As GPs embark on the Covid-19 vaccination programme, Lily Canter asks if it will leave space for anything else
‘There has been a lot of work I’ve not been able to do in my normal day-to-day job in trying to do this,’ says Dr Geetha Chandrasekaran, clinical director of North Halifax PCN, of the Covid vaccination programme.
‘Patient care is one side, but it’s also what this does to other services that you run that might not directly impact on urgent or immediate care, such as minor surgery.
‘You can’t run a programme of giving nearly 1,000 vaccines in three-and-a-half days without pulling resources from somewhere. If you have fewer appointments, access is affected. There could well be complaints.’
It’s fair to say that if last year was defined by the arrival of the Covid pandemic, 2021 is set to be the year GPs help defeat it.
On 2 December, the UK became the first country to authorise the Pfizer-BioNTech Covid-19 vaccine for use, after it passed regulatory safety checks set by the MHRA. A mere two weeks later, more than 200 GP-led sites in England started vaccinating patients. The next aim is for 1,000 sites, with the ultimate aim of all GP practices being able to administer vaccines at the height of the programme.
In Scotland, health boards are leading the programme and identifying venues for vaccination; in Wales, health boards are also leading operations. In Northern Ireland, practices are gearing up to deliver the programme via an enhanced service.
In the fast-paced world of Covid vaccinations, it’s hard to predict what will happen by the end of the day, let alone by the time you read this. What we do know, however, is that it will be pretty much the only issue in general practice for the start of the year. And the squeezing out of other routine aspects of general practice will have significant implications.
Some GPs and PCNs are finding a way of delivering the practice while continuing with their normal routine work by pooling resources (see case study, further below).
However, an analysis of results from a Pulse survey of 430 GP partners revealed that practices will lose, on average, four sessions per week of routine care. One in four respondents said this would include face-to-face appointments, with a similar number expecting to reduce screening. Around one in four said they would stop doing routine medication reviews and health checks for the over-75s altogether.
The main issue is around staffing. Some PCNs plan to hire and train more staff for the vaccination programme, including pharmacists and retired nurses. There will be community volunteers who will support non-clinical tasks, such as booking appointments and marshalling traffic at the vaccine hubs. But, in many cases, the bulk of the work in the vaccine hubs will be conducted by nurses and healthcare assistants working overtime – with GP oversight.
Dr Sajid Nazir, GP partner and clinical director at Viaduct PCN in Huddersfield, says that in the first week of vaccinations, his PCN was sharing the batches of 975 doses between three PCNs, and this needed his practice of 10,000 patients to release one nursing or healthcare assistant session per week. However, he adds: ‘If we ramp up to one batch per PCN, then potentially four to five sessions per practice would need to be covered.
‘It is very difficult for us to focus on anything else at the moment…Minor surgery will be reduced as we need nursing support for this. Routine health checks will need to be postponed.’
The BMA and NHS England have issued guidance on work that can be stopped. The BMA has advised practices to ‘re-prioritise’ and postpone routine activities to make way for the vaccination programme.
In an update to GPs at the start of December, it said: ‘The short timescale for delivery of this vaccine means that practices will need to re-prioritise and postpone other activities, such as non-essential health checks and reviews, in order to focus on the Covid vaccination programme, particularly with the short period in which the vaccine will need to be used.’
An NHS England letter sent on 4 December said: ‘The nature of the vaccine being deployed initially means we will need to focus efforts to ensure effective delivery.
‘While urgent care will [still] need to be provided across general practice, for the days on which the vaccine is being delivered from these sites, this programme will be the top priority.’
But for grassroots GPs, this sends mixed messaging. It is not clear whether NHS England has given them a mandate to cut back on routine care.
Dr Simon Hodes, a GP partner and joint PCN lead for his practice in Watford, says he is positive about the programme and the huge efforts being made by GP teams to protect patient, but adds: ‘They have said we should prioritise Covid vaccination, and that’s fine as a soundbite, but the reality is your patients are trying to come in for a blood test – and patients online are already saying, “I can’t get in to see my GP for a blood test for two weeks”.’
Of course, whatever happens, this will have an effect on patient care. Dr Hodes adds: ‘At the beginning of the pandemic, patients stayed away, were scared and were socially distancing. Now we’re back to capacity as it was before. I don’t know what we can safely turn away, or people start ignoring their chronic diseases, which is a detriment to health.’
The situation is particularly acute for PCN work. The care homes’ enhanced service and structured medication reviews were introduced in October last year, and more service specifications are to be introduced in April.
Dr Nazir says: ‘We have been struggling to focus on any other PCN priorities in recent weeks, and I suspect this will be the case going forward over the next few months. This may affect the recruitment of ARRS [additional roles reimbursement scheme] staff and could also have a detrimental effect on how we meet parts of the PCN DES.’
This comes at a time when there is mistrust around the whole PCN project. The England LMCs conference on 27 November voted in favour of the BMA balloting the whole profession around continuing the PCN DES.
There is also the issue of lost funding from not being able to carry out non-routine care. Dr Elizabeth Hersch, Somerset GP and clinical director of Three Valleys Health PCN, says each of the nine practices in her network will conduct a risk-based assessment of what services could be paused or stopped.
‘For example, we will look at phlebotomy clinics for non-urgent monitoring bloods, minor surgery, coil and implant fitting, health checks and low-risk, long-term condition appointments. Sadly, our income for the local authority contracts has not been guaranteed, so we will lose income by doing this.’
