Flu vaccination is proving one of the biggest success stories in enhanced services and could pave the way for a much wider vaccination role. P3 investigates the secret of its success

The only question mark over community pharmacy delivery of flu vaccinations should be why this is not a national service. Only around half of people aged under 65 in clinical risk groups were vaccinated against flu in 2011/12, while the NHS has set a target of 75 per cent by 2013/14. GP practices consistently struggle to vaccinate hard-to-reach groups, while pharmacies have proved highly effective at boosting vaccination rate with a cost-effective service that patients like.

Just over 100 GP practices out of 11,077 across England managed to reach coverage of 75 per cent or more in at-risk groups in 2012-13. But where they have been commissioned, pharmacy services have been extremely successful. Last year in Sheffield, for example, results from a pharmacy-based scheme showed:

• 20 per cent of patients were vaccinated for the first time
• 573 patients were vaccinated, of whom 93 would not have been vaccinated if it had not been offered by pharmacy
• 99 per cent of those vaccinated considered the service provision good or excellent.

Even if a pharmacy service is not commissioned, private PGD-based services offer plenty of patients the choice of an accessible and convenient option that raises vaccination levels and relieves the pressure on GP practices. A recent study shows that some at-risk patients, who are eligible for a free vaccination, still choose to pay privately for a pharmacy service because they believe that it is easier to access. Some of the most common reasons for choosing the pharmacy service were convenient location and opening hours, preference for the pharmacy environment and the inconvenience of getting to a GP service.

And there is a groundswell of support for wider pharmacy delivery. NHS Alliance, for example, in its response to the Primary Care and Public Health All Party Parliamentary Group’s inquiry into winter pressures, advocated greater commissioning of pharmacy vaccinations to take the pressure off GPs and A&E. ‘A number of minor projects were commissioned within community pharmacy to support winter pressure initiatives last year, but they were all too late, too small and too poorly publicised to make any difference at all,’ it said in its response.

GP resistance

But GPs are the biggest stumbling block in some areas, probably concerned about a potential loss of income. Pharmacies in Wales can deliver flu vaccinations as a national enhanced service, but Welsh BMA representative Dr Charlotte Jones claimed at the end of August that pharmacy flu vaccination schemes did not improve uptake and added costs. She also claimed that GPs had to do more administrative work than pharmacists in relation to the service, that pharmacists’ ability to offer private vaccinations means there is not a level playing field between the two professions, and that elderly or confused patients could end up being vaccinated twice. Meanwhile, local medical committees in Shropshire and Staffordshire have forced NHS England to delay the start of a pharmacy scheme until November.

However, the evidence does not back up Dr Jones’ arguments. There was not one case of a patient being vaccinated twice in Pharmacy London’s service, which delivered 76,000 vaccinations last year. And 38 per cent of its vaccinations were to under-65s, while 25 per cent of pregnant women who chose to get vaccinated, used a pharmacy service. The pharmacy service also vaccinated 2,500 people who were not registered with a GP.

The comments ‘beggar belief and I am appalled by their ignorance’, says Mimi Lau, Numark’s director of pharmacy services. ‘They seem to have forgotten the reason why the NHS introduced the service in the first place – which was to enable as many NHS-eligible patients as possible to have access to the flu vaccine because of its benefits.’

Many GP practices struggle to reach their entire ‘at risk’ groups for a variety of reasons. ‘Despite improvements, the reality is that practices are still falling behind government targets year after year. It is obvious that opening the service to pharmacy has a number of benefits – it raises public awareness of why a flu vaccine is important, increases access and gives patients a choice of provider to suit their needs. Isn’t this the mantra of the new NHS?’

Dr Jones’ views are not shared by other GPs around the country, says Ms Lau. GPs and pharmacists have successfully worked together to vaccinate more patients than either profession could have achieved on its own. ‘I have also seen area teams holding their ground, not buckling under GP pressure and commissioning the service through both GP and pharmacy.’

London’s learnings

Last season’s pan-London pharmacy service is a great example of the benefits of a successful flu vaccination campaign, and demonstrates how a large-scale service can be delivered efficiently and professionally. Of London’s 1,800 community pharmacies, 1,150 offered a flu vaccination service last season and 1,265 have registered for this coming season. Additional patient cohorts this year include staff from PHE, NHSE and CCG offices, and staff from primary care providers such as GP practices, dental, ophthalmology and pharmacy services, as well as staff in prisons and special schools.

A joint LMC and LPC (London-wide) planning group for the winter vaccinations 2014/15 has been set up to help promote better understanding of the pharmacy and GP vaccination services, to help build good collaboration and to share best practice between the two professions.

