Many of us will have been contacted recently by our LMCs on behalf of the BMA scoping the impact of this year’s inclusion of preschool vaccination and immunisations into QOF. I work in a PCN serving a deprived patient group with high turnover rates, immigration rates and English not as a first language.
We were alarmed as to how much money we would lose from this, and it seems that we are not alone in this – as Pulse’s story this week showed. Our practice is going to lose at least £7,200, but this could easily rise to £11,200 if even one family now registers and declines vaccination of their child. One of the other practices in the PCN stands to lose £27,000.
One of the reasons raised for including childhood vaccinations in QOF is because it could help reduce health inequalities by incentivising practices to chase patients even more than they are currently doing. However, multiple stakeholders (mostly GPs) raised very important points that would show how practices serving deprived areas /high patient turnover/ high rates of asylum seekers would be detrimentally affected by the inclusion into QOF without any real opportunity for ever achieving the full QOF payment. That is, unless you assume that such practices are doing a particularly bad job in the first place. Our practice recently did an audit and found that some families had been contacted over 30 times and now the child was too old to meet the QOF targets.
The other reason raised for including childhood vaccinations in QOF is because of the complexities of the current system of monitoring, procuring and measuring vaccinations. Thus, inclusion in QOF will simplify the process, of benefit to the practices, CCGs, PHE and NHS England – which I agree has some advantages.
However, it puzzles me that NHS England was made aware that practices facing such challenges would be penalised by the QOF inclusion yet it was implemented anyway without any additional direct help to practices to improve vaccination uptake. Indeed, the NICE indicator development programme consultation report for vaccinations and immunisations from August 2020 suggested that NHS England and Public Health England were aware of these inequities, yet the QOF indicator was still introduced. This change to QOF then surely does not achieve their aim to help improve health inequalities but rather does the opposite.
PHE’s ‘National Immunisation Programme: health equity audit‘ was published in February 2021, using data from 2017. The data for Nottinghamshire does not represent current rates in Nottingham City as a whole, let alone for our PCN. On page 10, it states that NHS England has ‘legal duty to reach groups…..people moving into the country from abroad who have incomplete or unknown vaccination status.’
However, as yet, our PCN has had no additional support despite having many such patients. On page 16, it states that the PHE and NHS England ‘work closely with … primary care …to increase access, information and choice for disadvantaged communities.’ Our PCN is not clear how this is being put into action on the ground and are looking forward to being contacted directly about this.
I understand that the 90-95% QOF target is for herd immunity, but it is unachievable for many practices, especially because of the age ranges of children given. What if a three-year-old child comes from abroad without any previous vaccinations? If QOF is not to be abandoned, then how about a DES whereby affected practices could demonstrate how they are trying to contact and educate families as a way of earning back the lost money? I am sure that there are several other more equitable solutions if we make it a priority to give practices serving deprived areas a level playing field.
The current QOF is intrinsically unfair. It would be like awarding 54 points for having interpreters or doing asylum seeker reviews; some practices would never be able to achieve these because of the nature of their patient group.
So the question is, does the NHS truly want to improve health inequalities? Surely QOF should therefore not further destabilise practices serving deprived communities. And should the conversation really be about health inequities and not health inequalities?
Dr Marcia Chamberlain is a GP partner in Nottingham