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Pandemic Influenza

Volume 467: debated on Thursday 22 November 2007

With permission, Mr Speaker, I should like to make a statement on the publication of the national framework for responding to an influenza pandemic and to provide the House with an update on the progress we have made to improve the UK's ability to respond to a pandemic. I will cover overall public health strategy and our approach to the use of clinical countermeasures, such as antivirals and antibiotics.

Influenza pandemics occurred every 30 to 40 years in the previous century. The last pandemic, in 1968-69, resulted in 80,000 additional deaths in the UK. The possibility of a new pandemic is one of the most severe risks currently facing the UK. Our planning assumptions are that 25 to 50 per cent. of the population may become ill and that, in accordance with previous analysis, between 0.4 per cent. and 2.5 per cent. of those affected could die.

So that the country will be prepared for the next pandemic, whenever it occurs, I am today publishing a new national framework. It builds upon and supersedes the UK influenza pandemic contingency plan published in October 2005, expanding it to cover a more comprehensive range of impacts and responses.

The draft national framework was issued for public discussion in March. This final version reflects a number of issues raised during the period for public discussion and takes account of the practical lessons identified from the national simulation exercise for an outbreak of pandemic flu, Operation Winter Willow, which took place earlier this year.

So that we are as prepared as possible, the framework suggests that more emphasis needs to be placed on planning at the upper ends of possible clinical attack and complication rates. Although the pandemics during the last century resulted in attack rates at or around 25 per cent., it is important that we consider a higher “reasonable worst case” scenario to ensure that our arrangements are robust and resilient.

The framework also includes the planning assumptions that describe the Government's likely position on such issues as school closures, and advice on social gatherings and the use of public places. The national framework will help organisations across government and in the private and public sectors to work together to prepare pandemic plans that can cope with a reasonable worst case scenario.

The framework is supported by a range of guidance. We are publishing an ethical framework for policy and planning, guidance on the provision of health care in a community setting and guidance to assist acute hospitals, social care services and ambulance services in their planning. We are also issuing for public discussion draft guidance on the following: death and cremation certification, proposing legal and other changes in the event of a pandemic; mental health services, assisting mental health trusts in developing their plans; surge capacity, managing the prioritisation of health services and patients at the peak of any pandemic; and NHS human resources guidance, dealing with the work force issues that may arise.

We are also launching a consultation on possible amendments to medicines and related legislation for use during an influenza pandemic. These aim to support the mass distribution of medicines and the maintenance of access to routine medicines at a time when front-line health care professionals will be focused on the most seriously ill. I have allocated additional funding of £10 million this year to assist the NHS in developing these plans. I expect every NHS organisation to have robust plans in place.

In the event of a pandemic there will naturally be a great deal of public concern. Our planning assumption is that we will rely on voluntary compliance with national advice during that period. However, should it be necessary to invoke emergency measures, we are taking public health powers in the forthcoming Health and Social Care Bill that could be considered in the event of a pandemic.

The development of the national framework and our response to pandemic influenza is grounded in the most up-to-date scientific evidence. The Department of Health’s scientific advisory group on pandemic influenza takes into account evidence from the UK and across the world. Under its auspices, independently peer-reviewed scientific papers were published in August 2007, dealing with the clinical countermeasures and the risk of a pandemic originating from an H5N1 virus.

It is clear from the science that good basic hygiene measures must be at the heart of our response. Using a tissue when coughing and sneezing, disposing of it carefully and washing hands often will reduce the spread of influenza, as well as of common coughs and colds. The latest public health campaign, “Catch, it, Bin it, Kill it”, is being launched to raise awareness of the importance of good respiratory and hand hygiene. It builds on the success of earlier campaigns.

Science has also informed our strategic approach towards stockpiling the clinical countermeasures we will need to fight a pandemic. The countermeasures will enable us to treat the symptoms of pandemic influenza, to reduce the number of complications and deaths and to reduce the spread of the virus.

