a pandemic influenza outbreak. The additional storage will be secure, hygienic and respectful.

10.4.1 The death certification process

The death registration process involves completion by a medical practitioner of a Medical Cause of Death Certificate (Form 11). The forms are prescribed and issued by the General Register Office of Scotland ( GROS) to registrars, hospitals, GPs etc. As part of pre-planning for a pandemic, GROS has increased stocks of Form 11 in proportion to its estimate of the likely additional deaths in Scotland.

The informant is required to attend a registration office within 8 days of the date of death to register the death. If necessary, as part of the GROS response to a pandemic, the Registrar General could grant a blanket extension to that deadline. Following registration of the death, the local registrar issues to the informant a certificate (Form 14) to confirm that the death has been registered. This enables the disposal of the body. While a burial may take place before registration of the death, the body may not be cremated before death registration and issue of the Form 14. GROS has prepared additional stocks of Forms 14.

A registrar is expected to report any sudden, suspicious, accidental, unexpected or unexplained death to the local Procurator Fiscal. In particular, the Procurator Fiscal will want to know from the registrar of any death where the circumstances or evidence suggest that the death may fall into one or more of the following categories:

• any death due to violent, suspicious or unexplained cause
• any death related to occupation, for example industrial disease or poisoning
• any death involving fault or neglect on the part of another
• any death as a result of abortion or attempted abortion
• possible or suspected suicide
• any death as a result of medical mishap, and any death where a complaint is received which suggests that medical treatment or the absence of treatment may have contributed to the death
• any death resulting from an accident
• any death arising out of the use of a vehicle including an aircraft, ship or train
• any death by drowning
• any death due to poisoning or suspected poisoning, including by prescription or non-prescription drugs, other substances, gas or solvent fumes
• any death by burning or scalding, or as a result of a fire or explosion
• any death due to a notifiable infectious disease, or food poisoning
• certain deaths of children - any death of a newborn child whose body is found, any sudden death in infancy, any death due to suffocation including overlaying, any death of a foster child
• any death in legal custody
• any death of a person of residence unknown, who died other than in a house
• any death at work, whether or not as a result of an accident
• any death where a doctor has been unable to certify a cause.

There is a risk of delays in the management of fatalities if registrars were to refer to the Procurator Fiscal every death due to pandemic influenza. Accordingly, the Crown Office Procurator Fiscal Service, in discussion with the medical profession, is setting in place a system to "fast-track" the completion by doctors of the Medical Cause of Death Certificate (Form 11) to indicate where the cause of death is pandemic influenza or presumed pandemic influenza. A guidance letter has been issued to all Practitioners, about the certification of pandemic influenza, which gives examples of situations, and outlines all circumstances that can be legitimately considered for certification. This will encourage and give confidence to practitioners to certify appropriately. GROS will subsequently instruct registrars to accept the cause of death as pandemic influenza or presumed pandemic influenza without reference back to their local Procurator Fiscal. This combination should reduce delays in the registration of deaths and the disposal of remains.

10.5 Business continuity/maintenance of UK's essential services

The Government has recommended that the UK's essential services, including essential public services provided by local government and other sectors, should build on and review their generic business continuity arrangements to reflect the potentially large number of staff who might be absent during a pandemic and other key interdependencies. The overall aim is to maintain business as usual as far as practicable and at the very least to maintain core services and businesses activities for several weeks, particularly around the peak of the pandemic when staff absences are likely to be at their highest.

10.5.1 Communications

At the onset of a pandemic, the telecommunications industry would expect to be able to provide a near-normal service. However, like other sectors, the degree to which services may be affected will depend on a number of factors including the nature of the crisis, the number of workers who contract the virus and the resulting level of absence. Above-normal absence rates during a pandemic are likely to result in a gradual increase in the time taken for telecommunications providers to deal with customer requests and in carrying out routine maintenance.

The telecommunications industry would respond to a crisis by seeking to limit the impact on services by prioritising fault repairs at the expense of routine maintenance and the provision of new services. New services provided during such a crisis would generally be restricted to urgent requests from emergency responders recognised as Category 1 and Category 2 responders under the Civil Contingencies Act 2004.

