Plenary, 03 Sep 2009

Meeting date: Thursday, September 3, 2009

Official Report 734KB pdf

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Influenza A(H1N1)

Good morning. The first item of business is a statement by Nicola Sturgeon on influenza A(H1N1). The cabinet secretary will take questions at the end of her 10-minute statement, so there should be no interruptions or interventions.

During the summer recess there were a number of developments in relation to the A(H1N1) virus, and I am grateful for the opportunity to update Parliament on the current situation.

Following the move from the containment to the treatment phase that I announced on 2 July, new surveillance arrangements for monitoring the number of cases in Scotland were put in place. Health Protection Scotland monitors the number of consultations with general practitioners for flu-like symptoms and the number of hospitalised cases and deaths, and we now report those weekly.

We know from that information that although the virus continues to circulate in Scotland, the rates remain relatively low. Figures published today show that last week there were 40.2 GP consultations per 100,000 of the population. We estimate that around 2,500 people contracted H1N1 over the past week. In Scotland, the numbers are still below seasonal flu numbers, although they are high for this time of year. For most people, the virus remains relatively mild and self-limiting, although for some people it can be severe. A total of seven deaths have been associated with the virus in Scotland.

As many members will be aware, the national pandemic flu service was launched in England on 23 July. So far, we have chosen not to use the service, because our primary care services—Scotland's GPs, supported by NHS 24 and the Scottish flu response centre—continue to respond well to the demands that they face. We have, of course, retained the option to join the service when and if we think it necessary.

In so far as prescribing antivirals is concerned, the chief medical officer has issued guidance to all GPs that gives clear advice on prescribing and on who to treat, and it recommends that decisions should be based on clinical judgment. That means that in Scotland, antivirals are provided only following assessment by a GP, which is in line with current World Health Organization guidance.

Since the Parliament rose for the summer recess, there have been a number of developments in relation to the vaccination programme. We continue to work closely with the other United Kingdom nations to develop the programme, and I will now set out where things currently stand.

On 13 August, on the basis of advice from the Joint Committee on Vaccination and Immunisation and the Scientific Advisory Group for Emergencies, I announced the first priority groups for the vaccine. Once the vaccine has been licensed, it will be offered initially to individuals aged between six months and 65 years in the current seasonal flu vaccine clinical at-risk groups; all pregnant women, subject to licensing considerations; household contacts of people whose immune system is compromised; and people aged 65 and over in the current seasonal flu vaccine clinical at-risk groups. Those groups have been prioritised because they represent individuals who are most at risk of serious complications from the virus. The vaccination will provide protection to reduce the incidence of serious illness and reduce the burden of serious illness on the national health service over the winter.

In addition to the clinical priority groups, health and social care workers who have direct contact with patients will be prioritised for vaccination. Those staff are more likely to be exposed to the virus in the course of their work and could act as a transmission route to vulnerable patients. Offering vaccination to those groups will also help to ensure the resilience of the NHS and social care services. Definitions have been agreed for each of the groups, and local authorities will continue to engage with health boards to progress planning for delivery of the vaccine to those groups.

Vaccination will also be offered to NHS 24 staff who work closely with NHS boards to provide out-of-hours services in Scotland and who make a significant contribution to the management of the pandemic in Scotland. Currently, there are no plans to vaccinate other occupational groups on the basis of business continuity or resilience, although that will be kept under review. The emerging evidence on the severity of the virus will continue to be monitored closely over the coming months. We will review priorities for the vaccination of other population groups in light of further expert advice.

At this stage, we anticipate that licences for the vaccine will be granted by the European Medicines Agency in late September or early October. If that is the case, we anticipate being able to commence the vaccination programme in the middle of October. Estimates of vaccine deliveries from the manufacturers are subject to change, but the current assessment suggests that more than 54 million vaccine doses will be delivered to the UK by the end of December. From that, we estimate a potential delivery to Scotland of approximately 300,000 to 350,000 doses per week from the date when the vaccine is licensed.

A UK-wide communication campaign to support the programme is being developed. It will include both professional and public materials to support the delivery of the programme. It will also provide advice and information to those members of the public who are prioritised for vaccination to ensure that they are able to make an informed choice about the vaccine.