To make sure that the UK has access to a pandemic vaccine I have signed advance supply agreements with GlaxoSmithKline and Baxter to deliver enough vaccine to cover the entire population. It should be the most effective vaccine against the pandemic virus. Those agreements mean that we are among the first countries to have contracts in place, and we will have a guaranteed supply of vaccine at a time when there will be significant international demand. Delivery of the vaccine is not immediate, however, as it can take a few months to develop an effective vaccine once the virus causing pandemic flu has been identified. It is important, therefore, that we obtain additional countermeasures.

Antiviral medicines are key to our response. If they are administered quickly to all patients with symptoms, they can reduce the duration of the disease and the risk of complications. To make sure that the UK has enough of the most common antiviral, Tamiflu, we have created a stockpile to treat a quarter of the population, assuming the rate of clinical attack seen in previous pandemics and putting us on a par with measures taken in countries such as Germany and the US.

I can tell the House today that the Government are planning to double the stock of antivirals, to cover at least half the population. We will continue to keep the level of stock under review in light of the scientific evidence, as we develop our business case.

The World Health Organisation has recommended that, in the event of a pandemic, antibiotics will be needed to prevent and treat the secondary bacterial infections that are likely to be the main cause of complications and deaths. Recommendations for the use of antibiotics are included in clinical management guidelines published recently by two medical journals, Thorax and the Journal of Infection.

The Government plan to procure 14.7 million treatment courses of antibiotics to treat and prevent the complications arising from pandemic flu. That stockpile will enable us to give antibiotics to vulnerable symptomatic flu patients, such as those with chronic conditions and the elderly, in advance of the development of secondary complications, and to treat others in the community if they develop complications. The antibiotics will also be used in hospitals to treat the sickest patients and may reduce the length of hospitalisation. The procurement of both antivirals and antibiotics will be subject to emerging scientific evidence and to normal commercial procurement procedures to ensure that we purchase those products at the best price, and achieve value for money for the taxpayer.

Maintaining the resilience of the NHS and social care will be critical. We must ensure that essential NHS and social care workers on the front line, caring for people with influenza, are protected. The World Health Organisation advises that health workers should wear face masks when caring for patients with influenza and use disposable respirators when carrying out clinical procedures likely to generate fine droplets from infected patients. The Government plan to purchase about 34 million disposable respirators and about 350 million surgical face masks for the use of health and social care workers in the event of a pandemic.

Although the available medical evidence does not support the use of face masks in all settings, I recognise that people may want to have access to face masks for their personal use. The Government will explore the approach that retailers are planning to adopt when stocking face masks for sale to the public.

Pre-pandemic vaccine is the only clinical countermeasure that can be used before the onset of the pandemic, but its success will depend on how much protection it gives against the actual pandemic virus, which is, of course, unknown until it strikes. The Government have a stockpile of 3.3 million doses of H5N1 pre-pandemic vaccine for health care workers. Its purchase in 2006 was an important step, designed primarily to support the health care response to the pandemic. The science underpinning the further development and potential use of pre-pandemic vaccine is cutting-edge and has just been reviewed by UK and international experts. We are actively considering their findings, and the implications for our policy, to inform future decisions, and I will update the House on any developments.

The preparedness strategy for pandemic influenza represents a significant investment. In assessing the options, we will ensure that value for money is balanced with the need to be certain that the UK is properly prepared. The significant progress we have made in protecting the UK has been recognised internationally, and we continue to work closely with the World Health Organisation. Dr. David Heymann, the assistant director general for health security and environment at the WHO, said this week:

“The UK is still in the vanguard of countries worldwide in preparing for a pandemic, and is also one of the leading global players in addressing the cross-sectoral issues in their planning.”

I can also announce that we have pledged a further £2 million to support the global pandemic influenza action plan to increase vaccine supply to help develop capacity to secure vaccine supplies for the developing world.

Today’s publication of the national framework and the ongoing work to develop our preparedness strategy reflect the importance the Government attach to responding to the risk of an influenza pandemic for the UK. This is not an issue for partisan politics, and I am grateful for the constructive engagement of the hon. Members for South Cambridgeshire (Mr. Lansley) and for North Norfolk (Norman Lamb). To that end, I will arrange for them to meet the Minister of State, Department of Health, my right hon. Friend the Member for Bristol, South (Dawn Primarolo), and key officials to discuss our plans in more detail.

