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Q&A: What we know about the Covid vaccine DES (Updated 23 November)


Covid question mark


Pulse’s Q&A focuses on what the Covid vaccine DES means for GPs based on what we know. This will be updated constantly. If you have any questions, please contact newsdesk@pulsetoday.co.uk or comment at the bottom of this article. Last updated 23 November 2020.


Payments and the DES

Money

How much will practices be paid?

Practices in England will be paid £12.58 per dose administered of whichever vaccine they have. The vaccines that are furthest along in development have two doses.

Practices will be paid £25.16 after the second dose is administered.

What happens if you are unable to administer the second dose of the vaccine?

Practices will still be paid the £12.58 if patients do not have the second dose for the following reasons (though this is only an indicative list at the moment):

(a) unsuitability for the patient:

(i) because of medicine intolerance or allergy discovered during administration of the first dose

(ii) if the patient has commenced end of life care before a second dose of the vaccine could be provided

(iii) if the patient has died before a second dose could be provided.

(b) the patient has chosen not to receive the second dose of the vaccine following a shared decision making conversation

(c) the patient did not respond to offers of receiving a second dose of the vaccine

(d) if the patient has moved out of the area covered by the PCN grouping (see below);

 (e) if the patient has moved in to the area covered by the PCN grouping after receiving the first dose of the vaccine from another provider.

How will practices have to organise themselves?

The first deadline for the programme will be for ‘PCN groupings’ to inform their CCG about their nominated vaccination site by Tuesday 17 November.

Practices will need to organise themselves into groupings, which will broadly align to their primary care networks. However, there are exceptions to this, such as PCNs with populations larger than 100,000 patients, or for PCNs smaller than 30,000 patients. Practices who are not part of a PCN will also be able to sign up in collaboration with their local PCN.

Each grouping will have to designate a single premises as a vaccination site. This will then have to be approved by the CCG. The CCG will rank the nominated sites. If there are too many sites, they will cut the number according to the ranked list.

NHS England estimate that there will be 1,000 to 1,500 sites in all.

Updated 17:50, 11 November

When will practices have to sign up?

There is a short deadline for this. The timetable is:

Wednesday 11 November: Briefing session for NHS England and NHS Improvement Regional Teams and CCGs on Designation Process

Tuesday 17 November: Deadline for PCN groupings to advise CCGs of nominated site for designation. (Note that where PCN groupings submit nominations earlier the designation process can commence. PCN groupings are strongly advised to discuss their likely nominations with the CCG in advance of submitting the form).

Thursday 19 November: Deadline for CCGs to have completed designation assessment process for nominated sites and submit recommendations to NHS England regional teams.

Friday 20 November: NHS England regional/national consideration of CCG recommendations and decision on which sites will be designated.

Monday 23 November: NHS England decision communicated to PCN groupings.

Late November: Final service specification published

When will practices have to start vaccinations?

This remains unclear, and depends on when the vaccines are approved and ready. But it is looking increasingly likely following Pfizer’s announcement that the first cohorts will start to be vaccinated pre-Christmas.

The health secretary has said under current plans if a programme starts in December GPs will not be required to deliver the majority of any vaccinations given this year.

He said the NHS is setting up vaccination centres to carry out the bulk of the work before the new year, alongside hubs in hospitals for NHS staff to receive the vaccination.

Updated 11:45, 23 November

Who will be able to administer the vaccinations?

Registered healthcare professionals will need to carry out the clinical assessment, consent and preparation of the vaccine.

However, the vaccine itself can be administered by a suitably trained non-registered staff member – while under the clinical supervision of a registered healthcare professional.

It has not yet been specified who the non-registered staff members will be, but this will be covered in a national protocol, due to be published soon.

What training will staff need?

Practices will need to oversee and keep a record confirming all staff have undertaken training prior to vaccination.

Training will be provided by Public Health England / Health Education England.

Practice staff are likely to have to take part in specific e-learning chapters – with each one taking up to 1.5 hours to complete.

Additional chapters of e-learning will be provided if new vaccines become available.

How will patients be notified?

Patients will be sent a letter by the national call/recall service telling them they are eligible for vaccination and that they have a choice of where they can get their vaccine.

Meanwhile, PCN groupings will also be expected to contact patients eligible for vaccination, using nationally agreed wording.

Patients will be given the choice to either book at a GP-led vaccination centre or use the national booking service to be vaccinated by another provider.