While the telecommunications networks have the capacity to support a significant increase in home working, the reconfiguration of the networks to enable them to handle significant short-term changes in the location and pattern of access cannot be achieved overnight. It is vital that organisations talk to their telecommunications providers about the contingency of additional home working. Organisations planning a move to home working will also need to ensure that they have the necessary hardware and software in place and appropriate arrangements to ensure support, oversight and audit of home-workers.

There may be some disruption to postal services due to peak staff absences, although a wide range of postal operators should ensure that the market maintains priority delivery services. Any reduction to Royal Mail's services would be overseen in accordance with a list of Corporate Priorities agreed with the Regulator, focussing on those services involving high social responsibility (access to cash/benefits). Deliveries and collections would be maintained as far as possible with managed degradation.

10.5.2 Energy sector

The energy sector is planning to maintain supplies of gas and electricity at near normal service levels during a pandemic. Whilst routine maintenance is likely to be afforded lower priority if there are staffing shortfalls, essential repairs will continue to be carried out. Similarly, planning by fuel suppliers is aimed at maintaining near normal levels. In both there may be some service disruption if peak staff absences coincide with technical or weather-related supply difficulties leading to potentially longer periods of service loss than would be normally expected or possibly related to disruption to imports from main overseas suppliers.

The Scottish Government regularly meets the sector to discuss its preparations, exercise regime and any specific issues which have arisen. In November 2006, it arranged a sector workshop which involved both upstream and downstream companies and organisations to further improve understanding on the subject. A further workshop in September 2007 looked at the relationship with other utilities such as water and telecoms to better understand interdependency between all involved.

10.5.3 Financial sector

Pandemic planning in this sector is being led and coordinated by the Tripartite Authorities ( HM Treasury, the Financial Services Authority and the Bank of England) who share responsibility for maintaining financial stability in the UK. Planning - involving financial firms, infrastructure providers and overseas financial regulators - is advanced and has primarily focused on business continuity (i.e. maintaining core business activities while experiencing above-normal absence levels) and provision of basic services, such as cash circulation, banking and payments systems.

In Scotland, the sector has created a group which regularly meets to discuss developments and progress. Towards the end of 2006, the Tripartite Authorities completed a 6 week UK sector-wide exercise which tested arrangements.

10.5.4 Food sector

Major food retailers are factoring pandemic influenza assumptions into their business continuity plans and testing and exercising arrangements. Joint planning for mutual assistance covers such aspects as staff pooling, mutual assistance to keep at least one store open in each area and the possibility of sharing transport resources. Overall the sector is working towards maintaining near-normal food retailing, although there may be some reduction in the choice of foods or short-term localised disruptions or closures of individual outlets due to staff availability.

The Scottish Government hosts a stakeholder group which regularly meets with the sector to discuss its preparations and any specific issues which have arisen.

10.5.5 Transport sector

Public Transport operators aim to run as near normal services for as long as, and as far as, that is possible during a pandemic and their plans provide for emergency timetables, redeploying staff and operating revised working (shift) patterns if required. Although the Government is not planning to impose closure of transport hubs/facilities in the UK, all sectors may experience operational difficulties when the pandemic virus is circulating and staff absence levels are significantly higher than normal. The aviation sector may also experience difficulty if non UK airports or airlines have operational problems or stop operating.

10.5.6 Water sector

Scottish Water has identified the minimum staffing levels required to maintain essential water supply and sewerage operations and has factored in potential staff absences in a pandemic influenza scenario. As many key operations are automated, Scottish Water is confident that it will have sufficient staff to sustain these essential operations during an influenza pandemic. All UK water companies have generic contingency plans for continuity of essential water supplies and have worked with suppliers and contractors to check preparedness arrangements, particularly in critical areas such as chemical supplies for water treatment.

10.5.7 Emergency services

Business continuity planning is well developed in emergency services across Scotland and multi-agency exercises have been conducted to test arrangements. Their general aim will be to maintain emergency provision at near normal levels and to support the wider response to a pandemic, although there are likely to be constraints caused by loss of key or retained staff. Some routine and non emergency functions could be affected by the need to redeploy and higher staff absence levels.