I commend the statement to the House.

I am grateful to the Secretary of State for advance notice of the statement and for the opportunity briefly to look at the national framework document published today. Although originally Ministers said that it would be published last January, I welcome its publication and the further measures that the Secretary of State announced, including the acquisition of a stockpile of face masks. He will recall that it is just over two years since we first asked his predecessor to do that. It has taken that long, but we hope the stockpile will be in place before any threatened pandemic eventuates.

I welcome, too, the Secretary of State’s announcement of £10 million for additional support for NHS planning. It is important that the work be done, and at present primary care trusts cannot allocate additional resources for it. The £2 million for the World Health Organisation is also welcome.

On finance, the Scottish Executive made it clear in a recent document that this year they expect to spend £5 million on pandemic preparations. From that, I deduce that the Secretary of State in England is probably expecting to spend about £50 million this year. Will he confirm that?

I thank the right hon. Gentleman for his remarks about the constructive engagement that began under his predecessor. I look forward to further discussions. He has responded today to some of the concerns I raised in our correspondence and I am grateful for that. None the less, I have a few specific questions.

The Secretary of State made it clear that he is responding to scientific advice from the Department’s scientific advisory group. He will be aware that the group looked at one model whose effect would have been such that even if one of the component interventions was ineffective it would none the less be possible to meet the targeted strategy, but the group noted that

“the impact of this combination is such that only localised outbreaks of seasonal flu proportions would be expected with all interventions effective”.

The scientific advisory group is modelling for an extremely effective countermeasures strategy, but within that there is not just a 50 per cent. antiviral stockpile, but a 75 per cent. antiviral stockpile. Although the Secretary of State says that he is not at the moment making any proposal for a pre-pandemic vaccine, the countermeasures contemplated in that model by the scientific advisory group include a 100 per cent. pre-pandemic vaccination. So will he undertake to consider in those discussions whether that is a viable model to allow further countermeasures to be put in place?

On a pre-pandemic vaccine, the 3.3 million doses of H5N1 that we have in hand were bought not only for possible use with health care workers, but for research. The Secretary of State knows that he cannot explain why they have not been used for any research, but research into H5N1, other vaccines and, indeed, vaccine technology is a vital part of our long-term preparations. Even if a pandemic does not occur in the next year or two or three—if it is 10 years hence—the efforts that we take now to improve vaccine technology so that we have cell-based or even DNA vaccines to respond much more quickly to a pandemic could be something for which we will be extraordinarily grateful in future.

The Secretary of State is still buying antivirals on the basis of treatment only. Will he undertake further to consider prophylaxis, particularly household prophylaxis, for antivirals and the acquisition of a stockpile for that purpose? Will he tell the House whether he has considered the threat of resistance developing to Tamiflu and whether he contemplates any subsidiary stockpile of Relenza, for example, for that purpose?

The framework document is very limited in its response on critical care beds. It is quite clear from work done by the Intensive Care Society two years ago that our critical care capacity will be overwhelmed in the event of a pandemic. It called for a doubling or a tripling of critical care capacity. What steps has the Secretary of State already put in place to expand critical care?

On school closures, the framework still pretty much says, “We’ll see where we get to, and then the Government will issue advice.” Did not Operation Winter Willow, if it was realistic, suggest that the Government will not be in a position to decide whether schools close in a severe pandemic? Parents will keep their children at home. Schools will close. Large numbers of health care workers and others will be at home, looking after their children. We must have a strategy in place that understands human behaviour in circumstances where the pandemic is severe.

Are the Government considering following the example set by the American Government of having not only WHO alert status, but their own view of the relative severity of a pandemic to guide the selection of countermeasures? It is certainly true that schools in America have already sent guidance to parents about what would happen at their school in the event of a pandemic.

