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A) Before the Pandemic

8. Preparation for a pandemic is already well underway in most areas. On workforce issues the main areas where NHS Boards and services need to make preparation now are:

• mapping their workforce
• identifying the likely impact on absence
• putting in place support systems for staff
• consulting staff organisations at a local level
• communicating with staff
• developing training for staff to assist in responding to the pandemic.

Mapping the workforce

9. In order to tackle a pandemic it will be necessary to take pragmatic decisions to sustain services. For example, Boards may need to redeploy staff into different roles or locations, ask them to work in new ways or call on professionals, who are not currently working, to assist if existing staff are absent. In order to make most effective use of resources, Boards may therefore need to supplement existing information that they hold on staff. Many Boards will already have begun this process. Re-engaging staff who have retired is addressed in paragraph 27.

10. As a minimum it is recommended that NHS services have systems in place to gather data on:

• details of staff travel arrangements to and from work, as evidence suggests that staff with lengthy or complex journeys may be at high risk of not being able to attend due to transport problems. In addition, it may be useful to collect information from staff on whether they would be willing to work at another location or setting nearer to their home even if this is in another Board's area. Staff could also be asked if they could provide lifts or whether they would be willing to share transport with colleagues. Employers should also consider the benefits of assisting with transport and begin to put any practical arrangements in place as soon as possible. Lift - share web sites are now in operation and could prove a useful tool, e.g. web site http://www.liftshare.org
• staff contact details for use in an emergency, especially mobile numbers.
• whether staff have dependants, especially school age children or other dependants, who they would need to care for. During a pandemic these staff may face major difficulties in attending work if, for example, schools are closed as a means of countering the pandemic.
• staff who have skills that would be used during a pandemic. In particular Boards should seek to identify those staff who have such skills but are not currently using them in their current work role. These staff could be trained up in a relatively short period through refresher training. For example, most hospital medical staff will have generic skills in addition to their speciality and could be redeployed if their current work were to be suspended as may happen with elective surgery. Particular attention should be given to respiratory support skills and general skills in assessment. Most nursing staff should also be able to provide general nursing care. As well as dealing with flu itself, specialists will continue to be needed to deal with emergencies and ongoing long term conditions during the pandemic. Many community care staff will also have skills which will be vital during a pandemic and home care staff can assist in helping the elderly thereby preventing hospital admissions.
• Boards should seek to build up for themselves as detailed a picture as possible of the skills of their staff and assess likely capacity and need for skills. Plans are also being developed to create "surge capacity" to allow flexibility in meeting demand during the pandemic. Guidance on this will be available in due course at http://www.scotland.gov.uk/Pandemicflu .
• On leaving employment, staff should be asked whether they would be willing to return in the event of an influenza pandemic, this could form part of an exit interview.

NHS services will need to operate within the framework of the Data Protection Act in the collection and use of this data.

11. In addition, Boards should identify the workforce issues for any contractors who maintain essential services such as cleaning and IT systems. Contractors should be asked to ensure that they can provide adequate staffing during a pandemic, and there should be contingency plans to address critical areas, for example, by asking volunteers or NHS services staff who are not normally involved in services that would be essential to the frontline pandemic situation to assist contractors.

12. There will also be a need to assess the impact on other local partners such as independent sector providers, local authorities and voluntary agencies. In particular the impact on care home providers, hospices and respite centres should be taken into account. It will be in the interest of NHS services and community care services to seek to maintain these facilities in order to prevent admission of residents. This may require sharing of staff and other resources. NHS services should work with Local Authority partners to assess the impact on care homes. This may be especially challenging due to the large number of small owner operated care homes. Guidance for adult community care is also available on the pandemic flu web pages at http://www.scotland.gov.uk/Pandemicflu

13. All employers should be encouraged to undertake similar mapping work and pool information. In particular, CHPs or other NHS Board sponsored local pandemic coordination body should take responsibility for identifying issues for independent contractors in their area. For example, some single handed General Practices may be at high risk. General Practices should be encouraged to "buddy up" to share staff and other resources during a pandemic and there may be scope for CHPs to help coordinate this. It is not envisaged that CHPs would take over the employment of GP staff or operation of practices except in exceptional circumstances. The levels of staffing in community services and role of staff such as community nurses will need to be reviewed. The role of other contractors such as community pharmacists, dentists and optometrists also needs to be considered. Further pandemic guidance on providing Healthcare in community settings is available at http://www.scotland.gov.uk/Pandemicflu.

