1. Extension of the seasonal flu immunisation programme – looking back and looking forward - any challenges? Dr Ardiana Gjini Screening & Immunisation Lead - Bath, Glos, Swindon, Wilts
The seasonal flu immunisation programme – look back and forward

2. Overview Introduction Review of 2015/16 flu season
System
Review of 2015/16 flu season
Lesson from previous and plans for upcoming flu season
Challenges: delivery via primary care (GP), delivery via school immunisations team
Challenges of flu Immunisation programme
Flu immunisation – delivering extension, facing challenges.

3. Introduction
NHS Immunisation programmes: Section 7a. NHSEngland commissioner supported (technical expertise) by PHE. SITs embedded in NHSE - System leadership (vs fragmented system).
In 2016/17 roll out of the school aged flu imms programme to include children in school years 1, 2 and 3.
BGSW (NHSEngland South Central): 2015/16 GP delivery model. 2016/17: B&Wschool. G&S GP.
BNSSSG&DCIoS (NHSEngland South West): 2015/16 mixed model (school, GP, Pharmacy based). 2016/17 school based.
In 2016/2017 extension to include children in school year 3
SPECIFIC AREAS DELIVERED BY GPS AND BY SCHOOL IMMS
Flu immunisation – delivering extension, facing challenges.

4. Time line of flu immunisation programme
Late 1960s: annual flu immunisation recommended in the UK - in clinical risk groups
2000: extended to all people aged 65 years or over
2010: pregnancy added as a clinical risk category for routine influenza immunisation
2013: phased introduction of an extension to all children aged 2-17yo began with children aged 2 and 3yo
2014: children aged 4 added
2015: extension of the childhood flu vaccination programme to school years 1 and 2
2016: extension to include school year 3
Again – 2016 extension to include school year 3
Flu immunisation – delivering extension, facing challenges.

5. Flu vaccine eligibility 2015/16
65 years and over
People 6 months to under 65 years in clinical risk groups
Pregnant women
Children aged 2, 3, or 4
Carers
People in long stay residential homes
Health and social care workers who are in direct contact with patients / service users
All by GPs
Plus added school year 3
NOT ALL BY GPS – school nurses for school aged children across 50%
School aged children  children who live/are registered with a GP in one area and attend school in a different area – risk of being vaccinated twice or not at all
PLUS ADDED School years 1, 2 & 3
Flu immunisation – delivering extension, facing challenges.

6. The not so good news …
During the 2015/16 flu season, in one CCG/LA alone
9 practices did not vaccinate any of the 2 year olds with any chronic health condition
6 practices did not vaccinate any 3 year olds with any chronic health condition
26 practices did not vaccinate any of their 6 months to two year olds who have chronic heart conditions
8 practices did not vaccinate any of their 5 – 16 year olds who have chronic liver disease
18 practices did not vaccinate any of their 5 – 16 year olds who are immunosuppressed
Flu immunisation – delivering extension, facing challenges.

8. Commissioning GPs to deliver school aged programme (2015/16)
A full service specification was written and sent in June 2015 and distributed to all Practices across BGSW (x189) for sign up
Sign up from Practices was via CQRs (GP payment system) with a deadline 30th June 2015
This was monitored on a daily basis and reviewed weekly
Reminder s were sent at the end of June & revised deadline of 13th July 2015
By August we had just under 50% of practices signed up!
, further reminders got us to the position with just x3 practices not signed up.
Flu immunisation – delivering extension, facing challenges.

9. Achieving 100% coverage
With around 100 Practices not signed up to delivering the service, with the requirement of having to achieve 100% coverage, with holiday season … … we were in trouble

10. New developments & changes in Screening

11. Achieving 100% coverage
We started daily phone calls to practice managers. By end of August - 3 practices (in 3CCG/LA) that even after SIL discussion with Practice Managers actively declaring they did not want to sign up. Joint approach with DsPH, CCGs Clinical quality leads. Planning Plan B (!!!) Further visit/telephone discussion of SIL with all 3 practice Senior Partners. Followed up by a letter from the SIL, Joint, CCG Chair, highlighting key issues:

12. Key issues in the letter
Health of their registered pop, GMS requirements, professional requirements
Issues for the practice:
reputation
vaccinating younger siblings
queries, complaints
sharing info and recording data – without remuneration
Offered support

13. Practices’ concerns
Concern that a new programme will generate a lot of queries, which may result in longer vaccination appointments
Recruiting additional nurses (unlikely for whole season, so discontinuity)
Current remuneration for the vaccinations is not financially viable
Unmanageable increase in services with no increase in capacity
Venue / clinic capacity
Issues - planning not up to date (signif. increase of cohort)
Flu immunisation – delivering extension, facing challenges

14. Outcome
Mid September one Practice that did not want to deliver the programme Assessing Plan B and C… Commissioned the programme via another ‘host’ practice for the ‘home’ (non- participating) practice’s eligible population. Much discussion and liaison and agreement – ‘home’ practice sends the invitation letters with location and contact details of the ‘host’ practices. The ‘home’ practice also agreed to update their patient records once vaccination had been given.
Flu immunisation – delivering extension, facing challenges

15. Flu season 2015/16 – Local data review
School Year 1 vaccine uptake %
School Year 2 vaccine uptake %
BANES
38.5
33.7
Gloucestershire
35.6
33.5
Swindon
31.3
28.2
Wiltshire
36.8
32.7
BGSW average
32.4
National average
54.4
52.9
Target was 40%-60% uptake and as expected a GP delivery model showed lower uptake than school delivery model.
Flu immunisation – delivering extension, facing challenges.

