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Table 6 A comparison between implementation of NHS England requirements and NICE quality standards by practices

From: A process evaluation of how the routine vaccination programme is implemented at GP practices in England

Domain

Requirement/standard

Adherence by practice

Outcome

2.4: to offer immunisation to 100% of eligible individuals in accordance with guidance.

Childhood: coverage at the large practices G, H and J is much lower than average and well below the 95% target.

Adulthood: similarly, coverage at the larger practice (F, G, H and J) is significantly lower than average.

Equity

2.11: to be able to demonstrate what systems are in place to address health inequalities and ensure equity of access to immunisation.

None of the included practices had any specific interventions or services in place to increase uptake in any population or demographic groups with low coverage.

2.11: to have procedures in place to identify and support those persons who are considered vulnerable/hard-to-reach

None of the included practices had any specific system in place to identify vulnerable or hard-to-reach populations. All practices did follow-up with parents of all young children who did not attend for vaccination.

Service delivery

3.6: to provide core programme elements, as covered in The Green Book.

18 programme elements are described, of which were met by all practices, except reducing variation (none), patient involvement (G and J only) and local communications strategies (nothing, aside from information provision within practice).

3.10: to address poor uptake for the services where local delivery is lower than the key deliverables to reduce the variation in local levels of performance.

None of the included practices had a system for accessing, evaluating and discussing data relating to their immunisation outcomes or focus on reducing local variation in their local population.

Missed opportunities

3.8: to take every appropriate opportunity to check vaccination status and offer immunisation to individuals who may have missed or not fully completed the national routine schedule.

QS2: children and young people identified as having missed a childhood vaccination are offered the outstanding vaccination.

Practices A, E, G and J discussed having a commitment to opportunistic vaccination. However, this was primarily for providing adults with singles and PPV when attending for influenza or other chronic disease health checks. Children were followed up more intensively by all practices at earlier ages, leaving less room for opportunistic vaccination. None of the practices had a specific strategy or protocol for reducing missed opportunities.

Consent

3.9: to adhere to The Green Book guidance on consent.

This was undertaken by all practices.

Assessment

3.10: to have systems in place to assess eligible individuals for suitability by a competent individual prior to each immunisation.

QS4: children and young people have their immunisation status checked at specific educational stages.

Aside from the use of searches on computer systems and the general commitment to opportunistic vaccination by some practices (A, E, G and J), no specific protocol or plan was used to check immunisation status. This was especially true for adolescents unless subject to a specific campaign (e.g. meningitis campaign).

Information systems

3.10: assessed the immunisation record of each individual to ensure that all vaccinations are up to date

QS3: children and young people receiving a vaccination have it recorded in their GP record and the Child Health Information System (CHIS) and in their personal child health record.

Record keeping was a high priority for all practices, although it was found to be time consuming and complex.

3.10: systems in place to identify those in clinical risk groups and to optimise access for those in underserved groups

In all practices, the electronic record system was used to identify patients in clinical risk groups, as per the schedule; however, no practices used it to identify people in specific underserved groups.

3.10: arrangements in place to report and co-ordinate responses to outbreaks of diseases

This was undertaken by all practices.

Reminder, recall

3.10: systems in place to identify, follow up and offer immunisation to eligible individuals

3.10: arrangements in place that enable them to identify and recall under- or unimmunised individuals and to ensure that such individuals are offered immunisation in a timely manner.

QS1: children and young people who do not attend their immunisation appointment are followed up with a written recall invitation and a phone call or text message

There was large variation in method and frequency of patient contact, reminder and recall activities. For childhood appointments, all practices sent letters first and used phone calls to follow up non-responders. Practices A and C sometimes called patients first. Practices A, C, H and G also used text messages. All initial patient contacts were made by a receptionist or administrator and follow-up of non-responders to non-attenders was sometimes undertaken by the PN (A, F, G and J).

For adults, most practices vaccinated opportunistically when an eligible patient was attending for a check (e.g. diabetes) or for flu vaccine (C, D, E, F, G and J). Practices B and H also sent invite letters. Practice A was alone in phoning older adults.

Vaccine administration

3.12: the provider has a duty to ensure it has, or will have, trained and competent staff to deliver (any) given immunisation programme they agree a contract for

This was undertaken by all practices.

3.12: the professional lead in the provider organisation must ensure that all staff are legally able to supply and/or administer the vaccine

This was undertaken by all practices.

Storage and wastage

3.13: have effective cold chain and administrative protocols that reduce vaccine wastage to a minimum and reflect national protocols

Responsibilities for maintaining the cold chain was divided between practices who allowed administrative staff to do this (C, G and H) and practices that used the clinical staff (A, B, D, E, F and J).

Ordering

3.14: centrally procured vaccines must be ordered via the ImmForm online ordering system

The distribution of ordering was split similarly to the requirement above.