H1N1 Influenza Pandemic Funding.

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A decision made (25/09/2009) regarding: H1N1 Influenza Pandemic Funding.

Decision Reference: MD-TR-2009-158
Decision Summary Title:	H1N1 Influenza Pandemic Funding expenditure approval		Date of Decision Summary:	23/09/09
Decision Summary Author:	Deputy Treasurer		Decision Summary: Public or Exempt?	Public
Type of Report: Oral or Written?	Written		Person Giving Oral Report:	N/a
Written Report Title:	H1N1 Influenza Pandemic Funding expenditure approval		Date of Written Report:	23/09/09
Written Report Author:	Deputy Treasurer		Written Report : Public or Exempt?	Public
Subject: H1N1 Influenza Pandemic Funding
Decision(s): The Minister decided to: Authorise the withdrawal of up to £1,347,000 by the Treasury and Resources Department from the Consolidated Fund, under Article 16 of the Public Finances (Jersey) Law 2005, to meet immediate and urgent costs associated with preparing for and containing H1N1 influenza. Lodge a Report and Proposition asking the States to approve the withdrawal of funding referred to above under Article 16(3) of the Public Finances (Jersey) Law 2005; and to approve the withdrawal of £4,200,000 of contingency funding to manage the consequences of an outbreak of H1N1 influenza, under 11(8) of the Public Finances (Jersey) Law 2005.
Reason(s) for Decision: Being satisfied that there is an immediate threat to the safety of islanders, to provide immediate and urgent funding to enable departments to prepare for and manage the potential consequences resulting from H1N1 influenza pandemic.
Resource Implications: Resource implications are contained within the attached report.
Action required: The Greffier to lodge the attached Report and Proposition and schedule for debate at the earliest opportunity.
Signature:		Position: Senator P F C Ozouf, Minister for Treasury and Resources
Date Signed:		Date of Decision:

H1N1 Influenza Pandemic Funding.

Appendix A – R105/2009

Appendix B

PROPOSITION

THE STATES are asked to decide whether they are of the opinion:-

In accordance with Articles 16(3) and 11(8) of the Public Finances (Jersey) Law 2005, to amend the expenditure approval for 2009 approved by the States on 23rd September 2008 in respect of the Treasury and Resources Department:-

a) to permit the withdrawal of up to an additional £1,347,000, from the consolidated fund in accordance with Articles 16(3), to be reallocated for the net revenue expenditure of a number of departments in order to fund costs associated with preparation and containment of a H1N1 influenza pandemic and that the funding should only be made available to departments from the allocation to the Treasury and Resources Department by public Ministerial Decision of the Minister for Treasury and Resources based on evidence of the need to incur these additional costs in order to prepare for, and contain H1N1 influenza.

b) to permit the withdrawal of up to an additional £4,200,000 from the consolidated fund in accordance with Articles 11(8), to be reallocated for the net revenue expenditure of a number of departments in order to fund costs associated with managing the consequences of a wave of illness caused by H1N1 influenza and that the funding should only be made available to departments from the allocation to the Treasury and Resources Department by public Ministerial Decision of the Minister for Treasury and Resources based on evidence of the need to incur these costs to manage the consequences of an H1N1 pandemic influenza.

MINISTER FOR TREASURY AND RESOURCES

REPORT

Background

The States’ Pandemic Flu Co-ordinating Group has advised the Minister for Treasury and Resources that a major wave of illness due to pandemic influenza A H1N1 2009 (swine flu) is expected this autumn or winter and that action is needed now to reduce the impact on the people of Jersey. Preparations are also needed to allow Jersey General Hospital to be ready to expand to maximum capacity.

The Group have advised that robust escalation plans for community and hospital care are essential during a major pandemic wave period, if the hospital is to be able to care for those with the greatest health needs.

The Minister presented the Group’s report (Appendix A) to the States on 21st September 2009 (R105/2009).

Purchases of the antiviral drug tamiflu and the H1N1 vaccine have already taken place, along with other preparations. The cost of these preparations to date amounts to £2.9 million; this has been funded from previous expenditure approvals.

