The dramatic escalation in the swine flu pandemic has prompted the government to accelerate measures to combat what has become a nationwide surge in cases.
A new telephone helpline and website for people who fear they have swine flu have been established to speed up the supply of Tamiflu, but with the number of people affected rising and predictions that the death toll across the UK could reach 65,000, hospitals are preparing to implement "special measures".
These would see operations delayed, appointments cancelled and staff redeployed as the NHS is forced to prioritise which patients are in most urgent need of treatment.
The National Pandemic Flu Service for England is expected to be operational by the end of next week, Sir Liam Donaldson, the government's chief medical officer, said. A telephone and internet-based service will put callers through a questionnaire about their symptoms in order to get a diagnosis of swine flu. A unique reference number will allow them to access Tamiflu, the antiviral drug that has been the NHS's main response so far to the H1N1 virus. A "flu friend" can then collect the medication from one of a series of secure depots around the country.
The devolved administrations in Scotland, Wales and Northern Ireland will not be part of the NPFS, but will continue to rely on frontline services to treat patients.
Donaldson acknowledged concern that some people might lie to the health line to obtain the drug. He said he was relying on the public's honesty to ensure that, once the answers to the questions became known, not everyone would automatically give them, in order that supplies could go to those most in need.
Some 2,000 people will initially staff the call centres, although more will be deployed if necessary. Many in the NHS have been asking for some weeks for such a service to be set up, and opposition politicians and senior doctors have publicly questioned the delay. The service was agreed months ago.
The Department of Health has judged that the pace of events now makes it a necessity, in order to relieve growing pressure on GPs and hospital A&E staff.
London, one of the worst affected "hotspots", alongside the West Midlands, is starting to experience significant pressure on its health services. People in Tower Hamlets, east London, are visiting their GP about swine flu more often than anywhere else in England, with 759 consultations per 100,000 population. The boroughs of Hackney, Islington and Lewisham are also badly affected.
"Hundreds of patients a day, all the way across London, are turning up at hospital A&E departments, GPs' surgeries and walk-in centres and calling NHS Direct," said Andy Wapling, head of emergency preparedness at NHS London, which oversees health services in the capital. "These are people who think they have got it, although some turn out not to."
One hospital in London is seeing 50 people a day more than usually present with flu symptoms at this time of year.
Although few of those are being diagnosed with the H1N1 virus, the others – who include what Donaldson called "the worried well" – are still adding to pressure on the casualty departments in the capital.
"This isn't an emergency at the moment, because the service is coping without having to switch off any non-urgent services. But it has the potential to become one," said Wapling. "At the moment we are coping, because people are just working harder to help. But if it does become a flu pandemic emergency we would take special measures to help us cope – that is, we would re-adjust how we do our business."
"Special measures" would include cancelling non-urgent outpatient appointments in areas such as chiropody, delaying elective surgery and redeploying staff to help cope with people left seriously ill with swine flu. "However, all the things we do to keep people alive, such as cardiovascular surgery and cancer surgery, would continue," he added.
The huge numbers of people now falling ill with flu-like symptoms may indicate that it is only a matter of time before certain hospitals have to implement such rationing of services. Those in London and the West Midlands are likely to be the first to go down that route. Donaldson said that pressure on the NHS in such hotspots was "absolutely intense".
The NHS has also made plans for hospitals in the worst affected areas to transfer swine flu victims to other hospitals potentially miles away under unprecedented "patient sharing" arrangements, because most have only a finite number of beds and intensive care capacity.
Anyone whose life is at risk because they have contracted the virus could be treated in intensive care units in another part of the country, if things worsen sufficiently. Already 652 people in England are in hospital, although only 53 of them are in intensive care.
Department of Health and senior NHS officials say their plans have been prepared on the basis of "standard reasonable worst case assumptions" – that is, assuming that the wave or waves of the pandemic ultimately affect 30% of the population overall and 50% of children.
Whether more drastic measures will have to be considered – such as postponing summer holidays for NHS staff and even more serious reprioritisation of who gets treated for other conditions – will depend on the virus's progress and behaviour over the summer. If it mutates and becomes more deadly, the NHS may think again.