Pharmacy London secretary and vice chair Rekha Shah highlights a number of key points that could be useful for other LPCs who wanted to set up a flu vaccination service. It is important to work collaboratively with the commissioner’s team, says Ms Shah, and is beneficial to help get pharmacy into position as an integrated provider so that it can vaccinate all included patient cohorts, rather than just specific groups.

A quick and consistent communication process is important, she says. ‘We found the email route worked really well and, because of the large area we covered, we sent the messages back and forth via the LPCs, as contractors are familiar with receiving information from them and might be more comfortable with raising queries with them.’

And contractors should be fully versed in all aspects of the service – from training requirements to how to get paid. ‘You want to hit the ground running as soon as stock arrives in town.’ Stock should be ordered in advance and ready in the pharmacy from day one.

Ms Shah urges contractors ‘don’t be shy’, and to share their team’s good practice with the LPC and other colleagues. ‘The more of a success you make of the vaccination service locally to show pharmacy can deliver as a profession, the more will come your way by way of other vaccinations and even other services being commissioned.’

Wider delivery

Success to date is paving the way for a wider role for pharmacists in vaccine administration. Community pharmacies in Cumbria vaccinated more than 11,000 primary school pupils last year, for example, representing more than 80 per cent of those vaccinated in the county.

Following a recommendation from the Joint Committee on Vaccination and Immunisation (JCVI) that will eventually see all children aged two to 16 years offered an annual vaccination, primary school children were targeted in seven pilot areas in England, although Cumbria was the only area that involved pharmacy.

The Department of Health announced in its latest flu plan that, although NHS England was likely to commission most children’s vaccination through GPs and schools, it would have the option of using ‘alternative vaccination routes’ such as community pharmacies. ‘Commissioners may wish to consider the continuation of local innovative services, such as vaccinations by pharmacists, where there is clear evidence of improved easy access and beneficial outcomes,’ it points out.

In 2014/15, all two to four-year-olds in England will be offered the intranasal vaccination and the pilot programme will be extended to include 12 areas for 11- and 12-year-olds. It is expected that, in 2015/16, vaccination will be offered to all two to six year-olds, in 2016/17 to all primary school children, and to secondary school children in 2017/18

Pharmacy London plans to build on the success of last year’s flu campaign and the increased awareness of pharmacy-based vaccination services by ‘making each contact count’, says Ms Shah. Because many people vaccinated against flu in pharmacy are likely to be eligible for other vaccinations, London pharmacies were expected to be commissioned this year to deliver the nasal live seasonal flu vaccination (Fluenz Tetra) for children and, where appropriate, vaccination for shingles (to people aged 70-79), pneumonia, and pertussis (to pregnant women).

“Despite improvements, the reality is that practices are still falling behind government targets year after year. It is obvious that opening the service to pharmacy has a number of benefits ”

Work was progressed to deliver these additional vaccinations, but Pharmacy London was informed in August that pharmacies were not going to be granted access to vaccines for shingles, pertussis and flu in children. These vaccines are currently ordered on Immform (the system used by the Department of Health, the National Health Service and Public Health England to record data in relation to uptake against immunisation programmes and incidence of flu-like illness; and to provide vaccine ordering facilities for the NHS) by general practice.

Therefore the service is going ahead for now with just the seasonal flu and pneumococcal (PPV23) vaccinations, as both are available to pharmacies directly from manufacturers and wholesalers. The service specification for this season also includes a lowering of the age range to two years (last year it was from age 13) and the subcutaneous administration route for patients suffering from bleeding disorders or on anticoagulants.

Pharmacy London hopes that the other three vaccinations will be commissioned as soon as the DH allows access to the vaccines.

Success of the Pharmacy London flu service

Key factors contributing to the success of the city-wide flu vaccination service established in London were:

• Agreement from the commissioner to look at London as a whole and ‘remove’ borough boundaries so that any pharmacy in London could vaccinate any eligible person, irrespective of which borough they lived or worked in. So patients didn’t need to take time off work or have to only go to their GP or a pharmacy near their home.
• Standardised publicity materials and brand – all pharmacies were asked to put up the same poster as part of one contracted annual public health campaign.
• A small ‘task and finish’ group of people from London LPCs was set up quickly to help NHSE start the service within six weeks of agreement to commission.
• Regular contractor briefings shared learning and best practice across London.
• LPC members of the task and finish group kept vigil over stock supplies and signposted appropriately to maximise the service potential. They advised better collaboration between pharmacies and GP practices over stocks of vaccine, even ‘buying’ excess stock from each other.
• An extremely versatile software platform was adapted as required. Patient data was transferred securely and easily, and regular reporting allowed close monitoring of the service. This IT platform also managed invoicing.