The Group have estimated the total additional cost of managing the flu could reach £5.5m (this excludes Social Security and Health Insurance Fund costs, estimated at £1.7 million). The detail of this is shown in the attached report and can be summarised as:

Preparation expenditure and maintaining containment phase £1.3m
Pandemic management and recovery phase £4.2m

Funding for the management and recovery phase will only be required if a major wave of illness due to pandemic influenza occurs.

Expenditure Approval Under Article 16 of the Public Finances Law

The Pandemic Flu Co-ordinating Group have advised that urgent funding is required for the first phase, of preparation and containment, and have asked the Minister for Treasury and Resources to consider authorising this expenditure immediately under Article 16 of the Public Finances (Jersey) Law 2005.

The Minister has considered this matter in consultation with the Pandemic Flu Political Steering Group, comprising the Chief Minister and Ministers for Health and Social Services, Social Security, Education, Sport and Culture and Treasury and Resources and receiving advice from the States Medical Officer of Health, and the States’ Pandemic Flu Co-ordinating Group. This advice is attached as Appendix B.
The Minister for Treasury and Resources is satisfied that there exists an immediate threat to the safety of the inhabitants of Jersey, and that immediate expenditure is required, and it cannot be met from existing expenditure approvals, and that there is insufficient time to secure any additional expenditure approval through Article 11(8) of the Public Finances (Jersey) Law 2005.
In accordance with Article 16(2) of the Public Finances (Jersey) Law 2005, the Minister authorized the withdrawal of up to £1,347,000 from the Consolidated Fund by the Treasury and Resources Department.

In accordance with Article 16(3) of the Public Finances (Jersey) Law 2005, the Minister is now seeking States approval for this expenditure withdrawal.

Expenditure Approval Under Article 11(8) of the Public Finances Law

The Pandemic Flu Co-ordinating Group have advised the Minister that in the event of the pandemic striking the Island, the aim will be to care for as many patients as possible in the community without them being admitted to hospital. However, it is inevitable that some islanders would become so unwell that they would no longer be able to be cared for in the community and the hospital would have to be ready to respond.

The Group has advised that if a vaccine becomes available ahead of the major wave then a vaccination programme offering vaccination to all islanders would be put in place.

The costs associated with the pandemic management and recovery will only be incurred in the event of a major pandemic wave of illness. This expenditure is therefore not required immediately, only in the event of a pandemic materialising.

The Pandemic Flu Co-ordinating Group, together with officers from Health and Social Services, estimate that the cost of managing a H1N1 influenza pandemic could be up to £4,200,000, as detailed in the Group’s report attached at Appendix A.

Expenditure approval for these costs is sought under Article 11(8) of the Public Finances (Jersey) Law 2005.

If the pandemic occurs before the States have the opportunity to debate this proposition, the Minister will consider authorising expenditure under Article 16 of the Public Finances Law at that time. The Minister will keep under the review the emerging data, receive regular briefings from the Pandemic Flu Co-ordinating Group, and consult with the Pandemic Flu Political Steering Group.

Management of Expenditure Approvals

All funds approved through this proposition will initially be allocated to the Treasury and Resources Department.
The Minister will appoint a group of senior officers to recommend the allocation of this funding to departments based on evidence of the need to incur these additional costs in order to prepare for, contain, and manage H1N1 influenza. The allocation of funds will be reported in a public Ministerial Decision and subject to the relevant Accounting Officer confirming:

That the goods and services being purchased are required immediately and are needed to respond to the threat to the safety of the island's inhabitants

That insufficient funds are available within existing budgets
that there are appropriate controls in place to ensure that funds are being spent appropriately,
that value for money is being achieved; and
that financial directions are being complied with in respect of this expenditure.

Financial and manpower implications

There are no additional permanent manpower implications arising from this proposal, additional staffing requirements will be met through overtime and temporary appointments.
The financial implications are to increase States expenditure approvals by up to £1,347,000 and up to a further £4,200,000 as set out in this report and its Appendix.

H1N1 INFLUENZA PANDEMIC IN JERSEY

Background

The States’ Pandemic Flu Co-ordinating Group has advised the Minister for Treasury and Resources that a major wave of illness due to pandemic influenza A H1N1 2009 (swine flu) is expected this autumn or winter and that action is needed now to reduce the impact on the people of Jersey. Preparations are also needed to allow Jersey General Hospital to be ready to expand to maximum capacity as we expect will be needed.