I am sure that what the Secretary of State said about the WHO and developing countries is very welcome, but he will know, and the House should understand, that if there is a pandemic with a high case fatality rate and as many millions of people in developing countries are immune-compromised as a result of HIV/AIDS, the potential threat worldwide is dramatic. So it is increasingly important that, for example, the Department for International Development and the Department of Health jointly work on trying to support contingency planning and countermeasures in some of those developing countries.

People often say, “We had BSE. We had SARS. We’ve had one scare after another. Isn’t this just another scare?” Frankly, it has never been my view, as the Secretary of State knows, that this is just another scare. We had three pandemics in the last century. The characteristics of this one, with H5N1 persisting in the bird population alongside large numbers of humans, are probably more like those of 1918. The case fatality rate in 1918 was 2.5 per cent. This is a severe pandemic. It might not happen in the next few years, but it will happen at some point. Therefore, the measures that we take, as an insurance premium, remain modest in relation to the dreadful consequences of suffering from a pandemic on that scale, without those countermeasures being in place.

I have no doubt that Britain remains among those who are best equipped and have some of the best planning in place, but so we should be. I hope that we will be an exemplar to other countries, both in how we respond here to a pandemic and in how we support others, particularly the least developed countries.

I very much welcome the hon. Gentleman’s constructive remarks. To pick up some of the issues, first, my right hon. Friend the Minister of State, Department for Transport said, when a Health Minister, that we would have a report ready in January. In essence, having the framework available now has allowed us to take full cognisance of Operation Winter Willow and to take into account the responses, because we had a closing date of 16 May for people to respond to the lessons that were learned. So the framework is better for the short delay.

The hon. Gentleman asks about the amount being spent, but may I give a hazard warning? I am perfectly willing to answer all questions on how much we spend on antivirals, antibiotics and so on after we have clinched a deal. The problem with our talking about the amount that we plan to spend is that it hampers our ability to get a good commercial deal. I can tell the hon. Gentleman that the advance supply agreements, for instance, cost £155.4 million over four years and the amount that we spent on H5N1 was £33.4 million, but I am reluctant to give the global figures for the stocks that we are due to negotiate on.

The hon. Gentleman mentions the scientific advisory group’s option about 75 per cent. coverage. He is absolutely right that that was an option. The question is whether that is a viable model, and the scientists are still discussing the answer and whether we can use the antiviral for prophylaxis, because that very important issue is still subject to emerging science.

The hon. Gentleman makes an important point about using H5N1 vaccine for research. He knows that I said in a frank piece of correspondence with him earlier this year that I did not know why it was not being used for research, but we can discuss why we cannot use that for greater research when we have the scientists in front of us.

Work is going on to look at Relenza, because of some evidence that people might become resistant to Tamiflu and because it is advisable to have two drugs available. At the moment, Tamiflu is the only one.

On critical care capacity, when the hon. Gentleman sees the surge capacity guidance, he will realise that we spend a great deal of time considering how we can deal cost-effectively with a surge that is likely to arise from a pandemic, and critical care is obviously a factor of that.

On school closures, I had some wise advice from my right hon. Friend the Member for Blackburn (Mr. Straw), who told me that when he was at school in 1957, during the Asian flu outbreak, the school was closed down. It is good to have such distinguished, wise and elderly colleagues in Cabinet to tell us about such things. Essentially, we believe that the best thing that can possibly happen is that anyone who has symptoms of pandemic flu goes home and stays there; they should not go anywhere where they might spread it. That is why we now say in the guidance that there has been a change in the assessment programme for antiviral access, for instance, for children under seven. Previously, the guidance said that they should be initially seen by a GP. We now think that we can deal with that through the national flu line service, thus avoiding parents having to take ill children to doctors’ surgeries, where we could get a greater spread.

The other very important point that the hon. Gentleman makes is about the need for international co-operation, particularly in relation to HIV/AIDS and having DFID, the Foreign and Commonwealth Office and our Department working together. We do that through the WHO, and it is a very important part of the partnership approach to the issue.

