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Analysis: How child vaccine payments increase inequalities

Analysis: How child vaccine payments increase inequalities

A Pulse Intelligence analysis has shown that practices are benefiting from changes to childhood immunisation payments, but those in the most affluent areas are benefiting most. Jaimie Kaffash reports

Changes to the way childhood vaccinations are funded in England have caused huge controversy over the past two years. Although the BMA’s GP Committee (GPC) predicted the changes would increase income overall, a number of GPs pointed out at the time that the changes introduced in 2021/22 benefit affluent practices more and so widen the inequality gap.

A Pulse Intelligence analysis of 2021/22 vaccination data has confirmed that both sides were correct. It’s true that the average practice is earning around £728 more than it would have under the 2020/21 arrangements. However, by far the biggest beneficiaries are practices in the most affluent areas – meaning the changes have indeed served to widen the inequality gap (see figure 1, below). This is hardly surprising, given that vaccination rates remain proportionally linked to the affluence of an area.

‘Cliff edges’

Under the old system, there were basically two key vaccination targets that all practices knew: 70% and 90%. Achieving them resulted in major increases in funding. The 2021/22 changes added a vaccinations domain to the QOF, and more vaccinations now attract item-of-service (IoS) fees of £10.06.

But the new system was criticised immediately for its complexities and its potential to increase inequalities. There are ‘cliff edges’, with practices receiving huge jumps in funding when they reach 80% or 90% coverage, meaning one unvaccinated child potentially makes a difference worth thousands of pounds.

This has been traumatic for the practices involved (see case study, below). But these tipping points are not new – the new system has simply moved them. In the old system, practices with 69% coverage didn’t receive a penny, whereas those with 70% received a huge chunk of funding. Indeed, you could say the new system provides more ‘cliff slopes’ than the one it replaces (see figure 2, below).

The practices that have lost out under the changes are those achieving around 70%-80% coverage for each vaccine. This tends to be those in more deprived areas. That said, the other losers are those in the 90%-95% region, as a result of the steep increase in QOF points within this narrow range. This higher range affects more affluent practices. Meanwhile, the new system has improved a dire situation for practices with 50%-69% coverage – usually in deprived areas – which have gone from no funding at all to receiving some funding (although admittedly not much).

How the payments work

Old system
Under the DES, for every child completing their course, an average practice received £11 if they had 70% coverage and £34 if they had 90% coverage. Practices with 70%+ coverage received an item-of-service fee for the initial MMR jab too.

New system: item-of-service fees
The IoS payments of £10.06 now apply to each dose administered (with the exception of Covid). If fewer than 80% of children have the jab then practices may face a clawback equivalent to half the cohort.

New system: QOF thresholds

DTP Three points are awarded at 90% achievement, with the remaining 15 points awarded at three per percentage point up to 95%.

The single MMR vaccination Seven points are awarded at 90% with the remaining 11points awarded at 2.2 per percentage point up to 95%.

Both MMR doses and DTP booster at five years Seven points at 87% with the remaining 11 points awarded at1.38 per percentage point up to 95%.

Worsening inequality

But there is no doubt that practices in affluent areas have benefited most. Indeed, based on average vaccination rates, practices in the top 10% most affluent areas have seen their income go up by an average of £1,300 – 10 times the increase in the 10% most deprived areas.

Deprived practices’ QOF payments were well down compared with the money they received for the 2020/21 vaccinations enhanced service. This reduction was only partially mitigated by the increased IoS fees.

There are caveats to this – the vaccination rates used by Pulse Intelligence to model the funding were based on the incentives for the new system: if the 2020/21 targets were still in place, practices may have behaved differently.

However, practices in deprived areas often don’t have the ability to increase vaccination rates, however they behave. Because there is often a cohort of families who cannot be reached, no matter how much work a practice puts in or how their activity is incentivised.

Professor Azeem Majeed, professor of primary care and public health at Imperial College London says his own practice in Clapham had been hit by the issue. ‘Like other practices in inner city areas, we have a very mobile population, high levels of deprivation and challenges in addressing vaccine hesitancy amongst parents.

