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Get childhood immunisation back on target

Thanks not least to Pulse's efforts, MMR will count for 25 per cent of target pay calculations instead of 50 per cent. But practices should beware of sitting back and assuming future top targets are now assured, warns Dr John Couch

Thanks not least to Pulse's efforts, MMR will count for 25 per cent of target pay calculations instead of 50 per cent. But practices should beware of sitting back and assuming future top targets are now assured, warns Dr John Couch

The campaign to restore the calculation balance to childhood immunisation payments, robustly supported and advanced by Pulse, has succeeded.

Although no date for implementation has yet been agreed it is to be hoped that 1 April 2006 will see the end of the 50 per cent value for MMR, which has cost so many practices dear over recent months.

MMR will revert to counting 25 per cent towards the target calculation with the five in one injection and MenC 50 per cent and 25 per cent respectively. Is the game over? Absolutely not, as there is a real danger of complacency if practices simply sit back and assume future top targets can now be guaranteed.

Unlike QOF targets, where there are several tiers of gently increasing achievement, immunisation targets have only two tiers with a precipitous drop between higher and lower levels. For childhood immunisations an average 5,000-patient practice earns £8,487 for the higher (90 per cent) target but only £2,829 for the lower (70 per cent) target. There is no payment at all for levels below 70 per cent.

Right now, each whole-time equivalent GP whose target percentage has fallen to between 70 per cent and 89.9 per cent loses an average £1886 per annum. As the formula is related to the numbers of children, practices with above-average numbers lose even more.

There will still be a problem (although smaller) when MMR counts for 25 per cent. The long-running negative press campaign against MMR still echoes in parents' minds. Although recent MMR uptake figures are slowly improving, a practice that merely relies on public opinion to bring MMR rates up is taking significant risks. Many practices still achieve less than 70 per cent for MMR and as the following example shows an MMR level above 66 per cent is required to stay above the top target level.

Check your figures now

You should look at your own figures now to ensure that current MMR rates will ensure figures comfortably above top target when the calculation basis changes. One or two children over will not be enough of a buffer, so try to put MMR on an upward trend. The hearts and minds of parents are gradually being won back to the efficacy of MMR and practices must capitalise on this.

Also, remember that it is not just MMR1 that counts against you; a child missing the five in one/MenC will count three times more!

Do not wait for the new calculation

If you lost out when the value for MMR became 50 per cent but were a higher target achiever before this happened, the situation is almost certainly rectifiable when the value of MMR returns to 25 per cent. There is no date for this, so why wait?

The numbers of extra immunised children required to get back to top target now will not be great and you are on a rising tide. Even if your practice has never been able to achieve higher targets, you should still review your situation. If neighbouring practices can do it then so can you. The following advice may be useful.

Reassuring patients and parents

Given that the numbers of extra immunised children required to get back above the top target level will not be high, there are four factors that act in your favour.

The huge body of evidence showing no autism/MMR link seems to be slowly reversing the damage done to parental confidence over several years. This message can be reinforced at each relevant patient contact by health visitors, GPs and nurses.Immunisation target payments are calculated and issued as a Directed Enhanced Service (DES) quarterly. This means that if you fall below target one quarter you have three months to rectify the situation for the next quarter, or at least start to turn your figures around.

The figures are calculated on a target population that is between two years and zero days old and two years 364 days old on the first day of each quarter. MMR1 is usually offered between 12 and 15 months of age. Therefore you have up to 12 months to get each child immunised before they count towards the target AND up to another 12 months to get them included in the quarterly figures assuming they had not had the MMR by age two. You have even longer (over two-and-a-half years) to attract the few children who have not had their five in one/MenC by four months of age. The main message here is that you should never give up trying to get an unimmunised child immunised.

Finally, do not forget that children in this age group are often frequent surgery attenders, particularly during winter months. This increases the chances for opportunistic immunisation.

The first step is to identify all unimmunised children for both MMR and five in one/MenC. You can decide your own age range. Personally I would target children 18 months to two years eleven months. In this way the next two quarters cohorts of new two-year-olds will be included. For an average practice the numbers will not be high, perhaps in the region of eight per whole-time-equivalant GP.

Tag all these patients electronically so that a clear screen alert is produced at each patient contact. Tag their parents' records electronically in the same way. This should increase the chances of opportunistic immunisation. Arrange a meeting with any of the health care team with whom they may come into contact. Agree a common 'script'; this is not a time for mixed messages.

Emphasise the weight of evidence against an MMR/autism link, listen to parental fears and provide appropriate literature and/or websites to allay these fears. Be prepared to give parents time for thought but, as importantly, make sure you have flexibility to give the vaccination immediately. Our nurse colleagues are usually more than happy to help but there is no reason why GPs cannot immunise too! Make sure all who may give the injection are aware of the consent protocol, location of the vaccine and recording requirements. A computer template helps greatly.

Is it worth doing a mail shot or telephone contact? I would say unequivocally, yes. While results of these are often disappointing, the small group size and low numbers required for success make such a move a must. Just one success could make all the difference. You must review your results a couple of weeks before each quarter end; it would be a great shame to miss the target by one or two patients when a final push could have saved the day. In some situations it may even be worth considering a home immunisation if transport or time are a problem for parents.

Remember to focus on the next cohort as each quarter passes and also to enter immunisation data for all newly registered children under six. Include them on your 'opportunistic hit list' for childhood and pre-school targets if they are unimmunised. We should never forget the clinical importance of getting MMR rates back to 'herd immunity' levels. The business package is now more compelling ­ but the morbidity and mortality benefits are incalculable.

Numbers of eligible children 59 (average 5,000-patient practice)

Numbers with five-in-one completed: 58, or 98.3 per cent

Numbers with MenC completed: 58, or 98.3 per cent

Numbers with MMR1 completed: 38, or 64.4 per cent

Overall target percentage: 89.8 per cen tie the practice has hit the lower target

If this practice had vaccinated only one extra child for MMR its would have reached its top target. This failure will cost this practice £1,414 per quarter and, unless rectified, £5,658 over the course of 12 months.

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