Every year, during the autumn, extra strain is placed on the NHS by patients presenting with coughs, colds and influenza. For many patients, influenza can result in hospital admission, even fatalities, while for the 'well person', influenza can be an irritant necessitating a day or two off work.
Pressures from patients presenting with influenza-like symptoms are felt across the whole NHS – pressure for appointments with GPs and pressure from the demand for hospital beds leading to public outcry that the system cannot cope.
The DoH has recommended vaccination for patients who fall into defined high-risk groups including those with chronic respiratory disease, chronic heart disease, chronic renal disease, diabetes mellitus and immunosuppression, all those in long-stay residential accommodation and all those aged 65 years and over.
Our practice has concentrated on the following patient groups:
- Age 65 years and over
- With diabetes
- With chronic obstructive pulmonary disease (COPD)
- With asthma
- With chronic heart disease
- Long-stay residential and nursing home residents.
The DoH states: 'Influenza is an important contributor to excess mortality that occurs every winter in the UK. Peaks of winter activity follow closely the pattern of influenza activity, resulting in an estimated average of around 12 000 excess deaths each winter.'1
St Leonard's Medical Practice, Exeter, where I work, has a long tradition of quality assurance: it provides full morbidity data on a weekly basis to the RCGP and is an NHS Research & Development Culyer-funded practice, researching common diseases and health problems at practice level.
The practice has developed numerous innovative approaches, using a team approach through an established quality assurance department. We therefore considered it logical to adopt a structured approach to the annual influenza campaign, where we hoped to achieve significant and demonstrable improvements in patient care. The ability to develop a system that evidence suggests could lead to a reduction in mortality is too powerful an opportunity to miss.
The practice has developed a well organised system for influenza vaccination. In advance of the programme a computer search generates a list of patients who fall into the high-risk groups. These patients are then invited for vaccination in a letter from their doctor. This request is reinforced by opportunistic patient education from other members of the primary healthcare team.
Influenza vaccination has been shown to be medically beneficial by reducing the morbidity and mortality from influenza.
Bradley et al2 estimated that in a high-risk year 40 patients would need to be vaccinated in the high-risk group (240 in the other groups) to prevent one death, and in a low-risk year 80 patients would need to be vaccinated in the high-risk group (500 in the other groups).
Although our practice has no clear evidence, the DoH states that 'immunisation of patients aged 75 years and over is not only justified but also represents good value for money in comparison with other healthcare preventions'.3
Watkins4 examined the uptake of influenza vaccination in Gwent in 1994 in 64 practices. He found that under half of patients identified as high risk had received the vaccine: 63% of patients with heart disease, 39% of patients with diabetes, 41% of patients with asthma and 25% of patients aged over 75.
A more recent article in Health Trends5 based on the GPRD database showed an increase in uptake of influenza vaccination in high-risk groups from only 19.2% in 1989/90 to 23% in 1996/7. Our results (see Figure 2, below) show that we have significantly improved the uptake of influenza vaccinations compared with Watkins' findings in 1997.
|Figure 2: Results of influenza vaccinations in the at-risk groups over the 5-year period 1996-2000|
The overall national uptake of influenza vaccination for patients aged 65 and over last year was 65%. Our campaign is focused on vaccinating patients at risk, through letters of invitation, whereas many practices operate a more open system and may not be able to fully audit their results. Comparison is therefore difficult.
Why adopt a structured approach?
Our campaign is targeted at people in the at-risk groups, with the sole aim of vaccinating as many of these as possible.
Practices are busy most times of the year. The vaccination programme increases the workload of the practice through telephone calls, enquiries and vaccination appointments – in our case for more than 1500 patients. Previously, hundreds of patients would deluge the telephone lines and reception for influenza, imposing a great deal of stress on the system.
All this has to be managed and controlled to ensure that the service provided is of the highest quality and that pressure on staff is kept to the minimum so that the normal day-to-day running of the practice is not hindered in any way.
We now have a structured approach that specifically targets the at-risk groups (see Figure 2, above). The annual influenza review held in June/July each year is our main planning tool. We also undertake to vaccinate at-risk patients with the pneumococcal vaccination.
This year the DoH has agreed with the GPC that Items of Service payments for every patient aged 65 or over will be paid without any claw-back of funds or conditions attached to them.
The GPC is also proposing a model Local Development Scheme (LDS) for at-risk patients aged under 65 to facilitate higher coverage of all at-risk patients, and encouraging local medical committees to negotiate with PCTs.
The organisation of the vaccination programme is probably best described under the following headings.
Aims of the practice flu campaign
- Vaccinate as many of the high-risk patients as possible
- Reduce pressure on staff
- Provide an efficient and effective service.
Annual review meeting (Figure 1, below): This is held in June/July in plenty of time to prepare and make all the necessary arrangements.The success of the programme depends on the involvement of various members of the practice team.
|Figure 1: Annual influenza review (record details in [ ] )|
Practices vary in the way they operate, but the following professionals ought to be included in the planning of the programme: GPs, practice manager, practice nurse, district nurse, computer operator or equivalent, and receptionist.
Agenda/minutes; agree plan for forthcoming campaign: It is very helpful to run a properly organised meeting with an agenda and minutes, as shown in Figure 1(above). This forms our action plan, and this year staff documented all the actions on their agendas at the meeting, thus saving time in having to prepare minutes after the meeting.
Review previous year: It is important to review the previous year's campaign (were targets achieved, if any had been set?), to highlight and address any areas for improvement and to congratulate staff where good work has been undertaken.
Reviews can take the form of a significant event audit, in December, while the campaign is still fresh in everyone's minds, to get a snapshot of how successful the programme has been. A full review should be planned for June or July the following year.