PCNs will be given the option to use the national booking service – or they can use their own appointment booking systems and schedule clinics in line with vaccine supply.

Currently there is no way of informing practices automatically when a patient books a vaccination with another provider via the national booking system, but this is being looked into further.  

Practices will not be contractually obliged to offer call and recall for patient cohorts that they are unable to reliably identify from their records, eg, health and social care workers – but are encouraged to do so if they can identify them.

Is this actually a Directed Enhanced Service?

It became apparent on 13 November that this may not actually be a DES, despite the BMA calling it such. It has been called an ‘enhanced service directed by NHS England’.

In reality, this probably won’t mean much for GP practices. It allows NHS England to change the requirements – or maintain ‘flexibility – but this was inevitable as we don’t know the characteristics of every vaccine as yet. And as there is no core payment involved – only item of service fees – PCN are in effect able to opt out whenever they like by simply deciding not to continue administering vaccines: there is no contratual mechanism that NHS England can use to punish them.

Another advantage of a DES is that it gives GPs preferred provider status. This might be a problem in future, but with such a vast vaccination programme, it is highliy unlikely that GPs will be discouraged from giving out the vaccination to as many patients as they can.

Added 8:45, 16 November

Will practices have to open on Christmas Day, as well as evenings and weekends?

Potentially. There is a requirement that they must ‘be able to deliver a vaccination service seven days per week including bank holidays between 8am and 8pm’. NHS England said that because of the nature of the Pfizer vaccine – with GPs having to be administer it within five days of receiving the batches of 975 doses – and the unknown delivery times, it may be the case that vaccinations could take place on Christmas Day, other bank holidays and evenings and weekends.

Updated, 11:00, 17 November

What is the case if no practice in a PCN area is willing to lead on the vaccinations?

This is the nightmare scenario for the Government, and one that hasn’t been fully answered. There will be ‘Nightingale’ style mass vaccination centres that could take up the slack. But it is unclear how many, and they won’t be able to vaccinate care homes or housebound patient.

We have seen this problem with test and trace, with people needing to travel long distances in order to get tested. This still needs to be clarified.

Added 18:00, 11 November

Is payment to the practice or the PCN grouping?

This is not yet completely clear, but we know it is a requirement of the DES to have a ‘vaccination collaboration agreement’ in place, designed ‘to support practices to put in place appropriate arrangements under the Enhanced Service for premises, data sharing, financial arrangements, subcontracting arrangements’.

Added 18:30, 11 November

Will we be paid for vaccinating our own staff if they are not registered with us?

Yes. The BMA has said: ‘Practices will be able to vaccinate their own staff and be paid for doing so.’

Added 18:30, 11 November

What is happening in the devolved nations?

All of the information in this Q&A relates to what is happening in England. Few details have been released for other parts of the UK so far, although in Scotland health boards will take the lead in running the programme.

In Wales, health boards and trusts will also be in charge of the vaccination programme.

However, Northern Ireland is expected to draw up an agreement with GPs that is similar to England’s contract.

Updated 11:45, 23 November


Patient care

Patient care

Will patients need to be monitored after being given the vaccine?

Only if they are driving. It had originally been said that patients will need to be monitored for 15 minutes after being given the vaccine. However, NHS England later clarified that this would only be the case if the patient is driving.

Updated 8:45, 16 November

What is the time needed between the two doses, and how soon after the flu vaccine can we start administering them?

The Joint Committee on Vaccination and Immunisation has yet to confirm that two doses are required – but practices have been told this is likely.

The committee has also not yet confirmed the maximum and minimum length of time between administering the two doses.

It is expected that there will need to be at least seven days between the flu vaccination and Covid-19 vaccinations, but this has also yet to be confirmed.

Is the Pfizer vaccine the only one practices will be administering?

Several potential vaccines for Covid-19 are in the later stages of phase 3 trials.

Following Pfizer’s early announcement that its vaccine is 90% effective – later revised to 95% following full analysis – results from the Oxford AstraZeneca vaccine have now been revealed, showing it can be stored at fridge temperature

The University of Oxford vaccine is also given in two doses and it has been shown to be 90% effective when given as a half dose followed by a full dose.

US biotech firm Moderna has also shown its vaccine to be 95% effective.

The UK has negotiated to secure 355 million doses of six different vaccines in development worldwide (although does not expect all to be effective). This includes 100 million doses of the Oxford vaccine, 40 million doses of Pfizer’s and five million doses of the Moderna vaccine.