The Group have advised that robust escalation plans for community and hospital care are essential to manage during the major pandemic wave period if the hospital is to be able to care for those with the greatest health needs.

The Minister wishes to present the Group’s report, attached at Appendix A, to the States.

Financial Implications

The Group have estimated the total additional cost of managing the flu could reach £5.5m (this excludes all Social Security and Health Insurance Fund costs). The detail of this is shown in the attached report and can be summarised as:

Preparation expenditure and maintaining containment phase £1.3m
Pandemic management and recovery phase £4.2m

The Group advise that urgent funding is required for the first phase, of preparation and containment, and is asking the Minister for Treasury and Resources to consider authorising this expenditure urgently under Article 16 of the Public Finances (Jersey) Law 2005.

Funding for the management and recovery phase will only be required if a major wave of illness due to pandemic influenza occurs.

Funding

Under Article 16 of the Public Finances (Jersey) Law 2005, where the Minister is satisfied that there exists an immediate threat to the safety of all or any of the inhabitants of Jersey and that immediate expenditure is required and it cannot be met from existing expenditure approvals, and that there is insufficient time to secure any additional expenditure approval through Article 11(8), the Minister may authorize the States funded body to withdraw the money or additional money so required from the consolidated fund.

The Minister will keep under the review the emerging data and consult with the Pandemic Flu Political Steering Group as he considers the request for immediate urgent funding. If authorisation is given, a Report and Proposition will, at the same time, be lodged with the States seeking approval for the authorisation.

If a major wave of illness due to pandemic influenza occurs over the coming weeks, the Minister will consider a further request under Article 16 of the Public Finances (Jersey) Law 2005 to make further funding available.

Appendix A – Report of The States’ Pandemic Flu Co-ordinating Group

CHIEF MINISTER’S DEPARTMNT (CMD) CO-ORDINATION GROUP – PANDEMIC FLU

H1N1 INFLUENZA PANDEMIC IN JERSEY: FINANCIAL PLAN

Foreword

(Foreword from Dr Rosemary Geller, Medical Officer of Health, 16/09/09)

Throughout history, global pandemics have occurred from time to time: in the 20th Century, the world experienced widespread flu due to new pandemic viruses in 1918, 1957 and 1968. 41 years on, it has long been recognised that the next pandemic was overdue and now it has begun.

In late April this year, the World Health Organisation (WHO) announced the emergence of a new influenza A virus and warned that a flu pandemic was imminent. This particular H1N1 strain, including human, avian and swine viral genetic material, had not circulated previously in humans. The virus was entirely new. On 11th June, WHO declared that the pandemic virus was spreading in more than two WHO Regions, and thus the pandemic was declared to have started. The next day, on 12th June, the first Jersey case was confirmed.

At the time of writing most countries have reported cases of the new virus, initially widely referred to as swine flu, but more correctly now termed Pandemic (H1N1) 2009. Although most people infected to date have experienced a relatively mild illness, a minority have experienced severe illness and some have died, with the countries of the Southern Hemisphere worst affected during their winter season. With on average 10-20 flu cases a week in Jersey, together with the rest of the world, we too have been witnessing the beginnings of the 2009 influenza pandemic.

No previous pandemic has been detected so early or watched so closely, right from its inception. In Jersey we can reap the benefits of our pandemic preparedness planning which has taken place over the last four years. In addition intensive work has been underway since May to further develop the Community Escalation and Hospital Escalation Plans ready to face large numbers of flu cases during this autumn and winter. These recent plans have been tailored to meet the specific challenges posed by the new H1N1 flu strain.

Throughout the pandemic so far we have planned for the worse and hoped for the best. Pandemics are unpredictable, nevertheless, the financial plan attempts to quantify what may happen during the forthcoming autumn and winter period. With continuing efforts underpinned by investment to contain the spread of the virus, treat infection and ensure as far as possible the sustainability of our hospital, we would have taken every reasonable and practicable precaution to protect the people of Jersey.

The finite capacity of health care facilities and staff is of concern: one island, one hospital, one intensive care unit. Every effort must be targeted at protecting the capacity we have available so we can treat the most sick when they need care. The ability of the hospital to provide specialist care to those in need during a flu pandemic is reliant on adequate investment, as well as the effectiveness and funding of the Community Escalation Plan to prevent severe illness and keep extra hospital admissions to a minimum.

