Important Londonwide CEO message number 13 - 20 July 2009
The world has gone nuts. I’m going to try and give you some clear input in this message which will cover six things:
- Pandemic Hysteria
- Under 1’s and Tamiflu
- Facts to help you with your diagnosis and clinical judgement
- National Flu Line
- Bureaucracy causing increased work
- Airlines and Certificates
1. Pandemic Hysteria
I’m afraid that our job as GPs is getting harder by the minute, as the media and now the midwives and airlines persist in fuelling public anxiety over what we know for the vast majority to be a mild self-limiting viral illness lasting a just few days. The consequences of this are that you are working longer and harder to target those who really need our help as doctors, be they sick from flu, or sick for other reasons, and the risk of missing something important as a result is increasing. Along with Birmingham (the other most affected area) I have made these points to the GPC/BMA, and as carefully as I can to the media. I and our team will continue to do so. Please let us know via flu@lmc.org.uk if your experiences are getting close to this viewpoint, or otherwise.
2. Under 1’s and Tamiflu
We are getting reports from all across the country that GPs are authorising the use of oseltamivir solution for adults and children who are not able to swallow capsules.
The advice is that we should be advising the emptying of the appropriate strength capsules onto something palatable and NOT prescribing the solution.
The solution must be limited for use in children under 1. This is causing an unprecedented demand for the solution and if we continue to use this strategy, we will run out of solution for babies under 1. The solution should ONLY be used for babies under 1. Children or adults who are not able to swallow capsules are asked to empty the contents of the capsules into a sweet sugary solution.
3. Facts to help you with your diagnosis and clinical judgement
- According to the HPA, there is no increase in the amount of adenovirus, parainfluenza or rhinovirus in circulation for the time of year. And seasonal influenza levels are lower (as my colleague Andrew Burnett has put it) than a grasshopper’s knees. So, if someone has flu-like symptoms and a temperature of 38 degrees C or more, then, on clinical grounds, they are likely to have swine flu.
- Most swine flu infections, so far, have not been severe, but there have been hospitalisations and deaths (generally in younger people, but not always in people with significant underlying illness).
- There remains uncertainty about the behaviour of the A/H1N1 virus: you can’t easily predict whether the course of the illness will be mild or severe in any individual, hence the precautionary approach that has been advised.
- Experience so far suggests that those at higher risk of serious illness or death are people with underlying chronic disease; with asthma requiring drug treatment; with immunosuppression (caused by disease or treatment); pregnant women; people aged 65 years or over, and children under 5 years old.
- Please continue to give priority for early treatment with antivirals to people in these higher-risk groups if you diagnose swine flu.
- The Chief Medical Officer recommends, when considering treatment of people aged 5-64 years with no underlying illness, taking a precautionary approach and offering antivirals to those with symptoms strongly suggestive of swine flu. You will, of course, use your clinical judgment: you may choose not to offer antivirals in circumstances where there are only minor or unrelated respiratory symptoms.
- The Chief Medical Officer also recommends that you do not usually offer prophylaxis to contacts of people with swine flu unless, for example, a household member has serious underlying health problems or there are other special circumstances.
4. National Flu Line
As you may have seen in today’s letter to all GPs and others from Professor Lindsey Davies, the national pandemic flu line is to start shortly. This is supposed to help to reduce pressure on GP practices, walk-in centres and A&E departments. People using the service(s) and who are identified as having swine flu will be able to obtain antivirals from an antiviral collection point. Without the need to contact their GP, to go to a walk-in centre or to an A&E department. You won’t be surprised to learn that I am not alone in remaining to be convinced about the appropriateness and the capability of this arrangement. Some PCTs are piloting their own Flu Lines and may use this, subject to being able to get sufficient staff, as an adjunct to the national service should it experience capacity problems.
5. Bureaucracy causing increased work.
i. Vouchers for Tamiflu
I have advised NHS London that London’s GPs will not be using vouchers for our patients and that the existing agreements to use FP10s, annotated with ‘convenient stationary’ will continue to be what we do. NHS London understand our concerns and are making these clear to the department of Health. So, for the following safety and best practice reasons, please tow the Londonwide line on this and contact us if you are coming under pressure to do otherwise.
a) They take us back to the Stone Age in terms of prescribing
b) There will not be a computer audit trail of date, dose etc.
c) Hand writing the prescriptions will lead to errors
d) Hand writing the prescriptions will mean that they can more easily be altered by patients
e) Due to them being gummed even using practice produced templates they cannot be consistently printed.
ii. Daily Sitrep/Flucon reports
This is on my list to tackle. Watch this space.
6. Airlines and Certificates
Despite what you and your patients may have read in the press, GPs will not be asked to provide fitness to fly notes. The BMA have today clarified with BA and Virgin that:
The airlines have made their staff aware of the swine flu situation and have given them broad instructions on how to spot possible symptoms. This is standard practice - they issued similar guidance during the SARs incident. If their staff have concerns, they can refer the passenger to their onsite medical service – Medlink – who will then assess, in cooperation with the patient, their fitness to fly. If they are not regarded as fit, they won't be allowed to fly and will be asked to ring the NHS flu line or go online to the symptom checker and then follow the normal advice for people who suspect they have swine flu.
Virgin and BA are not saying that fit notes will need to be issued for all patients and they do not believe that a passenger's GP needs to be involved at any stage of this process.
I’d like to hope this helps, but please let us know via flu@lmc.org.uk if patients are nevertheless demanding such fitness certificates. We have a cunning plan to deal with them.