The UK Vaccines Taskforce is expecting that Pfizer’s and the Oxford vaccine could potentially be approved by the MHRA this year.

Updated 11:45, 23 November

Which patients will practices need to vaccinate?

This is still not fully clear. The Joint Committee on Vaccinations and Immunisations has recommended the following order:

  1. older adults’ resident in a care home and care home workers1
  2. all those 80 years of age and over and health and social care workers1
  3. all those 75 years of age and over
  4. all those 70 years of age and over
  5. all those 65 years of age and over
  6. high-risk adults under 65 years of age
  7. moderate-risk adults under 65 years of age
  8. all those 60 years of age and over
  9. all those 55 years of age and over
  10. all those 50 years of age and over
  11. rest of the population (priority to be determined)

However, this is not confirmed – this will depend on the characteristics of the vaccines being administered.

Will practices have to provide visits to care homes and housebound patients?

Yes. Under the DES, practice groups will be responsible for both care home staff and residents, and will need to provide home visits for housebound patients.


Non-Covid vaccine workload

What work will practices be able to stop doing in order to carry out this programme?

NHS England says: ‘Practices administering the vaccine must demonstrate ability to coordinate clinical capacity in line with cohort prioritisation and national/practice call/recall schedules and in alignment with national communications guidance, whilst maintaining appropriate levels of wider general practice capacity.’

The conditions attached to the £150m also suggests that practices will need to increase their achievements for the learning disabilities DES, and will need to help clear backlogs in long-term conditions and other vaccinations.

What support will practices receive to do all their other work?

There will be a £150m general practice Covid fund from now until March (no other Covid funding) to keep normal services running. It will be up to CCGs and ICSs to decide how this money is used, but they have been given suggestions including hiring pools of extra salaried GPs.

How will GPs access the £150m fund to keep normal services running?

It will be for integrated care systems and CCGs to determine how best it is spent within general practice. NHS England said it should have ‘a focus on simplicity and speed of deployment’.

However, they say: ‘Accessing the fund will be conditional on practices and PCNs continuing to complete national appointment and workforce data in line with existing contractual requirements.’

They have also said that there will be no extra money given to practices to support them through Covid until April.

What will the £150m be used for?

NHS England say that it should be used to help ‘stimulate the creation of additional salaried GP roles that are attractive to practices and locums alike’. This includes the employment of staff returning to help with Covid, or to increase the time commitment of existing salaried staff.

It will also be used to:

  • Support the establishment of the simple Covid oximetry@home model – with details to be announced shortly;
  • Help identify and support patients with Long Covid;
  • Continue to support clinically extremely vulnerable patients and maintain the shielding list;
  • Help with the backlog of appointments including for chronic disease management and routine vaccinations and immunisations;
  • Make ‘significant progress on learning disability health checks’, with an expectation that all CCGs will without exception reach the target of 67% by March 2021. Current achievement is one fifth lower than the equivalent position last year; and actions to improve ethnicity data recording in GP records
  • Potentially offering backfill for staff absences where this is agreed by the CCG, required to meet demand, and the individual is not able to work remotely.

What additional workforce will be available to general practice to deliver the vaccine?

NHS England says that the vaccinations will need to be carried out with existing staff. However, they claim that the £150m can be used to help extend the hours of salaried staff and to attract people back into general practice.


The vaccine characteristics

How will the Pfizer vaccines need to be stored and where will practices be able to get fridges and other necessary resources for storing a vaccine at below 70 degrees?

The vaccine will initially need to be stored at minus 70 degrees. However, it will not be practice groupings who will need to do this.

NHS England’s specifications call on groupings to have refrigeration to store vaccinations at 2-8 degrees. This strongly suggests that the vaccines will be delivered in batches of 975, which will have to be used within five days of delivery.

The vials will come in vials of five doses, not 1,000 as Pulse had reported.

Updated 18:00, 11 November

Do they come in huge vials?

Pulse originally reported that the vaccines will come in vials of 1,000. However, this is not the case (and we apologise). The vials come in doses of five, NHS England has confirmed.

Updated, 18:00, 11 November

Are there any side effects of the vaccines?

It shouldn’t be forgotten that so far, only Pfizer has released a statement on its vaccine, and there are still regulatory hurdles to go through.