NHS boards are actively progressing their planning for the delivery of the vaccination programme. Over the past few months, we have been closely involved in discussions with the British Medical Association on payments to GPs for the administration of the vaccine. Those discussions continue, and I hope to be able to announce the outcome shortly. I am confident that the NHS in Scotland will be ready and able to deliver the programme as soon as licensed vaccine is available.

I turn briefly to the situation with our schools. Since schools returned for the new term in the week beginning 17 August, pupil and staff absence levels have been at or below normal levels. However, with local authorities, we have established a mechanism for monitoring rates of staff and pupil absence to give early warning of any increases in absence rates. Work is also continuing to ensure that suitable contingency plans are in place should there be a rise in swine flu cases over the autumn and winter. We have relaunched the national hand washing campaign, emphasising its importance in reducing the spread of infections. The response from schools has been very positive. It remains the case for everyone that regular hand washing and good respiratory hygiene are vital in helping to limit the spread of the virus.

It remains the case that we cannot predict accurately when the epidemic will peak, how many people will be absent from work or how many people will require hospital care. However, our preparations must ensure that we can respond to any scenario, including the worst case. Members will recall that reasonable worst case planning assumptions were published in July. Those assumptions have now been updated in line with our experience of the virus so far.

The updated planning assumptions, which are for the whole of the UK, are being published today and copies are available at the back of the chamber. First, they indicate that up to 30 per cent of the population might become ill with flu at some point over the course of the pandemic, which is unchanged from our earlier assumptions. Secondly, they indicate that up to 1 per cent of people who become ill with flu might require hospitalisation, which is down from the earlier assumption of 2 per cent. Thirdly, up to 0.1 per cent of people who become ill might die from the virus, which is also down from the earlier assumption of 0.35 per cent. Lastly, during the peak weeks, sickness absence rates might reach 12 per cent of the workforce.

I stress that those assumptions do not yet take account of the impact of our vaccination programme. Furthermore, they are not predictions; they are assumptions that allow us to plan for the worst while continuing to hope for the best. Although having lower estimates for hospitalised cases and fatalities is positive, the assumptions will be kept under review.

Contingency planning is being conducted across a number of public bodies and the business community. Understandably, much of the emphasis so far has been on health issues. Anticipating and preparing for the wider impacts of the pandemic is vital. That is why across Government we have been working closely with stakeholders and delivery partners, focusing on assessing the readiness of key sectors and their ability to maintain the delivery of core services. We are mindful, too, of the potential impact on economic recovery and on businesses large and small as they work to rebuild confidence.

Over the summer, officials met regularly the eight strategic co-ordinating groups, which bring together the key emergency responder agencies. That partnership is critical in tackling effectively what has proved so far to be a novel and at times fast-developing situation. We very much value the continued support of the SCGs as we move into the autumn and the work that has been done by local authorities, health boards and other key partners in helping to ensure Scotland's preparedness.

The potential threat from H1N1 remains. Even if it remains, for most, a relatively mild virus, its effects on the health service and on the wider economy could be highly disruptive. That is why we continue to press ahead with prudent preparations for responding to the virus and the impact of seasonal flu. I believe that we are in a very strong position to cope with the peak in cases that is expected over the autumn and winter, and we will continue to prepare in a way that neither exaggerates the threat nor encourages complacency. I will of course ensure that Parliament is kept updated as further developments take place.

The cabinet secretary will now take questions, for which we have almost exactly 20 minutes, before we move to the next item of business.

I thank the cabinet secretary for her statement and all the NHS staff and others in local authorities and elsewhere who have worked so hard on this issue at the front line. Although our thoughts are with the families who have been bereaved as a result of the H1N1 virus, I think that we are all relieved that the virus has so far not mutated or been as virulent as we might initially have feared.

I note what the cabinet secretary said about the negotiations that have taken place with GPs over the past months. However, given that the vaccination programme is now predicted to start within the next five to six weeks, we might reasonably have expected the cabinet secretary to be able to come to Parliament today to tell us that those negotiations had been successfully concluded. Will the cabinet secretary tell us why there has been a delay and whether there are any barriers to reaching agreement?

