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How GPs are preparing themselves for this year’s mammoth flu programme

vaccine infection

This year’s flu vaccination campaign is set to be twice the size of last year’s across the UK.

In England, 30 million patients are being targeted – double last year’s figure. July’s announcement on free vaccines for shielded patients and their households, as well as over-50s, means a campaign of unprecedented scale. If all those eligible participate, this amounts to 37 million people – or 66% of the population.

Wales and Northern Ireland have committed to vaccinating the same cohorts, while Scotland’s programme, to be led by health boards, will include social care workers, over-55s and household members of those who are shielding.

But crucial information is missing for GPs. There is no clarity around PPE specifications, or on whether additional staff will be made available, how many extra vaccine doses practices will be able to secure or how practices will be able to vaccinate so many patients at a time of social distancing – which some estimate may quadruple the time per patient.

I don’t think there’s the realisation among commissioners of the scale of the challenge

Dr Steve Kell

The solutions so far put forward by NHS England seem inadequate. One proposal – a home-visiting service for shielded patients – led GPs to ask when they would have the time to do this. NHS managers have also suggested practices consider ‘careful appointment planning’, provide patients with information in advance of their slot, recall at-risk patients, and use ‘drive-in vaccinations’ and ‘car as waiting room’ models.

The only concrete recommendation so far is to ask GPs to focus initially on getting at least 75% uptake among existing high-risk groups, with November and December saved for vaccinating 50- to 64-year-olds, dependent on supply.

An NHSX seminar on 20 August – the first NHS event devoted to the primary care response to the flu programme – considered the potential of technology. For example, Kent GP Dr Mark Essop discussed a system whereby each patient is sent an invitation letter with a tear-off, barcoded ticket to present at the practice flu clinic.

NHSX primary care director Dr Masood Nazir also talked about plans to allow trusts to administer vaccines and to improve record sharing between primary and secondary care.

But Dr Steve Kell, a GP partner in Worksop and a former co-chair of NHS Clinical Commissioners, says: ‘I don’t think there’s the realisation among commissioners of the scale of the challenge, the complexity or the workforce issues. They really need to focus on what they want us to deliver because these are exceptional times.’

A key problem is how to deliver vaccines while observing social distancing. Many, like Dr Essop, are innovating. East London GP and PCN clinical director Dr Farzana Hussain is building on work her practice did in vaccinating infants and young children in patients’ cars, after uptake fell through the floor at the start of the pandemic.

‘We are planning to do the same for flu and we have a gazebo set up over a patio for those without cars,’ she says. ‘I am planning to encourage families or bubbles to come together in one car so we can get as many done as possible.’

Dr Simone Yule, a senior partner in Dorset and clinical director at The Vale PCN, has booked an airstrip with a hangar for drive-through clinics. Her plan includes community transport to bring patients in. ‘Our first clinic on 14 September is booked up,’ she says.

‘It has been challenging but we always knew we couldn’t do it in the practice.’

The PCN is also organising a ‘flu bus’ to go round rural areas for those unable to attend. Other GPs are looking at using football clubs or a door-to-door service (see box, below).

GPs’ innovative solutions to meet flu campaign demands

Postman-style vaccine service

Dr Richard Davey, a GP at the Larwood Health Partnership in Worksop, is considering other ways to efficiently vaccinate his practice population, which is above average in terms of risk: ‘We have identified streets and areas that have a high density of at-risk patients and we are looking at doing door-to-door vaccinations. We will be sending out a text message saying we’re going to be starting at a certain time.’

Dr Davey has calculated the team will be able to get through the same number of patients as they would if using social distancing in a venue. ‘We are booking venues and looking at drive-through as well and it’s going to be a combination.’

Practices and pharmacists join forces

Back in June, the eight practices in Hyde PCN in Greater Manchester decided to pool their vaccines and set up a drive-through vaccine system in a large leisure centre car park.

‘We have around 25,000 vaccinations to do but we were still 9,000 short so we have agreed with the 13 local pharmacies in our patch that they will do a walk-in service with bookable appointments for those who don’t have cars,’ says PCN manager Sally Culmer.