Pandemic flu is likely to be the biggest challenge yet to face the Island’s Health and Social Services Department with a vaccination programme offered to the entire population for the first time and potentially an unprecedented number of islanders unwell all at once. As Dr Margaret Chan, Director-General of WHO has said “We are all in this together, and we will all get through this, together.”

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1.0 Purpose of report

The purpose of this paper is to provide a summary of the actions required to manage the H1N1 flu pandemic which is expected to strike Jersey in the autumn of 2009. This report aims to inform the States Assembly of the risk mitigation strategy, proposed actions and potential cost.

2.0 Background

A major wave of illness due to pandemic influenza A H1N1 2009 (swine flu) is expected this autumn or winter. Access to additional funding is needed now to take action to reduce the impact on the people of Jersey. Preparations are also needed to allow Jersey General Hospital to be ready to expand to maximum capacity as we expect will be needed.

Robust escalation plans for community and hospital care are essential to manage during the major pandemic wave period if the hospital is to be able to care for those with the greatest health needs.

Since the end of April 2009, when ‘swine flu’ was identified and a pandemic declared imminent by the World Health Organisation (WHO), Jersey has been successful to date - to a major extent – in preventing the spread of the infection within the island. The first case of swine flu was diagnosed here on 12th June, one day after WHO announced that the spread of the new virus around the world met the definition of a global pandemic.

3.0 Current situation

Whilst Jersey has sustained and achieved success in containment (testing and identifying cases, offering Tamiflu to contacts), other jurisdictions have not been able to do likewise. The UK, where containment was abandoned in early July, remains the most heavily affected in Europe and the source of the majority of the 10-20 cases of the new flu occurring each week on the island.

In Jersey, we can now reap the benefits of our pandemic preparedness planning which has taken place over the last four years. Intensive work has been underway since May to further develop the Community Escalation and Hospital Escalation Plans ready to face large numbers of flu cases during this autumn and winter. The plans have been tailored to meet the specific challenges posed by the new H1N1 flu strain. Community efforts to prevent the spread of the virus and to treat people at home are of paramount importance in an island situation with limited healthcare resources. The primary aim is therefore to keep the impact of swine flu on Jersey to a manageable minimum and within the (expanded) capacity of Jersey General Hospital and to prevent deaths and serious illness as far as is possible.

4.0 Modelling the potential forthcoming flu outbreak for Jersey

Throughout the pandemic so far we have planned for the worse and hoped for the best. Studies of past flu pandemics suggest that infection, once established, has tended to spread through the island over a period of 4-6 weeks. Studying the nature of ‘swine flu’ outbreaks in other parts of the world has also shaped our island planning. Whilst this new pandemic remains unpredictable, the potential Jersey flu outbreak for this autumn and winter has been modelled (Figure 1).

Figure 1 - The predicted timeline and size of the pandemic wave

The model illustrates the large peak in flu cases which could occur as soon as early autumn 2009. Such a high proportion of the population unwell at the same time would be a major challenge to the island as a whole and a particular challenge for the Island’s health and social services. An expected scenario for this has been estimated (Table 1) bearing in mind that the range of activity could be extend above and below this estimate. Even with this forecasting and analysis work, it is impossible to predict with certainty how many cases will occur and how severe their illness would be.

Table 1 Estimated Increase in Health and Social Care Activity from H1N1 pandemic as a basis for planning

	Expected scenario

Est. Pop for pandemic flu assessment	100,000
Pandemic flu attack rate (New H1N1 strain 2009)	35%
Number of people unwell with flu Of those who become unwell, some would get better within a week and a number would go on to have more serious illness	35,000
Resolved within a week without complications	30,281 (87%)
Complications – Primary Care Treatment with additional Social Care issues	4,019 (12%)
Hospitalisation – Hospital Escalation Response	700 (2%)

It is anticipated that approximately 35% of the population would be affected by the influenza pandemic during a four to six week period. A high proportion of sufferers, 87% are expected to be ‘unwell’ but these people would recover simply with the aid of Tamiflu. A significant number though, 12% could require additional primary care treatment for flu complications e.g. chest infections. Finally, 2% are expected to require hospitalisation due to the severity of these complications and up to 0.4% could die prematurely as a result of swine flu infection.