The impact of pandemic flu

14. Depending on the clinical attack rate (percentage of the population affected) the impact on NHS services will vary in intensity. A pandemic may involve one or more waves of around 15 weeks each, spread some weeks or months apart. While the cumulative clinical attack rate could be up to 50%, employers should be preparing for the reasonable worst case scenario of a clinical attack rate of 50% in a single wave [. Further information on the potential impact is available in "A Scottish Framework for Responding to an Influenza Pandemic" available at http://www.scotland.gov.uk/Pandemicflu

15. Pandemic influenza will affect NHS services and community care staffing in three ways:

• staff may themselves become infected and this is likely to lead to an unprecedented level of sickness absence due to the pandemic. Some staff may have fears of infection if they do come to work. In addition, stress levels will be high and this may increase absence.
• Staff with caring responsibilities may be adversely affected by public health measures such as the closure of schools. As a result these staff may wish to stay at home to care for dependant children or other family members or due to bereavement.
• Additional problems may be caused where staff are unable to travel to work due to local transport problems such as lack of fuel or staff shortages.

16. Research undertaken in England indicates that total absence rates could be increased by 15-18% to an average of 25% and in some smaller work groups up to 30% during the pandemic. This is based on a 25% clinical attack rate and even at this level would pose major challenges to the NHS and community care providers in sustaining services. Smaller work groups and "closed" institutions such as care homes could be at even greater risk due to faster spread in such conditions.

17. Advice on school closures will be provided by the Scottish Government but decisions to close schools and nurseries will be taken at local level and close liaison with Local Authorities will therefore be important. Private nurseries and other childcare services may also be affected.

Monitoring absence

18. Organisations will need to have robust information systems which will enable them to track the levels of absence during a pandemic. Further guidance will follow on what data needs to be collected. Current systems for reporting absence should be reviewed and clear guidance issued to staff on reporting arrangements. Where a member of staff exhibits flu-like symptoms including fever they should not go to work and if they do they should be sent home. It is essential that contact is maintained with affected staff so that an appropriate return date can be agreed. Those who do return will have some resistance to the initial influenza strain. Boards should be able to monitor flu related absence separately and will need to be able to report on this to the Scottish Government.

Sources of staffing

19. Due to the anticipated levels of absence it will probably be necessary to call on a number of different approaches to maintain staffing.

Internal redeployment

20. The main method of responding to absence will be internal redeployment. Some of the normal work of NHS services such as elective surgery is likely to be suspended and therefore staff working in these areas could be moved to deal with the pandemic. Local agreements on movement of staff will need to be reviewed to support a more flexible approach during the pandemic. There are some potential obstacles to redeployment of staff during a pandemic:

• staff may not have the right skills. This should be addressed by the skills audit and where practicable via retraining. In some cases staff may need to refresh their knowledge or need to work alongside colleagues. For example, most specialist medical staff will have had general training, which means that they can also provide general medical care. Pandemic flu patients will often have other conditions or complications and so a range of skills will be needed. Community care staff may also have useful skills to assist with care. Non clinical staff will also be essential to provide support and maintain services.
• staff may not be in the right location. Provided it does not compromise control of infection, staff can be asked to relocate as necessary. The needs of the situation may need to supersede usual work locations. Travel to work issues should be assessed and provision of transport considered. Existing local agreements on relocation may need to be reviewed to allow for changes of location. Where staff travel to work is disrupted, staff may ask to work at a more convenient location which may be with a different employer. Local discussions should take place on this. This needs to be done in a coordinated way and employers should ensure that staff can be used effectively in whichever location they work in.
• staff may be reluctant to be redeployed from their normal work area. In previous emergencies staff have generally been highly flexible. However, the nature of the pandemic may mean that there is a high level of staff fear of being moved to deal with pandemic patients. There needs to be work to explain the levels of risk and that NHS services will need all available staff resources.