10.5.8 Judicial process

The agencies involved in the criminal justice system (Police, Crown Office and Procurator Fiscal Service, Scottish Courts Service, Judiciary, Scottish Prisons service) are working together through the Criminal Justice Liaison Group to develop plans for action during an influenza pandemic. The overall aim is to minimise disruption to each element of the process although high levels of staff absences may lead to difficulties in maintaining normal activity.

10.5.9 Scottish prisons

Prisoners in Scotland number over 7,000 at any one time, and 22,000 individuals over each year. They have high background levels of poor health, as do the families and communities from which they come. Many are held in overcrowded conditions. The net effects of these factors mean higher likely levels of infectivity - up to 90% attack rate over a pandemic; higher levels of complicating illness, stress and bereavement. Staff are the most important resource and the level of service within prison will be dependent on staff absence.

The Prison Service, in association with Justice Service partners, will take 3 key steps:

• manage overcrowding and improve infection control
• continue to provide a public service in safety and health terms
• maintain a health service to prisoners.

Specific measures include:

• aiming to create single occupancy cell accommodation for as much of the prison estate as possible
• maintaining strategic stocks of vital supplies
• securing vital services such as food, medicines and supplies, and utilities on a daily basis
• allocating primary care resources to maintain an effective service
• ensuring that infection control is as effective as possible.

The Scottish Prison Service will endeavour to secure entitlement to measures that protect health for prisoners, those who are patients, staff and visitors.

The Prison Service will maintain key links with:

• local Strategic Co-ordinating Groups, the Justice Services and Health Services
• co-ordinate adjustments to the Justice system to reflect levels of illness amongst staff, and those who use the service
• enhance care in prison for those who have influenza complications, and secure intensive treatment in NHS hospitals, for those who are most likely to benefit on an equal basis with other patients.

In as many respects as possible, measures to protect and care for prisoners' health will be proportionate and equivalent to other members of the population.

10.5.10 Financial support

The Department for Work and Pensions ( DWP) and HM Revenue and Customs ( HMRC) provide and administer financial support to a range of customers, including children and their carers, people of working age, the disabled and their carers, and pensioners. DWP also supports customers in finding employment. During an influenza pandemic, DWP will aim to continue services that support people into work but give priority to maintaining financial support. Customer payments, which are largely automated, will continue to be paid. DWP and HMRC have robust business continuity plans in place to ensure that the administration and key services that support these payments can be maintained during a pandemic. Using existing legislation, a number of changes can be made to the way key services are delivered during a pandemic, to take account of priorities at that time. Suppliers that provide key services to DWP and HMRC, such as postal delivery or IT support, have their own business continuity plans in place to ensure these services can continue during an influenza pandemic.

10.5.11 Planning by Strategic Co-ordinating Groups and Local Authorities

SCGs and Local Authorities are focussing pandemic influenza planning on the following main areas:

• business continuity
• preparing for the wider impacts of a pandemic in their areas
• social measures to reduce the risk to individuals of infection
• supporting the health and community care response
• reviewing capacity to handle excess deaths.

10.5.12 Maintaining public order

Whilst the population usually responds in a calm and responsible way to any major disruptive challenge, an influenza pandemic is likely to cause public concern and anxiety, particularly if the virus causes high levels of illness and deaths and/or the communications strategy has limited success.

At a higher level of attack rate, factors such as capacity pressures on health establishments, the application of measures to control the spread of infection, possible shortages of basic necessities or short lived disruption to essential services could result in disturbances or threaten breakdowns in public order.

Preserving the rule of law, maintaining the democratic process and ensuring public safety will be important elements of Scotland's response. Engaging the public, ensuring that expectations are realistic and that advice and information is readily available prior to and during a pandemic are key elements of planning and should assist in minimising the risk of civil disorder.

In the event of any civil disorder, the Scottish Government would rely on existing legislation and normal enforcement measures as far as possible but may consider the need for additional powers should that become necessary.

Response plans should therefore, anticipate that operational or logistical assistance might be required to support health efforts to control the outbreak or treat patients or to respond to civil disorder. In this regard, it should be recognised that any request for police support is likely to be in a context of reduced police availability through illness and the need to service similar requests for policing support from other sectors.