There is still concern that the second wave of H1N1 will coincide with the normal seasonal flu outbreak. What arrangements are being put in place to ensure that the two vaccination programmes are able to run simultaneously, making the best use of our resources?

Given the unfortunate return of delayed discharges, has the cabinet secretary taken any specific action to increase the number of available hospital beds to deal with an increase in admissions as a result of H1N1 in addition to the normal pressures from winter seasonal flu?

I thank Cathy Jamieson for her questions. She is right to express her thanks to NHS staff and staff in other agencies who have been working very hard. I am sure that we all join her in expressing condolences to the families of those who sadly have died from the virus.

I am sure that Cathy Jamieson will accept that I would very much have liked to come to Parliament today to announce the conclusion of the negotiations with the BMA. However, given her trade union background, she will know that such negotiations do not always happen in the timescale that we would like. She will appreciate that I cannot say much more about the detail of the negotiations today, because they are on-going, but I hope that they will conclude shortly, and as soon as they do I will make known to Parliament the conclusions and the detail of what has been agreed.

Health boards are planning the delivery of the vaccination campaign that I have made clear I hope will start in mid-October. Health boards have plans, including contingency plans, to ensure that whatever the outcome of negotiations with GPs, the vaccination campaign can be delivered. I will keep Parliament updated on that issue over the days and weeks ahead.

All expert advice is that the seasonal flu vaccination campaign can run in tandem with a pandemic flu vaccination campaign. Clearly, the communication campaign that we prepare will have to take account of the two vaccination campaigns and ensure that people are given the right advice about not only the importance of the H1N1 vaccine but the importance of the seasonal flu campaign. The fact that—certainly in the early stages—we are in the main, although not exclusively, dealing with the same groups of people should, I hope, make that easier.

Cathy Jamieson's final question was about delayed discharge. I have said all along that I am not going to conduct any of the discussions around swine flu in a party-political way, and I will stick to that today. This Government is determined to keep delayed discharge at the targets that we have set—which is zero delayed discharge. That is a challenge for health boards and local authorities, and we will continue to ensure that they work together to meet those targets. I simply point out that although the Minister for Public Health and Sport and I were disappointed that the latest figures showed 55 delayed discharges throughout Scotland, that was considerably better than the 627 delayed discharges that were the last figure under the previous Administration.

I thank Nicola Sturgeon for the updates over the recess and I acknowledge the excellent work of the NHS to date.

How will the cabinet secretary ensure that patients with pneumococcal meningitis, the symptoms of which are similar to those of swine flu, are not overlooked during this period, given that swine flu patients should stay at home and meningitis patients should get to hospital as quickly as possible?

Someone asked me this question, so I ask the cabinet secretary to forgive me for asking her it. I have been asked whether the thousands of patients in Scotland who have already had swine flu will still have to get the vaccine when it comes out in October.

Given the recent media coverage on people's fears about the safety of the vaccine, the BMA has reported that many health professionals are reluctant to be vaccinated. What advice would the health secretary give in that situation and will she give us an assurance about the safety of the vaccine?

I thank Mary Scanlon for those three questions.

I understand that the point about meningitis was raised at a meeting that many MSPs attended last night, so Mary Scanlon is right to raise it today. She is also right to point out that in the early stages of any infection, whether it is viral, such as flu, or bacterial, the symptoms, such as raised temperature or aches and pains, can be similar. That is why the consistent message that has been given to members of the public since the start of the H1N1 virus outbreak is that if they have any concern about flu-like symptoms, they should contact their GP or NHS 24. Both NHS 24 and GPs are well aware of the importance of being able to differentiate between those who may be seriously ill and those who can be given advice to self-care at home. All the systems and clinical algorithms to manage callers are designed to identify seriously ill patients and ensure that, if required, urgent medical attention is provided to them. Receiving staff and junior medical staff in hospitals have also been provided with clinical algorithms to ensure that patients who are seriously ill, or perhaps are even in life-threatening situations, can be identified and treated appropriately. The Scottish flu response centre, unlike the national pandemic flu service, is clinically supervised, which is an important point of reassurance.

