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Hesitancy, vulnerable groups and the financial aspects of the Covid vaccine

Hesitancy, vulnerable groups

Eight PCN clinical directors joined Pulse editor Jaimie Kaffash on Microsoft Teams to discuss how the Covid vaccination scheme has progressed. Click here for part 1

Dr Tom Rustom Clinical director, Hawley PCN, East Surrey

Dr Robin Harlow Clinical director, Gosport Central PCN, Hampshire

Dr Partha Ganguli Clinical director, South Ribble PCN, Preston and Chorley, Lancashire

Dr Monica Alabi Clinical director, Titan PCN, Bedfordshire

Dr Reshma Syed Joint clinical director, Sittingbourne PCN, Kent

Dr Tom Holdsworth Clinical director, Townships PCN, Sheffield, South Yorkshire

Dr Helen McAndrew Clinical director, Abbey Health PCN, St Albans, Hertfordshire

Dr Sanjoy Kumar Clinical director, North East London PCN, Waltham Forest, London

Chair Jaimie Kaffash Editor, Pulse

Jaimie In our quick poll, deprivation seems to be the biggest barrier to patients getting the vaccine. What are the reasons behind that?

Tom R We can’t underestimate, actually, the damage this whole pandemic has done to the worst off in society. I don’t think we can talk about it enough, really, because we’ve seen domestic violence go up, we’ve seen job losses. If somebody gets invited for a vaccine but they’re a single parent and their kids aren’t at school and they haven’t got enough money for a taxi or they haven’t got a car, how are we supposed to vaccinate them? I think that those people get lost.

That’s where the local vaccination sites can be quite useful. Initiatives like [the vaccination bus in Sussex] don’t happen because someone’s told us we have to do it, they happen because we’re GPs and we care about our patients and it’s the right thing to do. Local vaccination sites are best placed to pick up these pockets of deprivation. We know about the guy that sleeps outside the supermarket across the road from the practice. We know about the families that struggle, the child safeguarding families.

Tom H One of the things that needs to be thought about more is matching vaccine supply with areas of greatest deprivation. NHS England has done a particularly bad job of that in Sheffield, which has caused a lot of upset.

They should recognise some of the problems deprived populations will have [such as] very large cohorts like cohort six, and the huge amount of multi-morbidity. Understand that we have to have translated consultations, that some people are not going to be able to use the technology to book in. Also we must flip this idea of hard-to-reach populations. Actually, a lot of these populations are not hard to reach, they’re underserved and that’s been built in over the years.

Partha When you’re looking at anti-vax campaigns, [they] sort of come together with [health inequalities] where there is not enough information given to these people. Also, there is a significant inequality in these groups. We work in a city centre area and there are people who don’t have a phone. Some of them only come in to see us in person. These things are not being taken care of, and there is no extra effort put in for these groups of people separately to approach them. There needs to be flexibility. In terms of the BAME issue, I personally had to phone a lot of patients who speak Punjabi, Bengali or Urdu and convince them, because they didn’t have the information. They all agreed to the vaccination. That’s something we need to look at, it’s GPs’ time but I think it’s worth spending.

Helen Last night I and my fellow clinical director personally did our local open door homeless shelter after hours, when [everyone was] there. No one else was going to do it. And there was a proportion of [people] who had been told by a local pharmacy that the vaccine wasn’t safe. So that made our job harder. We had to convince [people] without having relationships and they did actually all come round. There is no recognition that that is what primary care brings. That is a significant funding issue and we’re just all going above and beyond as we normally do.

Jaimie Is there anyone here who feels this should have been delivered on a practice basis from the very start and not at PCN level?

Monica We decided to have a hybrid model because we are in a deprived area and many of our patients said they will not under any circumstances go to the main [vaccination] site. We were able to get support from NHS England, support from our LMC although our CCG was very cross about it. And now all we do is we deliver AstraZeneca vaccines from the practice for our most deprived patients and Pfizers when we get them from the main vaccination site. But that option and that flexibility should have been built in and that should have been organised via the PCNs.

Tom R I think there were practical issues that would have made delivering [the vaccinations] from individual practices very difficult. Not everybody’s got the same access to estates. [Also] we’ve got other patients coming in for other problems, [who would mix] with the most vulnerable people who are coming in for their vaccinations. We’ve potentially got heart patients coming into practices so I think there would be a lot of complications about trying to deliver [vaccinations] at practice level only. Also, I think the Pfizer vaccine would have been particularly difficult to deliver from smaller practices. But it would be nice, as we have now, to have [had] the flexibility to take a few vaccines from the [main vaccination] site to the practices to deliver them.

Jaimie At the start of the programme, vaccinating vulnerable groups was probably costing more than you made. Did you expect to claw some of this money back once you started vaccinating younger, healthier patients, and has this happened?

Sanjoy All of our set-up was cost neutral. We hoped that when we started doing the 16 to 60-year-olds, we would then pay off some of the things [we purchased]. Now, though, GPs will be left out of pocket because now it’s payback time, we are not getting those [patient] cohorts. So it is unfortunately going to leave some GPs out of pocket.

This is a huge funding issue. GPs are not supported by the NHS England model and again, as my colleagues have said, they haven’t joined up the thinking with the pharmacy model. So there are so many people getting vaccinated at sites that will [result in] a complete financial loss to certain groups.

Partha When we are talking about loss and profit, we need to think about the time and effort the PCN group clinical directors have given. I don’t think that that’s being evaluated or valued at all. As a whole, we don’t expect to make a profit, which we should as a business. We are all worrying now that we might have a loss if we are actually taking into account the time we have spent.

Helen When you bring up the argument of not having access to the lower cohorts we’d financially accounted for, it’s been used against us as a reason why general practice [shouldn’t] continue to deliver the service.

Tom H Sometimes we’re stuck because we’re trying to operate like a business but at the same time we’ve got to do the right thing and that makes it really difficult.

And yet again, it comes back to transparency and communication. The initial question was ‘Can you deliver a vaccine service? But you’re not going to have any of the details of it or [only] very bare bones. Can you say yes or no by next week?’ What would you need, if you were a proper business moving forward? Well I’d like to know how long this would go on for. What’s the funding? Yes, there’s extra funding for management up until March, what happens after that? Without these details it’s so difficult.

So, yes partly [the problem is] the model but also it’s the lack of clarity and the difficulty with the communication.

Part one – Covid vaccinations round table: Tensions with mass vaccination centres