Healthcare assistants will be delivering the drive-through vaccination service with the help of community nurses. This means GPs and practice nurses will be left to continue their usual work.

‘We have had a few people interested in replicating what we have done but it took us nine weeks to get to this point and its not been an easy nine weeks… We just felt this was the safest way to do it. We knew this wasn’t feasible through practices.’

But other practices are finding things tougher. Angus GP Dr Natasha Usher says: ‘We are extremely worried about delivering this. We’re going for a skeleton service for a day for emergencies, then

all hands to the pump for jabbing. Two corridors, 12 vaccinators, in one door, along the corridor, get jabbed, out the other end. All two metres apart with masks, allowing six minutes each.’

Even where social distancing can be achieved, GPs are still encountering problems around supply, time, cost and PPE. Dr Yule says: ‘We are really hoping there won’t be a delay on vaccine supplies.’

Dr Hussain concurs: ‘I do have concerns about vaccine stocks as I only have 50% of what I need. I tried ordering 300 more and apparently I am on a waiting list.’

Vaccine supply is causing anxiety, after key UK supplier Sanofi admitted a third of ordered stock will not reach GP practices until November. Last year, flu clinics were cancelled as manufacturers staggered delivery of supplies.

There’s talk about return to the QOF – we can’t manage that with flu vaccination on top

Dr Richard Cook

GPs trying to order extra vaccines now are being told they are all being held for central procurement by the Department of Health and Social Care. The Government is also considering using Flublok – an as-yet unlicensed quadrivalent influenza vaccine from Sanofi. It has been used in the US and is expected to be licensed for UK use in November. The DHSC has promised more details about supply this month.

Aside from supply issues, GPs are asking where they will find the time to carry out all this vaccination work – and what work will need to be sacrificed in order to do so. Dr Hussain says: ‘It is going to take a lot of time and I am using existing staff but some other work will have to give. For example, how will we manage smear catch-ups?’

West Sussex GP partner Dr Richard Cook says his practice is in the fortunate position of being able to set up a one-way system through the surgery, but adds: ‘If it is going to take twice as long, something will have to give.

‘There’s talk about return to the QOF – we can’t manage that with flu vaccination on top and there is a lot of worry about an upsurge in patients with flu-like symptoms. This is going to be a very challenging time.’

Some of the concerns involve PPE. The RCGP’s guidance on mass vaccinations (see box, below) – released before the Government declared its goal of 30 million vaccinations – says that ‘under normal circumstances’, healthcare professionals could vaccinate one patient every one to three minutes. But ‘in these altered circumstances’, this will be ‘at least four minutes’.

But PHE has said that single-use PPE items are only needed where staff are likely to be exposed to body fluids or broken skin. It added that practice staff delivering vaccinations should wear a face mask for the whole session and use hand sanitiser in between in each patient.

Bromsgrove GP and co-author of the RCGP guide Dr Jonathan Leach says that without the need to change PPE, ‘you could get it down to around two minutes per patient.’

Another issue of concern is funding. The QOF points for flu vaccination and cervical smear indicators are to be doubled, from 29 to a total of 58, meaning reaching certain targets on coverage will be more important.

We have basically the same number of vaccines coming as last year, ordered nine months ago

Dr Neil Moody-Jones

However, there have been no details on how these points will be distributed or what the indicators will be, leaving practices facing uncertainty. It has also not been confirmed whether the item-of-service fee will remain at £10.06 or will increase to cover extra costs.

But we do know administering the flu campaign could be more expensive than usual. Additional costs will be incurred where practices need to hire an external venue, which is not cheap, says Worksop GP Dr Richard Davey, a colleague of Dr Kell. ‘We are looking into whether we can get some discounts but ultimately primary care may well make a loss by doing flu vaccines this year and we haven’t had details of any funding. We got a quote for £1,500 just for the first few sessions from one venue’.

This prospect has led some GPs to suggest they won’t be able to conduct vaccinations at all – a nightmare scenario for the Government. Hampshire GP Dr Neil Moody-Jones says: ‘We have basically the same number of vaccines coming as last year, ordered nine months ago, and each will take longer to administer. Show me the figures of how many more jabs we will get from NHSE first before we can commit to anything.’