I will be as brief as I can in answering Mary Scanlon's questions about the vaccine. Anybody who is in the priority groups for vaccination will be encouraged to have the vaccine. Given that we stopped laboratory testing for H1N1, there are some people who might think that they have had H1N1 but who might not in fact have had that particular strain of flu. The advice to anybody in the priority groups will be to go for vaccination.

On the safety of the vaccine, I assure Mary Scanlon and the Parliament that no vaccine will be used unless it is safe and no vaccine will be used unless it is licensed. Subject to satisfactory review of the data, we anticipate that the European Medicines Agency will grant a licence some time later this month or early next month. However, that is of course subject to the satisfactory review of the data. When we have a licensed vaccine, I will be encouraging all those who are in priority groups, and those in subsequent groups that are recommended to be vaccinated, to take the vaccine, because vaccines can and do save lives.

I, too, am grateful to the cabinet secretary for her continuous updating of members of Parliament on the situation. I join others in expressing our gratitude to NHS and other professionals who have effectively contained the disease.

First, I am grateful that in response to Cathy Jamieson's questions, the cabinet secretary clarified the issue of the two vaccination programmes, which is important. I regret that there appears to be some confusion about that, because of press reports on, for example, the way in which the virus reappeared in Australia, where it appeared to be replacing existing flu, which gave the impression that somehow people could take one vaccine and not the other. There is a need for communication. I seek further assurances on whether both programmes will be adequately publicised.

Secondly, I note that the cabinet secretary repeated the chief medical officer's clear advice that in Scotland, antivirals will be issued only following assessment. Members accept that, but it is disturbing that in its briefing, the BMA says that medical staff are suffering intimidation and threats of violence from members of the public who clearly have not listened to, have not heard or do not wish to understand that advice from the chief medical officer. Will the cabinet secretary advise what further steps might be taken to ensure that such intimidation is brought to an end?

Finally, the advice from down south is clear that one should not refer a young person to a GP unless they have a temperature of more than 38°C. I understand that one of NHS 24's early questions is about the person's temperature. Has the cabinet secretary given any further thought to whether, in order to avoid unnecessary communication, the issuance of thermometers should be part and parcel of efforts to control the way in which we use the NHS?

On Ross Finnie's first point about the importance of clear and consistent communication, I could not agree more. None of us has complete control over what appears in the media, but we all have a responsibility and a duty to ensure that we do everything in our power to ensure that consistent messages are communicated, whether they are messages about the severity of or preparedness for the virus, or messages about vaccination programmes.

On antivirals, I unreservedly condemn any intimidation or threats of violence against any medical practitioner. Such behaviour will always be taken very seriously indeed. I stress that antivirals are available for anyone in the population who, in the clinical judgment of their GP, would benefit from them. The key difference between England, and Scotland, Wales and Northern Ireland is that, at this stage, antivirals are not available without prescription in Scotland, Wales and Northern Ireland. That is the right way to conduct the matter, which is why we have chosen to go down that route for as long as we can.

On Ross Finnie's final point, the importance of temperature for diagnosing flu is well known and important. We have clear and clinically robust algorithms for determining the correct advice to give to patients. In the spirit of working together and openness, I will consider any constructive suggestions, including Ross Finnie's about thermometers.

We come to open questions. We have pretty limited time, so I stress one question and one brief answer, please, if at all possible.

The cabinet secretary provided information on the number of reported cases over the summer, and said that the rates remained relatively low. In the past couple of weeks, schools throughout Scotland returned from their summer break. Does the cabinet secretary believe that that low rate is a matter for optimism or does she consider that it is too soon to assess potential change?

The number of cases throughout Scotland is relatively low compared with seasonal flu rates, although it is high for this time of year.

There is a great deal of discussion and speculation about the impact of flu on schools. There has been a slight increase in the flu rate since the schools returned, although, interestingly, it has not been as steep as it often is in August. We are monitoring the situation carefully. As I said in my statement, with local authorities we have put in place a mechanism for monitoring and reporting staff and pupil absences in schools in order to give us early warning of any increase in flu rates. The Cabinet Secretary for Education and Lifelong Learning and I jointly relaunched the hand and respiratory hygiene campaign in schools, which is the most effective way in which schools can help to combat the virus.