Finally, the hon. Gentleman is absolutely right in saying that this is not another scare. It is very important to reassure the public that we are not making this statement on the framework because there is an impending outbreak of pandemic flu; we are doing so because there were no national plans in 1968 for Hong Kong flu, which was the last outbreak, when we just fudged everything and got through as best we could. We need to have these plans. The hon. Gentleman is right that there will be an outbreak of pandemic flu—it is not a question of if, but a question of when—and it is right that this country is properly prepared.

I am grateful to the Secretary of State for his early contact today to alert me to the statement and for early sight of the statement itself. He and the Minister responsible for public health have my reassurance that I am keen to co-operate fully on the process and look forward to hearing further about arrangements to meet with scientists and so on.

The statement comes just a fortnight after the outbreak of avian flu in my part of the world, in Suffolk. I fully understand that, as the Secretary of State made clear, there is not any fear of an imminent outbreak, but I guess that he would agree that we have been given a timely reminder of the absolute importance of getting a robust framework in place without delay.

On capacity in the NHS and social care, we talked yesterday about occupancy rates with regard to hospital-acquired infections. Is a system that is under quite a lot of strain in terms of capacity, in relation to both health and social care, in a state to cope with a pandemic flu outbreak? Is there a need to look further at whether to increase capacity in the NHS and social care?

On international action, I note that the Secretary of State made it clear that the UK is ahead of the game. That is good to hear. However, presumably it is important, in terms of our own interests, quite apart from the interests of others, to promote effective action across Europe—quite apart from globally. What co-ordinating work is taking place with other European countries to ensure that they get their plans in place effectively? A report from the WHO found that less than half of the EU countries surveyed provided defined plans for the distribution of antivirals or specific guidance on where vaccines would be stored, how they would be distributed and who would administer them. Two thirds of national plans depart from WHO guidelines on the crucial step of limiting people’s movements from affected to unaffected areas. What is the Secretary of State doing to ensure that the whole of Europe responds effectively and in accordance with WHO guidelines?

In December 2005, the House of Lords Science and Technology Committee issued a report that questioned whether the Department of Health could provide strong enough leadership in the event of a flu pandemic. It recommended the appointment of a Cabinet-level Minister, who would be responsible for co-ordinating implementation of a framework plan if there was a pandemic. Has that been considered, or is it under consideration currently? Is the Secretary of State happy that there is sufficient co-ordination with other Departments, and also, critically, with local government and public agencies? Reference has been made to the provision of resources to help the planning process. Does local government have sufficient resources to plan effectively in co-ordination with national Government?

Finally, on the time scale, can the Secretary of State give some indication of when the meetings in which the Conservative spokesman and I are to be involved are likely to take place, and when he hopes to get a final framework in place? We are all agreed that that is of the utmost importance and we all have a shared objective to get it in place as soon as possible.

I thank the hon. Gentleman for his constructive approach to the issue. He mentioned H5N1 in Norfolk. I know that he knows the medical advice, but it is probably as well if I read into the record the fact that H5N1 is predominantly an infectious disease of birds and that there is very little evidence of widespread human infection thus far, just as there is very little evidence of the kind of easy person-to-person transmission required to cause a human flu pandemic. However, H5N1 is a potential seedbed for the emergence of such a virus, which is why poultry workers in his constituency have been given the vaccine for H5N1 and offered regular seasonal flu jabs.

The hon. Gentleman asked whether the NHS will be able to cope. Yes, we are sure that it will. It will be able to cope much better for having gone through the national simulation project, Winter Willow, earlier in the year. We keep the situation constantly under review. The NHS showed its capacity to respond in relation to events such as the floods in Gloucester and my area recently. The situation, once the pandemic strikes, will of course be on a far bigger scale. However, all the evidence is that the NHS is ready to step up to the mark in these situations.

The hon. Gentleman asked about effective action across the EU. He is right that there is a necessity for that. The Minister of State, my right hon. Friend the Member for Bristol, South, hosted a conference in July of other European member states, and there was a discussion through the WHO in Washington recently, which included most European Union member states. We are all interdependent in the European Union, which is an important reason why the EU can give a focus to dealing with a pandemic. If the EU did not exist, we could not have that kind of cross-country co-operation.