Will patients need to self-isolate if they experience side effects?

The GPC has said it will not be necessary.

Added 9:00am, 16 November


Questions needing to be clarified

Question marks

How long will protection last and will there be annual vaccinations?  

We should know when the various vaccination candidates are approved.

Will patients still able to pass the virus on even after vaccination

This is the $64,000 question. We don’t know whether the Pfizer vaccine – or any other – prevents people from being infected or just stops them from getting ill. It is unclear whether even Pfizer has these results.

Will practices even break even from this, when taxation, wages and claw backs are taken into account?

Various groups are currently modelling this and we will update when we have more info.

What happens if we fail to book in the requisite minimum 975 patients per week – do we have to cancel the clinic or waste vaccine?

This is a major part of the DES that hasn’t yet been clarified.

If vaccinated, will people no longer have to self-isolate if they’re exposed to Covid?

Are there any groups that aren’t eligible for the vaccine, or for whom it wouldn’t be safe?

Will GPs be required to provide proof to workplaces, schools etc that patients have been vaccinated?

Will those with positive antibody Covid results be treated the same way – ie, do they need the vaccination at all, or the two doses?


Please comment if you have any more questions or email editor@pulsetoday.co.uk

READERS' COMMENTS [9]

John Oldring 10 November, 2020 2:37 pm

1.Is it known how good an antibody response the older pts will have to each vaccine
2.Will pts still able to pass the virus on even after vaccination
3.What is the risk of the virus mutating and hence making the vaccine less effective
4There will be various types of vaccine produced will there be patient exclusions for each type of vaccine.especially for those will already vulnerable immune systems as a result of illness or its treatment

Reply moderated
Jonathan Heatley 10 November, 2020 3:02 pm

I can imagine some of my families will not want their elderly severely demented relative to have this life prolonging vaccine. They are allowed to opt out of flu vaccine. Is the covid one voluntary?

Reply moderated
Robert James Andrew Mackenzie Koefman 10 November, 2020 3:02 pm

What is so manipulative about this is the headlines today say Matt Hancock says GPs are getting £150million for this which of course is not true as the above document explains.

Reply moderated
Huw Williams 10 November, 2020 6:25 pm

I suggest NHSE keep their £150m and £12.58 per immunisation and see if they can deliver a comprehensive, safe, timely vaccination program while still providing all of their routine services and managing a pandemic

Ashley Krotosky 11 November, 2020 11:47 am

Can someone explain how the single site per PCN works?
Do the fees go to practice of patient even if they are given elsewhere?
Are practices expected to second staff to participate in the process at the chosen site?
Will a PCN hire staff specifically for the process and distribute any profit among practices in proportion to patients attending?
If the host site doesn’t get all the income , will they be expected to receive compensation for hosting?

Reply moderated
Helen Crawley 11 November, 2020 9:19 pm

Question and reply from above leads to further queries:
Q: What additional workforce will be available to general practice to deliver the vaccine?
A: NHS England says that the vaccinations will need to be carried out with existing staff. However, they claim that the £150m can be used to help extend the hours of salaried staff and to attract people back into general practice.

My queries:
What are medical defence organisations going to charge to cover the additional sessions provided by doctors currently paying to cover less than full time work?

Can retired GPs be part of this workforce? How will this happen? Will they be working as doctors or as medical support workers (a key question if they have been sent the GMC letter stating that they are back on the MPL).

David jenkins 12 November, 2020 11:02 am

surely it is obvious that healthcare workers need to be done first:

a – you know where they all are, and it is easier to get in touch with them and organise it

b – the very last thing you want is a load of unimmunised, and possibly infected, healthworkers going around nursing homes infecting all the residents

c – you don’t want loads of staff going off with covid, or self isolating because they have potentially been exposed to anyone infected.

Guy Wilkinson 20 November, 2020 4:47 pm

Agree David Jenkins

Monica Stevens 20 November, 2020 5:58 pm

Before Public Health was decimated, this was their Raison d’etre. They should be vaccinating the public in large public spaces. That way, no vaccine doses will be wasted, staff can be in full PPE, with as little mixing as possible of people. The administration details will then be held centrally and then their GPs can be informed. They can train anyone to give the vaccine, under medical supervision. It does not have to be individual GPs.

It is not that we GPs are work shy, but that we are still looking after the general health of patients. We cannot discharge those duties and immunise as well. We do not want to become conduits for infection in the local community.