It is important that all employers in an area work together to tackle the challenges of the pandemic. The Boards will have overall coordinating role and at local level individual employers should seek to reach agreement on sharing resources including staff during a pandemic. Where practicable local protocols should be agreed in advance of the pandemic.

Other sources of staffing

Staff Bank

21. Most Boards operate some form of internal staff bank. These staff can be called on to work additional hours during the pandemic. Part time staff could also be asked to work additional hours. However, both groups will also be affected by pandemic related absence and so may not provide as much additional cover as anticipated.

Sharing staff between organisations at local level

22. Local agreements should be considered to support the sharing of staff between organisations at local level. For practical reasons and to limit spread of infection, movements are likely to be only within a limited area. Staff moving between employers should be seconded on existing terms and conditions. Where there is a high degree of disruption to the journeys of staff it may be feasible to allow staff to work at another NHS services facility nearer their home as long as this is useful.

Drawing on new sources of staffing

23. At some point there may be a need to supplement current NHS services staff with others. At national level NHS services are working with a number of stakeholders to identify potential sources of staffing during the pandemic. For example, the BMA's Retired Members' Forum, NHS Retirement Confederation and the Red Cross may assist. Updates on this work will be issued in due course. In the interim, employers should concentrate on building up their own local pool of potential employees who could be called on to assist.

24. The Department of Health on behalf of UK Health departments/directorates is also working with regulatory bodies to tackle the issue of restoring staff to the register in order to allow them to practice. The General Medical Council and the Nursing and Midwifery Council have indicated that they would give priority to the restoration of staff to the register. Fees would still have to be paid and employers should consider reimbursement of these costs in order to allow staff to return to employment. Disclosure Scotland checks will continue to need to be undertaken and further guidance will be issued on this aspect in due course.

Working with Local Authorities

25. There may be limited scope for Local Authority staff to assist in maintaining NHS services. For example, some staff from Local Authority childcare services such as nursery nurses, home care staff and social workers could be of great assistance. Local discussions should take place on this issue to identify the scope for cooperation though in practice this will depend on the impact of a pandemic on local authority staffing. NHS services will also need to work closely with home care services to maintain services and provide support post-discharge.

26. Local Authorities and NHS services should work together to assess what areas of work could be suspended during the pandemic to allow for flexible use of resources and staff. In particular Local Authorities need to consider if services such as day care centres, libraries and other community facilities should remain open. Nurseries, Sure Start and other childcare facilities are likely to be closed which may release some staff to assist NHS services.

Building up a local pool

27. Staff who have only recently left are likely to be the most effective group to call on for the local pool. Employers will be familiar with these staff and their skills should be relatively up to date. If not still registered they can be restored to the register relatively easily. As an initial step all staff who leave employment from now on, whether due to retirement or for other reasons, should be approached and asked if they would be willing to assist during a pandemic. Employers should keep in contact with these staff and consider offering refresher training at appropriate intervals, as is done for staff on maternity leave. Employers should also consider contacting staff who have left their employment in the recent past especially those that have retired and have skills that would be needed. These staff can be added to the "pool" that could be called on in the pandemic. Employers should collect the minimum data referred to in para 10 above as well as a skills profile for the staff concerned. The skills needed should be determined in conjunction with relevant medical specialists based on the needs identified locally. There may be some scope for using specialists to train up other medical colleagues in advance of the pandemic. This local pool may be useful in other emergency situations as well as pandemic influenza.

