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Let us vaccinate



There has never been a health crisis like that caused by Covid – it’s not only brought the NHS to its knees, but has paralysed the country as a whole, affecting every sector and threatening the livelihoods and the mental and physical health of many. We may not be at war, but we are very much on a war footing.

In the midst of Tier 4 lockdown and NHS England emergency measures for appointments, the appointment screens for my surgery show the wait times for telephone appointments are a matter of a few days at most, whilst the building is empty. The contrast between this situation and the horrific headlines on the nightly news could not be starker.

As members of primary care networks, we either signed up to the Enhanced Service contract, or delegated responsibility elsewhere. The latter group cannot say who has picked up the responsibility, and social media is awash with complaints from their patients about whether these practices know ‘whether there is a pandemic on’.

What seemed like an arcane contractual decision now has real ramifications for the credibility of these practices.

Those of us who subscribed to the PCN model did so when the Pfizer/Biotech vaccine necessitated a special site with ‘premises approval’ due to its requirement for storage at -70 degrees. But on 31 December, the MHRA gave emergency authorisation to the new AstraZeneca/Oxford vaccine.

This AstraZenca/Oxford one is a game-changer. It did away with the requirements for cryogenic storage and its complicated drawing up and delivery regimes. It did away with the 15-minute observation period that entailed the need for large waiting areas for inoculated patients that limited the ability of GPs to deliver it in typically-sized practice buildings.

With all those complications swept aside, the new vaccine is much akin to that of the flu and other routine vaccines that we deliver in general practice. Our empty buildings and shortened waiting times now look hard to justify. It can be stored in our fridges, is room temperature stable for six hours, and has a shelf life of six months.

The clinical considerations around giving it to suitable patients are not complicated or differing from the other vaccinations that we give routinely. Staff must have some rudimentary training such as anaphylaxis, hold basic life support training and have a cold chain policy in place – which they will do for the childhood immunisations and flu and travel vaccinations that they already give.

In short, the business of giving vaccinations is the business of general practice. This is what we do 

At a time when the country needs to vaccinate the greatest number of people in the shortest time, general practice has been sidelined by the dependence of NHS England on the apparatus of PCNs, and the rapid, almost daily changes in the fast-moving situation of vaccine deployment.

Many GP practices, like ours, are willing to step up and join the frontline. The ministerial ambition is to achieve vaccination of the top priority groups by 15 February – this could be about 30% of the population depending on demographics. Our local PCN has deployed 2,760 complete courses of vaccination in three weeks. From a standing start, this is a remarkable achievement and testament to the good will and community spirit of right minded people pulling together for the common good.

But it is not enough, and not sustainable.

Extrapolating this to the total numbers needed to vaccinate indicates that we will only reach the priority groups by 18 May. In the meantime, people will continue to contract the virus, and the longer it goes unabated, the more opportunity it has to mutate. Time is of the essence.

Local reports circulate of clinical directors refusing deliveries of vaccines because they do not have the logistical capability to deliver it through their PCN model. This is the wrong way around and should ring alarm bells. The logistics must be up to the job of delivering the vaccine. If there was ever a case of generals still fighting the last war, this is it. The AstraZenca/Oxford vaccine is a disruptive innovation, and no one seems to have noticed.

It seemed we received clear guidance from NHS England, reported in Pulse last week, that the new vaccine could be distributed to constituent Practices of PCN’s ‘where it is considered that this will improve patient access or increase vaccination capacity – which remains a prime consideration.’

Sadly, it seems they did not reckon on CCGs reverting to their bureaucratic instincts and insisting on ‘premises approval’ and a number of other stipulations, not having woken up to the opportunity that the new AstraZenca/Oxford vaccine represents, and seemingly unaware of its similarity with other vaccines that we are accredited to deliver.

CCGs don’t seem to realise that the UK already has a mass vaccination delivery vehicle – it’s called general practice. In a dire situation such as the one we’re facing, everything that can be done must be done. By crowd sourcing distribution from able GP practices, and any other provides who already do this work, such as pharmacists and dentists, there is an invaluable opportunity to tap into underused supply.

Billions have been spent upon building primary care in this country to world class standards. Many GP practices could deliver the new AstraZenca/Oxford vaccine in their daily clinics. There are approximately 4,700 GP practices in England, and if 80% allocated only three hours of clinic time to immunising patients with the new vaccine (at a rate of eight patients per hour) this would add an additional 450,000 vaccinations each week, or around two million in a month.

In reality, my practice estimates that it could devote up to half its daily clinics to this work – which, if replicated by 80% of practices nationally, would add around 1.8 million vaccinations a week, or around eight million in a month. By running clinics over weekends, we could achieve even more. The only constraint is the supply of vaccine – the capability is there, and the will is not lacking.

The AstraZenca/Oxford vaccine is a game-changer. Vaccine delivery is the business of general practice, and even though the lockdown conditions are time-limited, the NHS has not woken up to the incredible contribution that crowdsourcing unused capacity in general practice can make. Yes, some people will baulk at this and others will be constrained by staff absence from the virus itself, but if there was ever a time for general practice to step up, this is it.

#LetUsVaccinate

Dr Rubin Minhas and Denise Payne are a partner and general manager at Oakfield Health Centre, in Gravesend, Kent, respectively. Dr Minhas is an expert advisory to an MHRA Committee. However, the views expressed here are entirely those of the authors.

