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Devolving responsibility for implementation to local authorities may not be the best policy
In the worst case scenario, a pandemic of influenza in the United Kingdom would cause 750000 excess deaths. In the short term, gross domestic product could fall by some 0.75%, and in the longer term the cost to the nation could be around £170bn (€250bn; $350bn).
On 16 March 2007, the Department of Health and the Cabinet Office jointly published a new draft plan for pandemic flu.1 The plan builds on and replaces the October 2005 plan.2 It is supported by a range of additional documents related to acute hospitals, health care in the community,3 an “operational and strategic framework” for adults in social care,3 guidelines for staff in social care settings,3 ambulance services,3 and an ethical framework.3 Some documents offer strategic guidance, some offer operational guidance, and others guidance for individuals. Comments are requested on all draft documents by 16 May 2007.
The purpose of the framework is to set out the government's strategic approach to limit the domestic spread of a pandemic and minimise harms to health, the economy, and society. The document proposes a national framework within which organisations responsible for planning, delivering, or supporting local responses should develop and maintain integrated operational arrangements. The framework has many strengths.
Firstly, it makes explicit assumptions that guide the strategy—for example, in relation to clinical attack rates and estimates of excess deaths that might follow. In addition, explicit policy assumptions are delineated for planning purposes. These deal with important themes such as transport policy (for example, travel restrictions, health screening, financial support to airlines), international policy (such as repatriation issues, medical assistance to British nationals overseas), essential services, education and social mixing, broadcasting, pharmaceutical interventions, communications, and response and coordination. These issues have previously been neglected by many national strategic plans.4 Moreover, the policy assumptions are strategically linked to World Health Organization pandemic flu phases. The assumptions concur with WHO advice, again an area neglected in many national strategic plans and something likely to result in problems for international coordination and cooperation.4 5
In their February 2007 report on the status of European Union preparedness for pandemic flu, the European Centre for Disease Prevention and Control (ECDC) highlighted several neglected areas.6 One of these was making plans operational at local level, which is a profound challenge for all countries. The range of documents in this consultation exercise suggests this remains a testing exercise for the Department of Health.
In the UK, as the new plan makes clear, the primary responsibility for planning and responding to any major emergency rests with local organisations, acting individually and collectively through local “resilience forums.” Thus, operational planning will be guided by central government but will need to be implemented locally. However, can timely and effective implementation in a time of crisis be achieved under a devolved system? If it can, then preplanning is crucial—and these documents highlight the amount of planning needed at the local level.
The UK's operational plans remain under development. A checklist for how the arms of the health system relate to health care in a community setting offers a useful way forward. However, this tells organisations only what needs to be done—not how to do it—and similar checklists are not available for all stakeholder organisations. Moreover, no structured mechanism exists through which organisations can draw from the lessons of others or ensure their operational plans are similar to others. Monitoring implementation of local operational plans will be important to avoid chaos in a crisis.
Some resources—such as strain specific vaccine, antivirals, and antibiotics—may be in short supply. It is unclear who will receive them, how and where priority decisions will be made, and whether responses across local areas will be consistent. While the framework outlines a variety of options, the document offers little guidance for local planners. The linked ethical framework document largely avoids the issue of prioritisation; it takes a medical (rather than a public health) approach and mostly neglects the strategic aims.
It could be that some people may be deemed more worthy of receiving treatment or prevention resources because of their impact on transmission dynamics, public health, the economy, or on mitigating “social harm.” But this issue is not dealt with. Some countries' plans offer more explicit guidance on the controversial issue of how to allocate scarce resources.5 This is not simply an abstract moral dilemma. Further guidance from the Department of Health is promised.
Severe acute respiratory syndrome, a dry run for pandemic flu, taught us that “there should be clarity established beforehand, as to what decisions are taken at what level and by whom during an epidemic.”7 In acute crises, devolved authority tests health systems differently from top-down systems.8 Indeed, the government's generic guidance, “emergency response and recovery,” referred to in the framework, outlines eight guiding principles. Among these is preparedness, “all organisations and individuals that might have a role to play in emergency response and recovery should be properly prepared and be clear about their roles and responsibilities.”9 Concern persists at local level that current plans for pandemic flu in the UK do not take account of what we have learnt from the experience with severe acute respiratory syndrome.10
Ultimately, it will be a remarkable achievement if devolved operational authority is successful. History suggests that the political imperative in a national (indeed global) crisis will be to centralise strategic and operational authority. If this happens then much of the planning could be redundant and an alternative approach might be needed.
Competing interests: RC has received funding from F Hoffmann-La Roche, various governments, and the European Commission and has received honorariums and reimbursements from F Hoffmann-La Roche, governments, the European Commission, and the European Presidency.
Provenance and peer review: Commissioned; not externally peer reviewed.