The co-ordination in this country would take place through Cobra, chaired by the Prime Minister. The hon. Gentleman asked about co-ordination with public agencies. Gold command was another example of public agencies working together very well, in terms of both the security threat and the recent floods. I have absolutely no doubt that public agencies will be able to cope in the event of a flu pandemic.

Finally, the hon. Gentleman asked when we should have the meeting with my right hon. Friend the Minister of State and the experts and scientists. That should take place as soon as possible. I was talking to the hon. Member for South Cambridgeshire earlier. Perhaps we should organise a Hansard Society debate on the issue so that we can have all the available experts participating, as well as having important debates in the Chamber.

I thank the Secretary of State for an excellent statement. I am sure that the entire country will be pleased to hear that not only is Britain more prepared than any other country in Europe, but we are more prepared than we ever have been. The most effective and likely way of dealing with pandemic flu is the development of an effective vaccine. There are two problems with that. First, we have to develop the vaccine when we have the virus, and therefore we cannot do it yet. The second big problem is capacity for production. The biggest bottleneck we have is that, when there is a vaccine available, it will take some time to produce enough doses. What discussions has the Secretary of State had with vaccine manufacturers to ensure that there is enough mothballed capacity in the vaccine manufacturing industry in Europe and across the world to ensure that we get enough doses quickly enough when the vaccine is developed?

My hon. Friend raises a crucial point. That was an essential element of our negotiation of the advance supply agreement. We have the agreement with two companies: Baxter’s and GSK. Part of that is to ensure that we get the proper level of supply, and to ensure that, in the event of an outbreak of a pandemic, the country that the vaccine is manufactured in ensures that it reaches this country and is not prevented from doing so by measures taken in the country of production. That is why we have insisted that the vaccine must be manufactured in the European Union and why we have insisted on a clause stating that either the country of manufacture must have an agreement for sufficient supplies to the host country or that the companies must make that country aware of the agreement with this country. That is as far as we can go to ensure that we have the proper measures. The fact that we have the advance supply agreements in place—only two or three countries have similar agreements, so we are one of the first—means that we are better placed than most other countries to deal with the situation.

I congratulate the Secretary of State for Health on coming to the Chamber to make a statement. Perhaps he could have a word with his chum the Secretary of State for Transport to tell her that that there is nothing to be frightened of and that perhaps she should give it a go now and again.

One group that would clearly be under threat from an influenza pandemic is elderly people and those who are already infirm. Can the Secretary of State give any guidance on what advice would be given to people to be “good neighbours”? In rural areas, such as the area where I live, there tends to be a good neighbourhood policy in any event, particularly in relation to elderly people and those who live alone. One of the loneliest places, from my experience, is a city with a population of millions. People may live in a block of flats but still not talk to anybody on a day-to-day basis. Perhaps advice could be given that, particularly in the lead-up to what could be an outbreak of a flu pandemic, people should be good neighbours, look more carefully at people who live around them, and provide guidance and lifts to pharmacies or GPs.

The hon. Gentleman raises an important point, and guidance is an essential element. We are saying that if a person has any symptoms of the flu, they should go home. For the vast majority of the population, a flu pandemic will mean a couple of days in bed, and then they will be fine. The essential thing is that they do not spread the disease, so we advise them to stay at home.

We use the terminology “a flu friend”. A person with symptoms should not go to the pharmacy to collect their drugs, as they are likely to spread the illness. They should stay at home, and a friend, member of the family or colleague will go to the pharmacy for them, collect the antiviral, which is taken in tablet form, and take it home to them.

One of the many reasons that I am proud of this country is that there is still a community spirit. We saw it in the floods, and we see it every time there is an emergency. People are good at ensuring that they do as much for their community as possible. There can be a problem with ensuring that proper advice is given to people in isolated rural communities, who sometimes do not see a human face from one week to the next. We have to make sure that if they do not have relatives or friends nearby, someone is there and is responsible for ensuring that they receive the proper antiviral.