‘We do eventually get vaccination rates up to a high level, but this takes a lot of work in contacting families and addressing data issues because vaccine data is often missing from medical records when patient register with the practice.

‘This work often goes unfunded because we can’t meet the target in time for the QOF payments.’

Remedying the problem

Some practices have lost many thousands of pounds. For example, Dr Kirsty Hagan of the Lancaster Medical Practice says her practice missed out on tens of thousands because making the jump from the 90% coverage they achieved to the 95% needed for the full payment proved impossible.

Norwich GP Dr Ed Turnham, whose practice serves a deprived, multi-ethnic population, reports ‘losing all funding on one vaccine indicator (£1,700) this year because one family got their jabs late’.

But such scenarios happened for other practices in the old system. So, what is the remedy? First, other QOF domains include ‘exception reporting’, whereby, as long as practices have done everything to reach patients in eligible cohorts, they will not be punished financially if those patients fail to respond. However, when childhood immunisations were included in the QOF, no such exceptions were allowed. There is no reason they shouldn’t be in the future. Second, stopping the clawback for IoS fees – or at least lowering the threshold from 80% – would help many deprived practices.

It must be said that the NHS and the Government do have their own issues with vaccination achievement. The World Health Organization sets a target of 95% coverage across all childhood immunisation programmes, and England is failing on every one, according to NHS Digital figures.

‘This change is inherently unfair’

Patients in deprived practices are more likely to be in poverty, not speak English and be more transient, and all these factors make vaccination uptake worse. But in addition, we also have rumour and pseudoscience to listen to rather than professional opinion when it comes to vaccination.

Then you have this change to how we’re funded, which is inherently unfair. My business manager told me we have lost at least £10,000. If you’re doing this work and doing it to the best of your ability and miss the 90% target just by a little, there’s no incentive to do the work. If you miss the 80% you’re getting little money for your work and that’s just wrong.
Dr Anthony Gore, GP in Sheffield and clinical director children, young people & maternity, NHS South Yorkshire ICB

But targets-based payment systems don’t seem to be the best solution. Targets punish deprived practices for what are national public health failings. These failings are driven by increasing inequality across the whole country, which in turn worsens health inequality.

Dr Anthony Gore, a GP in Sheffield and clinical director at South Yorkshire ICB, proposes a solution: ‘There needs to be upfront payment at the beginning of the year to fund your work to bring people in for vaccines. The government is effectively doing nothing to challenge weirdly held beliefs [that stop people taking up] vaccination.

‘Stuff is happening in Sheffield [public health teams doing work on promotion] in local communities, but we won’t feel the benefit of that yet. Contractual change needs to happen so that practices do not end up out of pocket and are funded to do the work.’


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Please note, only GPs are permitted to add comments to articles

Michael Mullineux 26 October, 2022 11:15 am

X axis in 1 and 3 suggest most deprved do best!

Jaimie Kaffash 26 October, 2022 11:32 am

You are right! That was a typo, and we have changed that – thanks for pointing it out Michael!

Azeem Majeed 26 October, 2022 12:11 pm

It’s essential to look at how we fund incentive payments for childhood vaccination to ensure higher uptake nationally and a more even uptake between rich and poor areas.

David Banner 27 October, 2022 9:25 am

Once exception reporting was ruled out, this was bound to happen.
More ruthless practices simply remove refuseniks from their list, and bingo, target achieved.
The more forgiving of us not only keep them on, but inherit others’ refuseniks, destroying any faint hope of achieving targets.
When practices know they have zero chance of reaching targets, they stop putting in the effort and focus on other QOF targets instead.
This is classic case of an “incentive” rapidly becoming a “disincentive”.
In deprived areas this could lead to far lower immunisation rates than now. This is insane.
The solution is simple. Allow exception reporting (a signed refusal from parents should be mandatory). Once the refuseniks have been put aside we can push to >95% targets.
We shouldn’t be financially punished for out patients’ freedom of choice. They have the right to be wrong.