Other Sources of staffing

28. NHS services may be able to call on assistance from healthcare workers currently outside the NHS. For example:

• during a pandemic independent providers may have staff who could be released to work in NHS services as some of their normal work is likely to be suspended. Local independent providers should be involved in local planning around staffing issues.
• Staff who are job ready and registered but not currently working, such as refugee doctors and nurses, could be a useful additional pool of staff if these staff have been cleared to work in the UK and are on the GMC and NMC registers. There would need to be careful matching between their skills and those that are needed.
• Local Authority staff such as childcare and social care staff. These staff could be seconded into NHS services. Their availability will depend on the impact of the pandemic on Local Authority staffing and numbers released may not be large.
• Temporary agencies will be facing the same staffing issues as NHS services and are therefore unlikely to be able to supply many additional staff. National procurement contracts on temporary staffing and use of agencies are held by National Shared Services Scotland.
• If educational institutions are closed, to limit the spread of the pandemic, then educational, research and academic staff could also assist, for example by providing professional supervision and other support for healthcare students. The potential role of healthcare students is discussed below.

Where additional staff are employed this would usually be on a temporary basis. All staff, including temporary staff, would still need to be Disclosure Scotland checked. How this system would work during the pandemic is being kept under review.

29. Members of the public are likely to volunteer to help during the pandemic and could provide invaluable additional support in non-clinical roles e.g. support services, general assistance and providing basic information under supervision. Existing volunteer organisations such as the St Andrews Ambulance Association and the Scottish Council for Volunteer Organisations may have a valuable role and help access appropriate networks. Volunteers will need to be health and Disclosure Scotland screened with appropriate references being taken up. Retirees and volunteers should be required to attend a special induction or Health and Safety training session to ensure the Board complies with its legal obligations. Volunteers are not normally paid though expenses should be met. There needs to be clarity about the remit of volunteers during the pandemic.

30. The Scottish Government Health Directorates recognise that local arrangements may not be sufficient if the pandemic has a very high clinical attack rate and it may be necessary to make a more general appeal to those with appropriate skills to make themselves available to assist during the pandemic. This needs to be done in a coordinated way and further advice will be issued in due course. In the interim Boards should build up data for their own workforce pools.

General Practice

31. Discussions are underway at UK level to ensure that the GMS contract is modified to allow GPs to focus on work to tackle the pandemic. It will also ensure that GPs are not financially penalized.

32. Boards and GPs need to work together to ensure adequate staffing during the pandemic. Practices should work together at local level to sustain services. Boards may also need to provide additional support especially for smaller practices and will need to keep in close contact.

33. Staff in community services are likely to be working under considerable pressure and there will be increased demand on primary care services due to levels of infection. In addition some patients will need to be treated in the community who would ordinarily be admitted to hospital. Discussions are underway on what type of work could be suspended within the community setting in order to free up resources to concentrate on priority roles. For example could Care Assistants undertake some vaccinations? How prescribing would work is also being looked at. General Practices will also need to work closely with local authority social services departments to maintain support for patients in the community.

Educational and training issues

34. It is anticipated that the pandemic could severely restrict availability of educational provision for medical students, nursing students etc. For example institutions could close as a public health measure, due to staff absence or redeployment of tutors. The clinical attachments of students to NHS services should be dealt with pragmatically to ensure clinical services are maintained. Depending on when the pandemic strikes this could affect more than one cohort of students and is particularly relevant to NHS services for the continuous supply of new healthcare professionals.

35. The General Medical Council is considering how best to deal with graduation of final year medical students. One option would be to allow these students to graduate without taking their final exam. They would be given provisional registration and would therefore be available to support employers. These steps would only be taken where the pandemic had reached a level where this approach would be beneficial. There would then need to be transitional arrangements for the operation of the Foundation Programme. The General Medical Council is continuing to work on policy proposals in this area. The Nursing and Midwifery Council is also looking at similar issues for nursing students.

36. Employers would need to consider how best to deploy medical students if feasible and beneficial to do so. Medical and other students already carry out a range of tasks and could therefore provide a range of assistance during a pandemic. They would supplement rather than substitute clinical staff. The level at which students could work will depend on the competencies they have at each stage of their studies. This varies widely depending on the medical school curriculum and to a lesser extent between nursing schools. It is therefore suggested that Medical and Nursing Schools and relevant employers agree a protocol on their expectations of the role of students during a pandemic. Students in the latter years of their course are likely to be the most useful and will probably be required to undertake a wide range of tasks from making initial assessment and observations to administering drugs through to putting in IV drips. For nursing students it could include elements of nursing that they have already experienced. Duties would need to be determined locally based on assessment of competence. Students should not be asked to take on duties outside their competence and should have appropriate supervision.