Managers are likely to try to encourage a spirit of co-operation between practices under the auspices of PCNs. NHSX’s Dr Nazir, a partner at a 26,000-patient practice in Birmingham, said: ‘We are looking at working with nearby practices, and I know others are doing the same – how as a PCN they can hire a venue to do this.’

Fiona Adamson, chief executive of the Hartlepool and Stockton Health GP federation – which includes all practices in the locality, covering 300,000 patients and seven PCNs – has created a ‘hub-and-spoke’ model.

The work we are doing on how to give flu vaccinations will inform how we do Covid vaccinations

Dr Andrew Lee

‘Practices continue to look after care homes, opportunistic vaccines and vulnerable groups in the “spoke”, and we run mass vaccination via large local venues and hopefully drive-through sites as the “hub”,’ she says. There have even been discussions with the fire service around premises and support.

The demands of this year’s flu campaign may also bring a détente between general practice and pharmacy, which have been at odds over the issue in recent years.

Dr Hussain says she has worked with her local community pharmacy to try to ensure they get everyone covered – something Hyde PCN in Greater Manchester has also done, on a much bigger scale.

Graham Phillips, a pharmacist who has branches in Kent, says: ‘Our local practice wants us to target a specific list of their patients whom they feel they can’t reach, either due to capacity or patients’ reluctance to receive the jab. We’re able to offer a more flexible service and over a longer period. I’ve long argued for collaboration, not competition.’

The campaign will be a huge effort for GPs this winter. But it might also serve as a trial run for an even bigger programme – for a potential Covid-19 vaccine.

Sheffield GP and global health expert Dr Andrew Lee says this year’s flu programme could prove a useful model for a Covid vaccine campaign but doesn’t think it likely primary care could deliver that on its own for the whole population.

He says: ‘The work we are doing on how to give flu vaccinations at scale will inform how we do Covid vaccinations. For the whole population, you can’t rely on a single site at a practice – you need to look at mobile units, other venues and home visits for the housebound.’

He notes that early results from the Oxford vaccine trial have suggested two doses will be required. ‘The scale is the issue, but even if it was a single dose that is a heck of a lot of people.’

Dr Lee warns: ‘If results come from the trial in the autumn and it works, we could be delivering the Covid vaccine early next year, at the height of winter – when there might be a Covid outbreak. If primary care staff are already dealing with that, who’ll be doing the vaccines?

‘We might need to look at other people who can vaccinate – potentially medical and nursing students, the military.’

Key points of RCGP guidance for delivering mass vaccinations

Prior planning and leadership

  • It may be more efficient and cost effective to provide immunisation across a number of providers, pooling resources and sites.
  • A single clinical lead should be appointed to take responsibility for coordinating planning and delivery.
  • There may be additional regulatory requirements if the lead practice or host is delivering vaccinations outside their usual premises.

Choosing location

  • Consider the best setting (GP surgery, pharmacy, larger community health facility, school halls, drive-through, etc).
  • Indoor and outdoor queuing may be considered. A ‘fast-track’ queue may be needed for vulnerable patients.
  • Other factors include digital infrastructure and record keeping, infection control, and transport/traffic issues.

Checklist of equipment requirements

  • Furniture (chairs, tables, screens), barriers, refrigeration.
  • IT (computers, broadband), power supply.
  • Waste disposal (general, clinical, sharps).
  • PPE.
  • Welfare (rest area, catering/refreshments).
  • Vaccination equipment and supplies.
  • Medical equipment (couch, resuscitation and diagnostic).
  • Screening and lighting for staff rest areas and for patients taken ill.
  • Clear signage outside and inside a venue.

Checklist of layout requirements

  • Flow of patients (separate entrance and exit).
  • Reception and triage space (to identify patients and assess any who are unwell).
  • Queueing space (to maximise social distancing).
  • Fast-track route (for patients with limited mobility or additional requirements).
  • Toilet and handwashing facilities for patients and staff.
  • Emergency/first aid area.
  • Secure storage for vaccine stocks, PPE and IT equipment.

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