The expected scenario assumes that the pandemic wave hits the Island in advance of the pandemic-specific vaccine being available. The use of Tamiflu as the main line of defence should decrease hospitalisations by about 60%. We are hopeful, however, that with continued effort to slow flu circulating among islanders, the vaccine could arrive in time to prevent much of the potential island flu outbreak.

5.0 Preparation, Containment and Treatment

Previous funding was agreed by the States in order to make preparations for pandemic flu (Proposition 67) in May 2008. This funding was largely used to stockpile certain supplies based on the premise that once the World Health Organisation (WHO) declared pandemic phases 5-6, stocks of essential supplies would not be available due to international demand exceeding manufacturer’s capacity to supply.

These preparations were relevant to any flu strain with pandemic potential so, much of the stockpiling of essential supplies for the current H1N1 flu pandemic threat have already been funded. Now that a pandemic is underway the action phases which are yet to be funded or remain partially funded are:

5.1 The containment phase

As a flu pandemic has now been declared by WHO, the aim is to initially contain the virus and minimize the spread within the community. This includes the Public Hygiene Campaign and the diagnosis and treatment of flu cases and their close contacts.

5.2 The community treatment and social care response

When the pandemic strikes and the Island can no longer remain in the containment phase, the aim will be to care for as many patients as possible in the community without them being admitted to hospital. GPs would be the mainstay of this work. Family Nursing and Home Care would divert resources to offer more care to flu sufferers and social care provision would need to continue and to be co-ordinated well.

5.3 The hospital escalation response

Inevitably there are those who would become so unwell that they would no longer be able to be cared for in the community and the hospital would have to be ready to respond. Up to an estimated 700 additional hospital admissions might be needed with patients suffering from severe chest infections and respiratory problems or worsening of their underlying medical problems.

To manage this additional activity extra beds and staffing would be freed up by postponing routine surgery to be cancelled and rebooked for after the pandemic. Also outpatient clinics would be reduced and some patients discharged to their home or to nursing or residential care if this was considered safe.

5.4 The vaccination programme

The aim of the vaccination programme is to offer vaccination to all islanders to protect them from the effects of this flu pandemic. If the vaccine becomes available ahead of the major wave then the number of people experiencing the effects of flu would be considerably reduced. This in turn would reduce work absenteeism, reduce losses to the economy and of course reduce the pressure on the hospital.

5.5 Estimated Costs

The total additional costs of managing the flu pandemic have been estimated as £5.5m (excluding all Social Security and Health Insurance Fund costs). The detail of this is shown in Appendix I

As a guide this sum can be broken down into the following estimates:

expenditure committed and spent to date - £0.3m
Further funds to be spent immediately as essential preparation and to sustain containment - £1.0m (£0.9m revenue and £0.1m capital)

Preparation expenditure and maintaining containment phase £1.3m

Funds needed during a major pandemic wave - £3.5m
Recovery costs - £0.7m

Pandemic management and return to business as normal phase £4.2m

The CMD Co-ordination Group – Pandemic Flu recommends that:

The Treasury and Resources Minister approve immediate access to £1.3m to enable the urgent purchases to date and the further necessary preparation and containment process to be funded.
a further £4.2m be made available to enable the Island to manage in the event of a flu pandemic.

The total additional cost, if the island suffers from an influenza pandemic is estimated at £5.5m (excluding £1.7m of Social Security and Health Insurance Funds costs).

There are no additional permanent manpower implications to this proposal, all staff costs are temporary appointments or payments to existing staff.

It is recommended that any additional funding is managed by the Minister for Treasury and Resources, with funding being issued to departments where the expenditure is proven necessary.

This recommendation is compatible with the overall island wide strategic aims of:

Protecting the people of Jersey against the consequences of pandemic swine flu
Organising and adapting health and social care systems to provide treatment and support for those suffering from pandemic swine flu or its complication.