Set targets for high-risk groups: The practice has concentrated on the major high-risk groups and set targets annually. Targets should be agreed and accepted by everyone involved, and be challenging but ultimately achievable. This is why we have not yet gone for 99%, but we hope to do so one day.
Set dates for clinics and number of clinics: When and how the clinics for the influenza vaccination programme are organised is crucial in planning the campaign. Dates for clinics should be decided and agreed at an early stage of the plan because most of the other deadlines hinge on when the first clinic starts. Know your end goal.
The following pointers should help in developing a plan:
- Timing: Most campaigns are held throughout October and November. Bear in mind that half-term falls at the end of October and could affect the response to invitations.
- Number and frequency of clinics: This is really down to practice preference, but the following options are worth considering:
- additional clinics over a 1- or 2-week period between Monday and Friday. The number of clinics will be determined by the number of patients expected for vaccination
- weekend-only clinics
- a combination of Saturday morning clinics and a catch-up week of clinics between Monday and Friday. This has proved very successful over the past 2 years.
Agree searching codes and patient invitation list: This must be done in plenty of time before the clinics. Generate a computer search to provide a list of patients who fall into the high-risk groups. This will enable the practice to invite patients, by letter, to the clinics and will help decide how many influenza vaccines to order.
Inform patients: The success of the programme is dependent on informing patients about the influenza vaccination clinics and how they make an appointment. Having identified patients in the high-risk groups, the practice should ensure that letters are sent at the appropriate time.
The key points are:
- Generate a list of patients, use mail merge to produce a standard letter, place in envelope and stamp the letters
- Letters must identify how patients make an appointment and when the clinics are being held.
- Timing is crucial and must allow sufficient time for the appointment to be made.
Booking appointments: Booking additional appointments (>1000 patients) for influenza vaccination puts a huge strain on the telephone system and reception, especially when it is concentrated over a short period of time. We overcome this by using an additional telephone line for booking vaccination appointments only. We call this the 'Fluline'.
- Fluline: A dedicated telephone number available to patients between 0900 and 1300, Monday to Friday, for an appropriate period of time before the clinics. This has proved very successful. Initially it was not cost-effective because the telephone line was not used for the rest of the year, but this has now been addressed and the line has been integrated into our new telephone system.
Ordering vaccines: Pharmaceutical companies are keen to secure their order from you as soon after your last campaign as they can, at a time when you may not have given much thought to the numbers required for the following year.
Ensure that you are not obligated to proceed with an early order. Shop around to get the best discount. By conducting a search on the high-risk groups of patients you should be able to get a reasonable idea of how many vaccines to order. It useful to use a company that offers sale or return.
Staffing: The programme is staff intensive, but this is the key to an effective and efficient campaign. By applying the necessary resources at an early stage, a huge amount of pressure and strain is removed from the receptionists, who can then get on with their normal work.
The influenza campaign is also a good opportunity to invite patients in for pneumococcal vaccination. This vaccine can be given at the same time as the influenza vaccine. It should be borne in mind that that patients must not have a further pneumococcal vaccination within a minimum of 5 years.
Evidence of implementation and change
The practice influenza programme involves the whole practice team and includes an annual audit cycle in order to improve the practice performance.
The St Leonard's Medical Practice influenza vaccination campaign has been regularly audited. New target levels have been set for each priority group by the clinicians involved, and improvements have been made to increase uptake to these levels (see Figure 2, above).
This improvement has been achieved through considerable hard work from all members of the practice team, with annual review meetings to plan and revise each year's programme and hence complete the audit loop.
Figure 2 shows the target levels for each of the high-risk groups, except patients aged 65 and over, and the percentage of patients vaccinated over a 5-year period.
Generally, each year shows a year-on-year improvement, except for 1997. This was an exceptionally good year, and the only explanation for the high percentage of vaccinations could be that we invited more than 500 patients in for pneumococcal vaccination for the first time. This may have had an effect on the uptake of influenza vaccination.
Figure 3 (below) shows the uptake of vaccination by patients aged 65 years or over. In 1999 we did not specifically target this age group because we were concentrating on the over-75s.
|Figure 3: Influenza vaccinations given to patients aged >=65 years|
Spreading best practice
The practice was awarded Beacon status for improving patient care in general practice in three activities underpinned by a team approach, one of which was uptake of influenza vaccination.
The practice has been able to share its ideas with other health professionals, including GPs, nurses and practice managers, by various means:
- Small presentations, in the practice, to local practices.
- An evening presentation to a larger audience of area-based practice at a local venue.
- A series of presentations to primary care professionals from health authorities in Wiltshire, Avon, Dorset and Southampton.
Through the systems developed in our practice, we have been successful in vaccinating 17.3% of our adult population (aged 15 and over) in 2000, including 78% of patients with diabetes, COPD, or ischaemic heart disease and 70% of all those aged 65 years or over.
These figures are higher than those achieved in published public health studies.4 They demonstrate the efficiency of our practice quality assurance system and the importance of a team approach to influenza vaccination.
- Department of Health Influenza Immunisation Programme 2001/2002.CMO Letter PL/CMO/ 2001/4.
- Bradley M, Sheldon T, Watt I. Influenza vaccine and older people: an evidence-based policy. Br J Gen Pract 1997; 47: 271-2.
- Department of Health. Influenza immunisation. CMO Update. London: HMSO, 1998.
- Watkins J. Effectiveness of influenza vaccination policy at targeting patients at high risk of complications during winter 1994-5: cross sectional survey. Br Med J 1997; 315: 1069-70.
- Health Trends 30: 51-5.
- Department of Health. Influenza immunisation. CMO/CNO/CPO. London: HMSO, 2001.