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New vaccine target pay rules are petty and penny-pinching

Far from improving vaccine uptake, making it harder to hit payment targets will only mean GPs paying the price for Government ineptitude, argues Dr Mike Fitzpatrick, who has an autistic child

By making it even more difficult for GPs to achieve immunisation targets, the Government is expecting us to pay the price for its inept handling of the MMR controversy. This is not the way to improve uptake.

The Department of Health's argument is that, because the introduction of the new 'five-in-one' vaccine last year has reduced workload, the two-year target of 90 per cent uptake will now be calculated on the basis of only MMR and the 'five in one' (instead of four vaccines - DTPolio, pertussis, Hib and MMR).

The object is to raise the stakes on MMR, thus putting us under more pressure to revive uptake, still languishing at 80 per cent nationally.

But this petty, penny-pinching approach reflects a profound lack of understanding of the realities of our baby clinics. The immunisation workload is not limited to the few seconds it takes to draw up a vaccine into a syringe and plunge it into an infant thigh.

It is largely determined by the many minutes spent in explanation and reassurance, sometimes continuing into protracted discussions, occasionally even arguments, with parents who have been rendered anxious and confused, angry and distressed, by raging public vaccine controversies.

If anything, this time has been extended by the new 'five-in-one' jab, whose introduction in the post-MMR climate provoked a predictable flurry of ill-informed media scaremongering.

As many doctors have observed, the inescapable effect of the new scheme will be an immediate cut in income for many practices. This will certainly be the case in our inner-city surgery where, despite all our efforts, uptake remains stuck at the London average of 70 per cent.

It is ironic that the Government is now effectively penalising GPs for the consequences of its own bad faith: the single biggest blow to confidence in MMR was Tony Blair's equivocation over whether his own son had received it.

Though the Department of Health should be congratulated for holding the line against demands to provide single vaccines as an alternative to MMR, the ineptitude of the wider Government response to the anti-MMR campaign has helped to compound parental anxieties. Having borne the brunt of these anxieties over the past five years, we are now going to be rewarded with a pay cut.

Embarrassed at being worsted once again by the Government, the GPC is pushing for an 'informed dissent' clause to allow the removal of MMR refuseniks from the target denominator.

But this attempt to introduce a primary care equivalent of the 1898 provision for 'conscientious objection' to compulsory smallpox vaccination is likely to be ruled out as bureaucratic and impracticable (like its predecessor).

I suggest a simpler solution: why not simply lower the target threshold - by say 10 per cent - to correspond to the reality of a situation that the Government has done much to create?

It is worth noting that parents and politicians have both tended to exaggerate the influence of target payments on immunisation uptake. The introduction of these payments in the 1990 contract did help to improve vaccine uptake, but much more dramatic increases occurred in the 1980s before incentives were introduced.

Similar incentive payments for cervical smears, also introduced in 1990, have never been controversial, though the health gain from this procedure is vastly lower than that from childhood immunisation.

I recently saw my first case of measles for 20 years (in a baby who was on a waiting list for the single measles vaccine at a private clinic). Seeing a child again with all the miserable symptoms of measles (even without any complications) after such a long time was a powerful reminder of the main reason why GPs have always been enthusiasts for immunisation. We have seen children suffering - even dying - from measles and its complications.

The recent mumps epidemic among students has also been a reminder that this is an unpleasant disease with even more unpleasant complications. The prospect of a return of cases of congenital rubella is almost too terrible to contemplate.

We have seen the tremendous benefits of the child immunisation programme in making measles and other infectious diseases a rarity in this country. Perhaps we should simply tell parents that this - far more than any paltry target payments - is why we recommend vaccinations for their children.

Meanwhile, we should tell the Government that while we are keen to promote immunisation, we expect to be paid adequately for doing this, especially when its interventions have made our work in this area increasingly arduous and time-consuming.

The most useful contribution the Government could make to improving vaccine uptake would be to maintain silence on the issue.

Although an announcement from Gordon Brown that his son has received MMR would be helpful in restoring public confidence and redeeming the Government's tarnished reputation, at least in this area.

Michael Fitzpatrick is a GP in Hackney, east London, and author of MMR and autism, what parents need to know, Routledge, 2004

MMR deja vu? Whooping cough in the 1970s

In March 1974 consultant paediatric neurologist Dr John Wilson published a study of 36 cases of children admitted to Great Ormond Street Hospital in London over a period of 11 years with 'neurological complications' following pertussis immunisation.

Most of the children admitted received their vaccine in the combined form of the triple vaccine. A campaign against the vaccine was launched and an Association of Parents of Vaccine-Damaged Children was formed. By 1976 uptake had dropped from 80 to 30 per cent. A court case in 1990 heard evidence from 19 expert witnesses on whether the whooping cough vaccine could cause damage and concluded the alleged link was not supported by evidence.

A review of Wilson's 36 cases revealed that in only 12 cases was there a close temporal association between the vaccine and manifestation of brain damage - notably epileptic fits.

While controversy raged around the vaccine, whooping cough returned, resulting in 27 deaths and 17 cases of permanent brain damage during epidemics between 1977 and 1979.

Adapted from 'MMR and autism, what parents need to know',

Fitzpatrick M. Routledge 2004

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