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Don't let pharmacists cream the easy patients from the top

Giving flu vaccination services to pharmacists is a false economy, as at-risk patients may be missed and GPs can’t afford to run mop-up schemes, says Dr Charlotte Jones

GPs are not against any properly thought-through initiative to improve flu vaccination uptake. However, the widening of the programme to allow community pharmacists to offer the jabs has been publicly questioned by many GPs – and the GPC in particular – who doubt the need for the move. Some have called for the whole scheme to be overhauled.

GPs have been the lynchpin for the successful delivery of most of the public health vaccination programmes for many years and they generally do an excellent job.

We are relied on to deliver the large-scale programmes like the flu campaign, as well as ‘mop-up’ schemes when other healthcare professionals are unable to capture their entire cohort.

Unfair fees

But the latter is done for the same vaccination fee, which is not appropriate. Delivering a large campaign brings economies of scale and efficiencies. The same cannot be said of ‘mop-up’ and catch-up campaigns.

In Wales, we have had community pharmacists included in the programme for the past two years. Their involvement is based on a desire to increase uptake, especially in those hard-to-reach groups GPs were apparently ‘failing to capture’.

Our experience has clearly demonstrated that this change has not done what it was supposed to do. A tiny number of additional immunisations were given by community pharmacy across Wales – the latest figures available show 1,537 in total.1 Many individual surgeries deliver more than this.

If you factor in the training costs and additional administration of including pharmacists, the cost-effectiveness argument is clearly not made. Also, pharmacists don’t have to send formal invitations to patients in at-risk groups, and can charge a private fee if they vaccinate customers who are not in those groups.

The risks of saying no

The programme as it stands looks and feels unfair.

There is a real risk that GPs will start saying ‘no’ to aspects of work that are no longer viable from a business perspective, particularly for smaller programmes that rely on GPs picking up this work where either there is no alternative, or other healthcare professionals are unable or do not wish to do it consistently across the UK.

What will inevitably happen is that when the chief medical officers suggest increasing vaccine orders, practices will rightly consider whether they can afford to do so if they are likely to be left holding expensive stock at the end of the campaign.

If GPs were to disengage from flu vaccination or the programme was given to other qualified providers, it is likely uptake would diminish, as most other providers pick and choose who they deliver it to.

And it is possible that some patients could be harmed by mixed provision. There will be confusion about who is doing what, reduced uptake and some groups could be left at risk if there is no provider willing to give the vaccine to them.

Evaluating the schemes

Proposals to widen involvement in these schemes need to be properly evaluated. 

In particular, any proposal needs to identify clearly the value to patients, the cost-effectiveness to the NHS (given we are working in such a financially austere environment) and make sure that it is fair to all providers involved in the scheme.

From an operational perspective, public health needs a consistent national campaign for flu jabs. 

Pharmacists should not be allowed simply to cream the easy patients off the top, leaving GPs with a higher workload.

And to reach targets, GPs need more investment to cover the administrative workload attached to the programme. Vaccination payment rates should also be uplifted to reflect the true costs of delivering the scheme for GPs, and the NHS should consider a higher payment for programmes given on a smaller scale, such as mop-up campaigns.

GPs should also be allowed to vaccinate community-based NHS and social care staff to save these workers time and improve uptake, as the figures for this group are significantly under target levels. They should also be allowed to vaccinate patients privately outside the at-risk groups.

GPs need a level playing field for providing vaccination services. Quite frankly, it is time for honest debate on this subject. 

Dr Charlotte Jones is a GP in Swansea and chair of GPC Wales

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Readers' comments (20)

  • Without access to medical records, a pharmacist has limited ability to target 'at risk' groups unless the patients risk is obvious from their medication.

    I run a flu vaccination service and our accessibility and customer focus is very much appreciated by it's users. I think that classifying certain groups as 'easy' highlights a viewpoint that is plain wrong.

    I also vaccinate children with nasal vaccine and believe me, these vaccinations are regularly far from easy.

    I also advertise and promote the service which takes money and effort.

    I would happily vaccinate any patient who is eligible for a vaccination. The fact that I am not in possession of this information is not my fault.

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  • A few things:
    1 - "At risk patients may be missed" - figures show GPs are ALREADY missing at risk patients, otherwise PHE would not bother extending the service to non-GP providers
    2 - GPs are expected to mop-up when other healthcare providers do not capture their entire cohort - please see note 1 above
    3 - Pharmacists can charge a private fee for not in the at risk groups - this is a red herring; any patient not in the target groups does not receive an NHS flu jab and so has NO impact on costs to the NHS - this is a private service between the pharmacist & the patient (in much the same way that GPs write private prescriptions for items not to be supplied on an FP10)
    4 - GPs need more money to cover the admin to reach the targets - so, a) you admit GPs are not reaching the targets b) GPs have patients notes so have, at their fingertips, details of every target group patient and can contact them directly, simply by adding a note to the repeat portion of the FP10s they issue (which many have already done)
    5 - GP flu clinics - how many GPs ACTUALLY administer vaccines in these flu clinics? My experience is that it is the practice nurses & HCAs who carry out this service, the GPs just oversee it. In the pharmacy service, every injection is given by an appropriately trained pharmacist
    6 - Pharmacy based services offer vaccinations through-out the flu season (ie right up until the end of March) - those NHS patients I saw last year were unable to get the vaccine due to lack of stock or lack of accessability -since all stock for GPs is ring fenced, that is due to poor management by the practice involved
    7 - I have already had patients asking if I am providing the service this year because liked the service they got from me last year as it was a more personalised one, not a cattle market of getting as many patients through on a Saturday morning (1 every 2 minutes - way to go on production-line healthcare!)
    8 - It's simple - provide the service people want and no-one (patients or commissioners) will WANT to go anywhere else - Clearly, GPs have failed in this area - get over it!

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  • Training costs are borne by the pharmacy, paid for out of the same fee that GPs get and NOT passed on, so are at NO COST to the NHS

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  • You want GPs to provide private flu jabs - hang on, you can't cope with the workload of getting the NHS service to target levels but you want to do MORE?

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  • A tiny number - that's almost 1600 MORE patients vaccinated than last year - agreed, tiny compared to GP totals but still an additional 1600 patients, at no additional cost (other than what it would have cost had GPs vaccinated)

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  • "GPs are not against any properly thought-through initiative to improve flu vaccination uptake" - providing it increases the amount of money available for GPs!!!

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  • The problem is GP practices have consistently missed the targets for high risk patients hence the move to open flu to pharmacists. I suspect practices might lose the whole contract unless we can get the high risk rates up

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  • Why not just ask the patients what they prefer? Isn't that what the NHS is meant to be doing these days. Although 1537 may seem lie a "tiny" number to you that's still 1537 patients who have chosen to be vaccinated in pharmacy. The pharmacy scheme is, relatively, in it's infancy and I'm sure this number will grow year on year as patients exercise their right to chose the service they prefer at their convenience

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  • GP's only want to do what they get paid extra for, and at times don't care about patents that really matter and need support unless there is a £ sound in front of their name.
    Medication reviews are just stamped as down without seeing the patient so why would a GP care about vaccinations ... unless the £ signs there?

    Pharmacists are pharmacists, not GP's and I wouldn't want to be alone in a room being examined by a male. The surgery offers more protection and more accountability!

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  • I do not think there should be any problem in deregulating healthcare services; let the primary care also develop their own pharmacies. This will reduce wastage and improve funding for GP practices to enable them to improve their infrastructure, and staffing. It will also improve access by creating extra clinics run by practice pharmacists to deal with trivial medical ailments.

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