READERS' COMMENTS [10]

Joanna Davies 14 January, 2021 10:42 pm

Said the exact same thing in an email to my MP this week. AZ vaccine could be a gamechanger if it can be delivered to individual practices rather than tied up in the additional logistical loop hole of distributing from PCN hubs. We calculated in our practice -list size -9000 if we opened at weekends and did a fri sat and Sun vacc clinic we could vaccinate 840 patients a week.

John Elder 15 January, 2021 10:08 am

Agree – this is bureaucratic madness! It is what we do best – all the effort & press coverage of pharmacies & supermarkets totally unnecessary – just give us the tools & we will get it done – and very quickly!! We easily managed 450 flus on one Saturday (just under 5000 patients) so if we made a big effort would be completed in 4 weeks max!

Rubin Minhas 15 January, 2021 11:20 am

Joanne & John
Thank you, straight to the point and heartening to hear such can-do positive attitudes from colleagues.

Let’s keep pushing……we (9000 pt practice) also reckoned we’d get this done in a month.

David Jarvis 15 January, 2021 12:46 pm

They do seem allergic to the idea of general practice making money out of this when happy to throw money every which way to anybody else. But also not realise our expertise in giving vaccines quickly. As a practice we did 1500 flu jabs in 2 days winter. 8 until 4 and this was slowed by social distancing.
But as a PCN we are lucky with a location and sharing staff we can sustain a high throughput for weeks and currently vaccine supply is the limit. I do worry how much of these headline large centres and 8-8 or 24/7 rubbish is relevant. We could certainly do 2000 a week in normal working hours and 3000+ if you add weekends and I would guess another 1000 without 15min waits. 42000 over 18’s to jab.

But ? level playing field. What will the pay per jab be accross the different provision.

Subhash Chandra Bhatt 16 January, 2021 10:10 am

Absolutely correct steps suggested Rubin minhas

Hello My name is 16 January, 2021 10:49 am

‘What seemed like an arcane contractual decision now has real ramifications for the credibility of these practices.’ Overall a good article, but the dig at practices who did not sign up, was needless. Some practices had very real concerns about their ability to staff, the demands that would be placed on them (hours etc), and the potential for loss-making which might undermine their ability to provide basic medical care for their patients, as per their contracts. A contract which could be changed unilaterally at any point? With a renowned double-crosser? Please don’t paint your colleagues in a bad light. Do you think we do the job for fun? We have your same sense of duty (just perhaps not the blind trust). We have been let down time and again by our CCGs and NHSE and unsurprisingly, some of us are now cautious in our dealings with these bodies. But yes, general practice could roll these out very quickly if there was a reliable funding package and the guarantee of income. We could find the resources and bring in volunteers or retirees. But the real issue is – can we trust NHSE as far as we can throw them?

Peter Scott 16 January, 2021 12:51 pm

‘Giving vaccinations is the business of general practice. This is what we do’
Never a truer word spoken. I am livid that pharmacies, (however well intentioned) and 7 mass-vaccination sites (that sprang up overnight last week), and now most hospitals are offering vaccinations.

Give the AZ- Oxford vaccine to GPs, watch us get the job done in 4 weeks.
We are best placed to get it from fridge to arm, and record it coherently.
My other worry is that too many cooks spoil the broth, and you will end up with people being done ‘twice’, and many missed out totally.

This year we got through 1000 flu jabs in 3 weeks, when normally we would have done it over 6 weeks (flu epidemic not withstanding), we can do it again. Our phones are busy, but our surgeries are close to empty.

Rubin Minhas 16 January, 2021 2:20 pm

Peter Scott, David Jarvis
Your experience in getting mass imms done is proof positive they just need turn on the tap they already have.
Some of the numbers you do are amazing.

‘Hello my name is’.
No, not the fault of GPs that didn’t sign, lots of good reasons why not!
I know one that opted out on staffing/safety grounds and now wants to opt in, this excerpt from a Partner there says it all…
“Our PCN didn’t sign up. The CCG has not commissioned alternative delivery. We’re struggling now to persuade them to allow us to sign up after the deadline….MPs are now involved and we may still make some progress.”

terry sullivan 19 January, 2021 6:36 pm

just say no

David Jarvis 26 January, 2021 8:49 am

I understand the stress a lot of practices are under. For those I am very sympathetic if you are already understaffed. Some are looking purely financially and one of the problems of general practice is the huge variation in general practice income. Having gone from lower to higher with a merger in the midst of PMS GMS fair shares. Still took 5 years to level us up to fair share. Some have been levelled down.
But looking beyond money we signed up because we see it as a way out of where we are and we personally stand to gain from that not simply in monetary terms. We are not looking at a loss and potentially a small profit.
Having signed up we are controlling some of our own destiny so all staff and GP’s vaccinated along with other local community staff. All smiling and grateful. Happy patients to get their jabs and happy staff even though putting in extra hours feeling they are making a difference. All involved top to bottom from senior GPs to the most junior. Getting it organised has been a challenge but now we are set up the massive frustration is vaccine supply way below what we have the capacity to use. We are onto our over 70 cohort.
But looking at the fact that 1 in 10 GPs not vaccinated while passively expecting someone else to do it is a little bit of cognitive dissonance.