16. Flu immunisation – delivering extension, facing challenges.

17. Outbreak data – re schools?
Also updated data -
Flu immunisation – delivering extension, facing challenges.

19. NHS Gloucestershire CCG
Flu immunisation – delivering extension, facing challenges.

20. Flu immunisation – delivering extension, facing challenges.

21. Flu immunisation – delivering extension, facing challenges.

22. Auditing practice
Purposeful sample – 50 practices with highest uptake vs lowest uptake
Findings:
Most practices (93%) have a named flu lead
Invitation: Letters more commonly used by practices with higher uptake (88% vs 55%);
Text invitations more common by lower uptake practices (59 vs 47%);
Lower uptake practices more commonly use only one method of invitation (75 vs 67%)
Fewer lower uptake practices provide evening clinics (45 vs 68%)
We developed Good Practice Guide.
Flu immunisation – delivering extension, facing challenges.

23. Flu immunisation – delivering extension, facing challenges

24. Percentage of UK outbreaks 2015/16 by region
Flu immunisation – delivering extension, facing challenges.

25. Flu outbreaks by institution type
Flu immunisation – delivering extension, facing challenges.

26. New developments & changes in Screening

27. School outbreaks, flu season 2015/16
44 and 26 outbreaks of ILI reported in schools in AGW and DCS, respectively. This compares with a total of 3 outbreaks in 2014/ (80%) of the outbreaks in primary schools. Five of these schools only had children aged between 7 and 11 yrs old. Eight outbreaks in schools secondary schools (11yrs+); a further 6 outbreaks in mixed (primary and secondary) schools.
Flu immunisation – delivering extension , facing challenges,

28. BGSW: Delivery model for 2016/2017
Initial aim was to deliver entirely via school immunisations teams – challenges with providers
Delivery across Wiltshire and BANES via school immunisation team
All schools accepted the service
Delivery across Gloucester and Swindon via primary care
All GP practices accepted the service (lessons – timeline, awareness)
Next seasons aim is delivery entirely via school immunisations team
Flu immunisation – delivering extension, facing challenges.

29. Challenges for delivery in primary care
Increasing number of children eligible
Flu clinics – planning and venue
Staffing
Call-recall /invitation
? Lack of available vaccine
IE does the practice know that the children picked up as ‘at risk’ on ImmForm are considered to be ‘at risk’
Flu immunisation – delivering extension, facing challenges.

30. Challenges for delivery in schools
Schools’ engagement
Issues with letter templates requesting school leave to avoid viral shedding  information pack for head teachers
? Porcine gelatine
Flu immunisation – delivering extension, facing challenges.

31. Delivery to other cohorts
At risk children – local service at special schools (B G W) Pregnant women and at risk patients – in Trust service (largely maternity) Focus HCW
Flu immunisation – delivering extension, facing challenges.

32. Challenges for delivery in a split model
Residents in an area that is school based delivery but go to school in an area in that has a GP based delivery model - boundary issues
Risk likely to be minimised due to hopefully achieving min 40% uptake  minimizing spread
Choice – final decision comes down to patient/parent in partnership with school nursing team and clinical judgement of GP
Flu immunisation – delivering extension, facing challenges.

33. Julie Yates, SIL South (South West)
Flu immunisation – delivering extension, facing challenges.

34. NHS England South (South West ) Summary – priorities for 2016/17
Increase FHCW uptake, including care homes
Specific work for different at-risk groups
Maintaining excellent tactical comms, with support from local and regional NHSE and PHE teams
Effective commissioning of the pharmacy model
Maintaining (and developing) local planning groups
Informed by BNSSSG flu group and NS imms group, and local SIT but other issues that will come up through presentations
South West (South) Flu Conference 2016

35. Focusing on improving uptake in children – breaking transmission
Increase uptake in healthy 2 – 4 year olds
Increase uptake in children with ‘at risk’ conditions
Schools-based model for childhood flu across the patch

36. Pregnant women - Midwives delivering vaccinations
South West (South) Flu Conference 2016

37. Extra challenges Late seasons – it has an impacts on risk perception
School outbreaks last season
Low effectiveness of vaccine in 2014/15
Fluenz LAIV effectiveness – no longer being used in the US and Canada , Finland – moderate effectiveness
Expansion of the programme – not just cohorts but the size of the cohorts
Health & Care Workers – perception that NHS workers ‘for free’ but not the care workers – systems? STPs?
Flu immunisation – delivering extension, facing challenges.

38. Many GP practices have been left with surplus vaccine, which the GPC has suggested could lead to a combined £4m loss to practices
New developments & changes in Screening

39. New developments & changes in Screening

40. Flu immunisation – delivering extension, facing challenges.