GP partner Dr Gavin Jamie analyses what the Covid-19 vaccination entails, and whether it is in practices’ best interests to take it on
Some details of the Covid-19 vaccination enhanced service are still to be finalised, but based on what we know there are several figures that give some insight into how the logistics, workload and payment will play out.
The approach favours urban populations
The suggestion is that there should be a single vaccination centre in each PCN, with the exception of the couple of dozen PCNs which have a list size of over 100,000. Practices without a PCN can take part in the vaccination programme as well.
There are expected to be between 1,000 and 1,500 centres, which suggests that each will cover around 50,000 patients. In central London that could mean covering less than 5 km2 – but in around half the country they will cover at least 100 km2 and often much more. Patients may therefore have to travel a long way to their nearest centre, so this would appear to be a service much more suitable for urban areas – although these are also the areas that currently have the highest prevalence of Covid-19 infection.
Vaccination sites hugely resource intensive
Each vaccination centre will be expected to be open up to 12 hours a day seven days a week (84 hours) in order to administer vaccinations. The plans indicate the first vaccine to be available has only a short shelf life at fridge temperature, with practices having a week to use a batch of 975 doses, which comes in vials of 5 doses.
That could mean that the centre will have to be able to give at least one vaccine every 5 minutes, on average, throughout those 84 hours.
In addition, it is expected that each patient will need to be observed for at least 15 minutes after the vaccination if they are driving – requiring at least three socially distanced seats in an observation area. In practice, however, this will need to be more like five seats, to keep things working.
These hours will need roughly three whole-time equivalent (WTE) vaccinators and another three WTE staff to guide patients and keep an eye on the observation area. It will also need a GP on site at all hours to deal with complications.
In summary each site will need:
- Premises accessible 84 hours a week
- Socially distanced space to observe five patients
- 84 hours of vaccinator time
- 84 hours of reception time
- GP time OOH as required
- Management and administration of the system – including meetings to set it up, appointment booking etc.
It is expected that this will take place in GP surgeries. At the moment it is not clear when the service will start and for how long it will go on, so committing to facilities outside the surgery is likely to be difficult – and will also be considerably more expensive, as they would not usually have a GP on site during the week.
Payment depends entirely on vaccination uptake
Payment is £25.16 for a course of two vaccinations – it is listed as £12.58 per dose, but is to be paid upon completion of the course. Although there will be a number of vaccination providers, patients will be usually expected to have both doses with the same provider.
For patients who have only a single vaccination dose, there is a system of exception reporting, similar to the personalised care adjustment in QOF. The details of the rules for this are yet to be announced but patients who cannot have a second dose for clinical or social reasons, along with patients who decline a second vaccination or simply do not respond to reminders, can be exception reported.
Of relevance here is that one of the vaccines supposed to be close to delivery – The Oxford Astrazeneca one – has shown a relatively high rate of pain, fatigue and chills in the four or five days after administration in early trials.
We will not know how many patients will consent to complete the course until the programme begins. Distance to the vaccination centre and recall arrangements are also likely to have an effect. We also don’t yet know how much variation from the three or four-week booster interval would be allowed.
A reasonable rough estimate of income would be around £150 per hour when operating at capacity.
Of course, money is not the whole story. General practice is constrained by staff and premises availability, at least as much as finance. Money cannot create these things overnight. Much else is uncertain. There is no confirmed start date. If vaccine supply is limited then centres may not open every week, making staffing arrangements more complicated. There is an intention to vaccinate the housebound and care home residents but the practicalities of delivering the vaccine and observing the patients afterwards are not detailed. Equally there is no indication that a mobile unit travelling between practices would be acceptable.
NHS England has announced an additional £150m funding to support general practice, but has made it clear this is separate to the vaccination programme, and comes with several strings attached.
- £25.16 per completed course – two jabs at £12.58
- Exception reporting should help limit losses due to drop-out
- No start date, or indeed end date
- Vaccinations may be intermittent at least at first – week by week
- Domiciliary and care home service not yet specified.
Choice of appointment system will also impact resources
Practices can make their own appointments or use a national service. There are advantages in both systems. Making your own appointments will give greater control to the vaccination centre, but will incur extra cost. Appointments for second doses can be made whilst the patient attends the centre for the first.
The timeline is incredibly tight
After months of vaccine development and weeks of negotiation practices have been given a week – until 17 November – to submit complicated proposals.
In other words, we still do not have the final details on many aspects of the service from NHS England or the GPC, but have a deadline of next Tuesday. That is simply unrealistic.
The programme requires more flexibility
Finally, some stats to consider for when this is rolled out more widely:
- A thousand vaccinations centres with a capacity of a thousand vaccinations weekly suggests a national capacity of a million vaccinations a week.
- With a population of 60 million and two doses needed it would take 120 weeks, or two years and four months, to vaccinate everyone.
- This year practices vaccinated over three million patients against the flu in September alone, although the vaccine was not delivered until well into the month. The total Covid-19 capacity is likely to be less than flu under the current plans.
Personally, I agree that general practice is ideally placed to lead on the delivery of a Covid-19 vaccination programme.
But with current personnel this will be a challenge and I can entirely understand why some feel it will be too much for us in our current circumstances.
The strength of practices has always been about finding innovative and adaptable ways of delivering the required services. These proposals reduce the potential to do that, specifying the number of sites, the opening hours etc. Couldn’t the service travel around to get closer to patients?
Lastly, the whole approach seems to be loaded with other agendas. We can see ‘working at scale’ and ‘8-8 7/7’ clearly running through the outline of the scheme. I am concerned that dogma may inhibit the delivery of this vital vaccination to patients.
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF Database website