Appendix I – Summary of Costs – Preparation, Containment Phase, Pandemic Wave and Recovery

Summary of Costs – By Phase

CHIEF MINISTER’S DEPARTEMNT (CMD) CO-ORDINATION GROUP – PANDEMIC FLU

H1N1 INFLUENZA PANDEMIC IN JERSEY: URGENT FUNDING REQUEST REPORT

1.0 Purpose of report

The purpose of this report is to state the case for the urgent expenditure of £1.3 million for the further containment and preparation phases for Pandemic influenza (H1N1) 2009 - previously known as swine flu.

2.0 Background

A major wave of illness due to pandemic influenza A H1N1 2009 (swine flu) is expected this autumn and/or winter. Access to additional funding is needed now to take action to reduce the impact on the people of Jersey. Preparations are also needed to allow Jersey General Hospital to be ready to expand to maximum capacity, as we expect will be needed.

The finite capacity of health care facilities and staff is of concern: one island, one hospital, one intensive care unit. There is no doubt that even with an effective community response the Jersey General Hospital will have to get ready with plans and supplies to admit a lot more patients than usual.

Pandemic flu is likely to be the biggest challenge yet to face the Island’s Health and Social Services Department with a vaccination programme offered to the entire population for the first time and potentially an unprecedented number of islanders unwell all at once. The situation currently faced by the island, and indeed the world, is exceptional, with the flu pandemic predicted to reach proportions last seen in 1968.

Purchases of the antiviral drug tamiflu and the H1N1 vaccine have already taken place, along with other preparations. The cost of these preparations to date amounts to £2.9 million; this has been funded from previous expenditure approvals. This report recommends further immediate expenditure relating to the containment and preparation of H1N1 influenza.

3.0 Current situation

We now stand at a junction with broadly two possibilities as to how the flu pandemic will affect Jersey during this autumn and winter:

Optimistically:

We will continue to be successful in containing the spread of the virus until the vaccine arrives and, through an island-wide vaccination programme, largely prevent the outbreak of flu which is imminent.

Or:

The vaccine will not be available soon enough and in sufficient quantities to prevent the majority of the cases we expect. In this case, the approach would be to protect flu sufferers as far as possible from serious illness by treating them with the antiviral drugs Tamiflu or Relenza and through enhancing the capacity of GP and other community health services. This approach would in turn prevent the hospital from becoming overwhelmed; the hospital should then remain in a position to treat those islanders who do become seriously ill as a result of flu. NB Vaccination would also be offered in due course, under this scenario, to prevent a potential second wave of flu.

The current situation remains current for a relatively short period of time in relation to the new flu. The situation changes weekly across the world and locally with new findings emerging which require our planning and actions to be flexible and timely.

4.0 Funding request

Expenditure on the equipment, consumables and services detailed below is required immediately to respond to the threat of a wave of illness relating to H1N1 influenza that will affect a significant proportion of the island's inhabitants.

There are insufficient funds available within existing budgets to meet these immediate costs.

Resources are needed immediately to address the following phases of the pandemic flu response:

Continued containment to prevent the spread of the virus
A vaccination programme to protect islanders from becoming infected
Community treatment for those who could be about to become ill
Hospital escalation (increasing hospital bed numbers) in order to ensure sufficient hospital capacity to treat those with severe illness as a result of flu.
Preparing for the possibility that more deaths may occur than usual.

It is estimated that the cost of these phases (i.e. containment and preparation) could total £1,347,000. The following paragraphs detail this proposed expenditure.

4.1 Containment (estimated cost £216k)

At the current time the island is in the ‘containment phase’ which means limiting spread from the small number of cases as they occur. It is important to remain in the ‘containment phase’ for as long as possible.

A mainstay of this phase has been the public awareness campaign – ‘Catch it, bin it, kill it’ and the more detailed advice available through leaflets. This campaign will be ratcheted up further during the next few weeks. The approach advises hygiene measures which individuals can follow to protect themselves and others.

GPs have already become extremely busy with additional home visits and it has been agreed that patients will be funded by the Health Insurance Fund for the difference of the cost of a home visit versus an appointment at the surgery if the home visit is associated with suspected flu.

For each flu sufferer, once H1N1 flu is confirmed (following the result from a throat swab sent to a laboratory in the UK), their contacts are identified and offered a course of Tamiflu in order to contain and prevent the spread of the virus.