Is the cabinet secretary aware that, notwithstanding paragraph 27 of the pandemic flu guidance, two out of 14 health boards—Lothian and Grampian—do not even have lists of retirees, 11 out of 14 have not yet made any effort to contact retirees to assess their willingness or capacity to help, and almost all are waiting for national discussions on suitable training to be finalised? Is she satisfied with that level of complacency in our pandemic planning? Most boards seem to be waiting until things get bad enough to require them to take up the issue of trainees and to take any necessary action.

The Government could be accused of many things, but complacency in its pandemic flu planning is certainly not one of them. It is a matter of slight regret that Labour seems to be keen to break the helpful consensus that we have had so far as we have faced up to what is a considerable crisis.

Richard Simpson should be aware—although, judging by his questions, he obviously is not—that guidance for NHS Scotland boards on pandemic flu and workforce issues was published in August 2009. It provides advice on preparing for and dealing with the workforce implications of pandemic flu. A national co-ordinating group has been set up to deliver an action plan for education and training to support the NHS during a pandemic. The group is chaired by the chief executive of NHS Education for Scotland, Malcolm Wright, and is due to produce its action plan by the beginning of November. I have always responded constructively to Richard Simpson's comments about retirees, and I will do so again. Further, I will raise his points with NHS boards, which I am sure will respond to him.

Scotland has not taken part in the national pandemic flu service, or the helpline, as it is called. However, the minister stated that she retained the option to join if necessary. Will she develop that point? For example, is she concerned that there is sufficient capacity for Scotland to join, given the overload that occurred at the UK launch?

The reasons why we have chosen not to go into the national pandemic flu service at the moment are twofold, but they are connected. First, we do not require to join because our existing systems—NHS 24, with the addition of the Scottish flu response centre and our GPs—are responding very well to the demand that they face. I have always taken the view that as long as the existing systems can respond, it is right that we allow patients to access the NHS by traditional and familiar routes rather than by new routes. Secondly, it is important that clinical supervision is at the heart of our response to flu. For as long as possible, we should ensure that Tamiflu or other antivirals are available only on prescription. If we were part of the national pandemic flu service, we would not be able to ensure that. Therefore, if we can avoid joining we will do so, but we retain the option to join, and we will keep the situation under constant review.

I want to ask the cabinet secretary about the on-going work on contingency plans for schools. Will the plans include guidance on school closures and the information that should be made available to parents? When will they be ready?

We are in regular discussion with local authorities and, through them, with schools. Very full information was distributed to schools at the start of the school term. We will keep that under review as the situation develops.

Since we have moved from the containment to the treatment phase, it is less likely in future that schools will close in order to try to limit spread, because the advice is that that is less effective as we get further into the pandemic than it is in the early stages. It is always possible, of course, that because of high levels of pupil or staff absences it may be necessary to close schools. Obviously, decisions will be taken locally, with full input from public health officials, in order to ensure that those decisions are based on the right factors. We will keep the situation with schools under close review. Our decision to reopen schools, as planned, in August is entirely in line with the decisions that other countries, in the UK and elsewhere in the world, have taken.

In the next few weeks, thousands of young people will travel to Scotland from all over the world to attend Scotland's colleges and universities. Is any advice being given to them on the importance of registering with a GP, and on not confusing the symptoms of H1N1 with what might be described as a heady student lifestyle?

Jackson Carlaw clearly has more experience of that than I have.

The short answer to his question is yes. There is discussion with colleges and universities on guidance, which will include the advice that students are encouraged to register with a GP wherever they go to college or university.

The cabinet secretary mentioned the deaths that might occur in any pandemic. What steps have been taken to advise at-risk members of the public that they are in a particularly vulnerable group? What steps will be taken to give them assurances, given some of the concerns that have been expressed about the safety of the vaccine?

I dealt with some of that in my statement. Hugh Henry is right to indicate the relatively small number of people who unfortunately might die, as in any flu outbreak. The planning assumptions that are being published today—although they are not predictions—lower the estimate of likely deaths during the pandemic. That is positive, although we must remain vigilant.

The communication campaign for the vaccine, which is being worked on at the moment, will very much focus on the priority groups, as they are the early groups for vaccination. I assure Hugh Henry that steps will be taken not just to advise the priority groups of the importance of vaccination but to deal with any concerns about vaccine safety.