The Secretary of State has made it clear that there is no chance of people catching avian flu from eating poultry, provided that it is properly prepared and cooked. Given that this is an important time for the poultry industry, will he work with his colleagues in the Department for Environment, Food and Rural Affairs and with the industry to promote that message in the run-up to Christmas?

I will do that, but I am absolutely sure that my right hon. Friend the Secretary of State for Environment, Food and Rural Affairs needs no reminding. I have heard him make the point absolutely clear. It is essential that people are reassured that there is absolutely no danger from eating turkey—provided, of course, that it is cooked properly. If it is not, there would be a danger in any circumstances.

As has been said, effective pre- and post-pandemic vaccinations are likely to be the most important tools for limiting the severity of an outbreak. The speed at which vaccines are developed is very important. It depends greatly on international surveillance to identify any emerging pandemic, including perhaps in less developed countries that do not have the facilities. What support are our Government giving to worldwide surveillance, so that we can identify any potential pandemic?

We are completely supporting the World Health Organisation’s attempts to ensure that that takes place. I have announced the extra £2 million that we are providing to ensure vaccination in developing countries. We are better placed than we were when previous pandemics broke out, as there is closer collaboration with other countries and better communications. That can mean that the pandemic spreads more widely, more quickly, so it is a double-edged sword. Surveillance, the necessity of concentrating on tackling an outbreak wherever it is in the world, and ensuring that the outbreak is an epidemic, not a pandemic, are central features of trying to protect the British public.

I declare a personal interest, as my wife is a director of public health. I first questioned the attack and fatality rates in the Department’s assumptions last July, so I very much welcome a fresh look at those assumptions. Why is the Government’s worst-case fatality rate still only 2.5 per cent., given that among humans catching the avian variant the fatality rate is in excess of 50 per cent., and given that the Department has accepted that there are no comparable statistics for the precursors of earlier epidemics? Secondly, will the Secretary of State work with Ministers in the Department for International Development to increase production capacity in south-east Asia for pre-pandemic antiviral treatment, which might help to suppress an outbreak at source and increase global capacity for antiviral production?

All I can say to the hon. Gentleman is that we are following the best scientific advice, which is still that the upper level for deaths will be 2.5 per cent. of those affected by the pandemic. That remains the case, and that is the reasonable worst-case scenario. To take absolute precautions on the reasonable worst-case scenario, and ensure that we have what we call defence in-depth, we should move from 25 per cent. coverage to at least 50 per cent. coverage. The scientific advice is very much with us on that. The mortality rate remains 2.5 per cent. I suggest that the hon. Gentleman speak to his hon. Friend the hon. Member for North Norfolk (Norman Lamb), who can explore the issues when we gather with the experts, but that still remains the best scientific evidence, and I must be guided by that evidence.

Inner-city communities such as mine are characterised by very high population turnover—we have 30 per cent. change on the electoral register—high diversity, and a very low proportion of registration with GPs. That feeds through into relatively low screening and immunisation rates across the board. That is bad enough for measles, mumps and rubella and cervical cancer; it could be catastrophic in the circumstances that we are talking about. Will my right hon. Friend assure me that he is liaising with primary care trusts, hospital trusts and local authority organisations to deal with the particular pressures on inner-city communities, where people are not registered with GPs? There is also the issue of casualised workers who do not have sick pay entitlement; we need to have a dialogue with employers, to encourage them to ensure that employees take time off when symptoms occur.

My hon. Friend is right to say that that co-ordination is essential. Our plan is for the national flu line service, run by NHS Direct, to be the first port of call. GPs’ surgeries, and hospitals in particular, should be left for the most serious cases. Our plan is that people ring an easily accessible number and explain their symptoms. The national flu line service can then ensure that there is a supply of antivirals ready to be picked up from a supply depot. The flu friend I have talked about would then go and collect it for them. In the vast majority of cases, there will be no need to go to a GP’s practice. We have to make sure that people understand that, and understand the arrangements that are in place, so that when there is a pandemic outbreak, the national health service and GPs’ surgeries are not inundated with people who are there because they think that the GP may be able to do something for them, when we have plans in place to ensure that antivirals can be distributed without the GP being involved.