Working with the independent sector

37. One of the issues that need to be taken into account in a pandemic is how independent sector providers, and the Scottish Prison Service, may be affected. Independent sector providers that provide elective care will, like NHS providers in this area, probably have some of their work suspended during a pandemic. Their staff, or NHS staff with practicing privileges or attachments, would therefore become available for use in the NHS. As these staff are already in employment and have been Disclosure Scotland checked they would be an extremely useful reserve for NHS services to draw on. Independent providers should therefore be involved in workforce planning at local level and where possible agreements should be reached in advance to support use of these staff. Secondment arrangements are likely to be the easiest model. Those NHS staff currently attached to or working under "practicing privileges" to the independent sector may also be available. Many staff working for independent sector providers however also work in the NHS so these arrangements may not produce a large additional resource. Non NHS nursing and medical staff should however be available.

38. Some independent sector providers of services to the NHS will need to be maintained during a pandemic. For example, some residential mental health facilities and primary care services. Additional support may be required to maintain essential services. In these cases NHS Boards should make arrangements to second staff into these facilities if absence levels are affected by the pandemic. This may require some training for the staff affected e.g. to familiarize themselves with the locations and potential patient needs. The providers have the main responsibility to maintain services but NHS services need to make contingency plans to sustain these facilities.

39. Care home providers should also be supported. It is in the interests of NHS services and community care to maintain older people in care homes during a pandemic. It is likely that there will be outbreaks of pandemic influenza in care homes leading to increased rates of absence amongst staff. Because of the enclosed nature of the facilities, pandemic influenza could have a major impact in care homes. Secondment of staff into care homes should therefore be considered if this would prevent the home from being closed due to staff shortages. Care homes service continuity arrangements should be covered by community care plans. NHS services and Local Authorities need to work together to support homes providing long term care.

40. A range of other healthcare staff may also be available, such as dentists, optometrists and other independent contractors and staff in some parts of the private sector that may decide to suspend their business. This could free up staff to assist NHS services and NHS Boards should ensure that they discuss these issues with relevant contractors e.g. some type of basic dental and optometry services will need to be maintained even during the pandemic.

Issues in mental health services

There will be particular issues in mental health services in a pandemic. Acute psychiatric services in general and old age wards will need to continue to function, perhaps with reduced staffing and an emphasis on reducing admissions and managing more cases in the community. Long term residential facilities will need to be kept open to avoid transfer of residents to acute hospitals. As with other facilities, this will be a staffing challenge as these units are likely to be affected by staff absence and it may not be practicable to deploy staff from non-mental health areas into these units. Non residential facilities may need to be closed and redeployment of these staff into the acute and community sector could help address shortages in other areas of the NHS but may be challenging. Local Authority non residential facilities may need to be closed to limit infection risks. Learning disability facilities will need to be maintained in challenging circumstances.

41. Treatment may also be needed for residents with influenza and/or other acute conditions during a pandemic. Wherever possible this treatment should be given on site to limit infection risks. All staff will need familiarisation and appropriate training, for example in infection control. Non registered staff in mental health units can be trained up to undertake some tasks in order to use staff most effectively during absences but will need access to clinical supervision. It is possible that demand for mental health services could increase as a consequence of the stresses created by the pandemic. Further guidance on making pandemic arrangements for mental health services is being prepared and will become available in due course at http://www.scotland.gov.uk/Pandemicflu.

Other Areas

42. The issue of medical services in other institutional settings such as prisons and detention centres needs to be taken into account in Health Board's planning. Health Boards have overall responsibility for public health in their area and will need to work with the relevant organisations to ensure staffing is maintained. ( DN Prison primary healthcare is the responsibility of SPS in Scotland).

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