NHS England has said other income – including QOF and enhanced services – is protected. But some GPs are worried about the detail of this income protection. Dr Hodes says: ‘It’s not at all clear. We’re still ticking off QOF targets, and still getting lists and emails sent asking if I can deal with this, that and the other – that’s extra workload I could do without right now, that I do not think benefits patient care.’
This is especially acute because of the issues around the Item of Service fee of £12.58 paid for each dose of the vaccine in England. The England LMCs conference mandated the BMA to reopen negotiations with NHS England around this fee.
A Pulse survey of 205 PCN clinical directors in November found that 60% felt the funding was inadequate – including 38% who said they would be making a loss.
The workload increase from the vaccination programme is not just due to healthcare staff being removed from routine care. There are issues around the locations of the vaccination sites.
For the next three to four months, community centres, school halls, football clubs and even cathedrals will become temporary vaccination centres for the first phase of the programme, alongside GP practices and community hospitals.
Dr Nazir says there was no choice but to find an external venue: ‘We have eight practices in our PCN in central locations, and there is no space available where we could carry on with business as usual at the same time. Neighbouring PCNs had the same issues, so they are joining us. The proposed site, which is a cathedral, fits within the boundaries of all three PCNs and will serve 160,000 patients.’
He says the effort required to set up this space has been vast: ‘The PCN manager across the five PCNs is a full-time project manager on this. Because our site is not an NHS location, there is so much more paperwork we have to go through. We need to purchase or rent cold storage for the vaccine, a locked room and insurance.’
‘We will be pooling resources and existing staff will be doing additional hours’
We are really up for this as we want to do it for our community. Our PCN has 63,000 patients across three practices in Bishop’s Stortford, Sawbridgeworth and Much Hadham in Hertfordshire.
We decided to build our Covid-19 vaccination programme using the winter flu programme as a blueprint because this has been very successful. We are following the same structure but expanding the model and using a different IT system.
Our site is the local football club and we’ll run a walk-through service with no waiting. The site is so big we can have a 15-minute, post-vaccine observation area, all two metres apart.
Several practices are working together, so the football club’s massive car park will come in very handy. We have bought fridges to be securely housed within the club, so we have all the vaccine doses on site.
We will deploy the staff we need to. There has been a lot of community spirit: nurses are coming out of retirement, and paramedics are happy to help. We will pool resources and existing staff will do the work as additional hours, in overtime. There is a real sense of everyone coming together. We also have amazing volunteers, including our patient participation group.
Our plan is to run a parallel service for core work – we are not suspending any routine work. When each vaccine comes on line, we will adapt but we’d like to continue working as a PCN. It has been very hard work and we have done incredibly well to get this far.
Dr Sian Stanley is a partner at Church Street practice, Bishop’s Stortford
Adding to the workload, patients have been calling their local practice for details about getting the vaccine, not understanding that the delivery site is elsewhere, or to ask if the vaccine is safe and whether it will interfere with existing medication. ‘We could do with a national or local helpline, rather than people phoning their GP for information about getting the vaccine,’ says Dr Hersch.
The ever-changing situation creates workload pressures too. Last month, two healthcare workers receiving the Pfizer vaccine had allergic reactions.
This prompted the MHRA to update its guidance to say patients should be observed for 15 minutes after receiving the jab. This change left some GPs with no choice but to pull out of the vaccine programme, with just days to go before their first clinics.
Dr Steve Rossi, North East Derbyshire PCN clinical director, says: ‘We have had to pull back, primarily but not solely due to the reintroduction of the 15-minute observation period, which makes our site unusable.’
But if there is one thing GPs possess in spades, it’s initiative. PCNs are working hard to make the process as streamlined as possible. NHS England guidance says GP-led sites should be able to deliver the programme 12 hours a day, every day.
In reality, PCNs are aiming to administer batches of 975 doses a week within usual GP hours – or, alternatively, completely out of hours.
Dr Michael Lambert, GP partner and joint clinical director of Winchester City PCN, says: ‘The hours will depend on the delivery and volume of the vaccine. We are starting on a Monday to Friday basis within our core hours. But we can expand, maybe to 8am to 8pm, through to the weekend if we need to, and if there is enough vaccine supply.’
Meanwhile, most of the delivery sites in Doncaster will be at external locations, and much of the work will be conducted out of hours, says Dr Dean Eggitt, LMC chief executive and a GP in the town.
‘We are going to share staff, so no one practice has to take the burden,’ he adds.
And, although the ever-changing situation does create pressures, there may also be positive changes. Many of the problems for GPs and PCNs stem from the characteristics of the Pfizer vaccine.
As Pulse went to press, the Oxford/AstraZeneca vaccine had yet to be approved; when it is, it will significantly simplify the process.
The AstraZeneca vaccine is far more stable, can be stored in a standard vaccine fridge, and has a shelf life of six months. It will also be supplied in packs of 10 vials containing eight or 10 doses, making it suitable for transport to sites of all sizes.
Dr Jim Kennedy, clinical director of Wokingham North PCN, says: ‘The AstraZeneca vaccine would be a hell of a lot more user-friendly. The Pfizer vaccine is like dealing with nitroglycerine. It is such fragile material. It is not suitable for vaccinating the entire population.’
Despite all these concerns, this is a programme that’s essential and ultimately needs the involvement of general practice.
Dr Kennedy adds: ‘We do not underestimate the scale of the challenge. The practices are all on board with this to secure our community and our country more widely. It shows, yet again, the value of general practice. We know this is a big ask. But I am heartened by the support to push this out.’