Worcestershire 2011/12 Childhood Immunisation Action Plan

Transcription

1 Worcestershire /12 Childhood Immunisation Action Plan 1. INTRODUCTION 1.1. NHS Worcestershire (NHSW) has been set aspirational immunisation childhood immunisation targets for /12 that are unlikely to be fully met based on recent performance As NHS and Public Health reconfiguration is implemented over the next few years, it is important to continue to increase stakeholder awareness of immunisation issues and to maintain a focus on quality and performance in the midst of a changing operational landscape The aim of this report is to provide the strategic direction for maximising the uptake of childhood NHS immunisations during / The objectives are to identify the key barriers to success and to provide a clear action plan for avoiding or mitigating against the risks identified The report should be read in conjunction with the Worcestershire 2010/11 Immunisation Report. Flu immunisatons are outside the scope of this report and readers should refer to the /12 Worcestershire Flu Plan. 2. ORGANISATION OF IMMUNISATION SERVICES 2.1. Overview of pre-school immunisations All infants and children should receive a series of immunisations starting at two months of age based on a national immunisation schedule (Table 1) All pre-school immunisations are delivered exclusively by GP practices. The teenage booster immunisation given between 13 and 18 years of age is delivered by School Nurses (SN) or by GP practices The Child Health (CH) department of the Worcestershire Health & Care Trust (WHCT) maintains an immunisation database called the Child Health Information System (CHIS). CHIS generates lists of children that are due immunisations, allocate them to appointment slots in GP practice immunisation clinics and writes to parents to alert them that an immunisation is due. Some practices elect to contact patients themselves. Details of vaccinations administered are sent to CH who updates the CHIS. GP practices also need to update another system, EXETER, which is used to calculate immunisation payments. This system is summarised in Figure 1. 1

2 Table 1: National routine childhood immunisation programme Age Diseases protected against Vaccines given Two Diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b DTaP/IPV/Hib (Pediacel) months Three months Four months Pneumococcal infection PCV (Prevanar 13) Diphtheria, tetanus, pertussis (whooping cough), polio DTaP/IPV/Hib (Pediacel) and Haemophilus influenzae type b Meningitis C MenC (Menjugate or Neisvac C) Diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilus influenzae type b DTaP/IPV/Hib (Pediacel) Pneumococcal infection, second dose PCV (Prevanar 13) Meningitis C, second dose MenC (Menjugate or Neisvac C) Between 12 and 13 months Meningitis C, third dose Hib, fourth dose Measles, mumps and rubella Hib/MenC (Menitorix) MMR (Priorix or MMR VaxPRO) Pneumococcal infection, third dose PCV (Prevanar 13) 3 years 4 months or soon after MMR second dose Diphtheria, tetanus, pertussis and polio MMR (Priorix or MMR VaxPRO) dtap/ipv (Repevax) or DTaP/IPV (Infanrix-IPV) Girls aged 12 to 13 years 13 to 18 years Cervical cancer (HPV) vaccine, which protects against cervical cancer (girls only): three doses given within six months Diphtheria, tetanus and polio booster (Td/IPV), given as a single dose Cervarix Td/IPV (Revaxis) 2

3 Figure 1: GP immunisation system in Worcestershire Birth, HV, SN, imm. forms notification Available vaccination clinics Child Health Information System (CHIS) Appt. calls Parents Attend Vaccination calls and clinic lists GP run vaccination clinics Appt. outcome Update patient record Quarterly uptake Ad hoc vaccinations & new patients GP Practice records Data on vaccinations to Exeter for payment COVER National surveillance of EXETER Source: Worcestershire Immunisation Report by Orla Dunn, 3

4 2.2. Surveillance NHSW reports on immunisation uptake in submissions to the Department of Health (DH) which subsequently publishes PCT level immunisation uptake results. West Midlands SHA sets targets for some but not all routine immunisations. Further details are provided in Table 2. Table 2: Summary of surveillance systems Immunisations Description Definition Pres-school childhood immunisations COVER results at 1,2 and 5 years of age NHSW submits 4 quarterly and 1 annual result each year Quarterly results are published on the DH website quarterly Annual results are published on the DH website annually e.g. MMR2 COVER result at 5 years of age = a / b where: a = No. children reaching 5 years of age during the financial year who are fully immunised with 2 doses of MMR before their fifth birthday b = No. children reaching 5 years of age during the financial year HPV Teenage booster IMMFORM NHSW submits 12 monthly and 1 annual result each year Both monthly and annual results are published on the DH website KC50 NHSW submits annual KC50 results KC50 results are published annually on the DH website % uptake = a / b where: a = no. 12/13 year old eligible girls that are vaccinated during the academic year b = no. 12/13 year old eligible girls Only compulsory submission is total no. children aged 13 to 18 who received the teenage booster in the financial year Optional submission is the total number of children aged 13 to 18 who were eligible for the teenage booster in the financial year (i.e. had not already received the booster in previous years) 4

5 3. CURRENT PERFORMANCE Table 3: Summary of SHA childhood immunisation targets for 2010/11 relative to 2010/11 performance Description Target for /12 DTaP/IPV/Hib at 1 year of age 95% 94.6% RED MMR at 2 years of age 95% 89.9% Hib/MenC at 2 years of age 95% 93.5% MMR2 at 5 years of age 95% 83.1% Performance in 2010/11 % RAG rating 1 point scored for each target met. GREEN = 4 points, AMBER = 2-3 points RED = 0-1 points NHSW will not meet any of the 4 SHA targets for /12 if the performance in 2010/11 is repeated (Table 3) Modest improvements in performance could lead to the DTaP/IPV/Hib and Hib/MenC targets being achieved (resulting in an AMBER RAG rating) but the two MMR targets will not be achieved in / It is important to note the MMR targets are aspirational. In 2009/10, only one PCT in England achieved the 95% MMR at 2 years of age target and none achieved the 95% MMR2 at 5 years of age target. 4. ISSUES 4.1. Not all immunisations undertaken are recorded on CHIS The reported childhood immunisation uptake for Worcestershire is based on data extracted from CHIS (except for HPV immunisations) and is likely to be an underestimate of the true immunisation coverage GP practices do not always provide CH with details of all the patients who have had immunisations administered in the GP practice. CH send practices a clinic list for each childhood immunisation clinic they run. This lists all the children that are due to attend and the immunisations that they require. Practice are required to write directly on this clinic list indicating for each named child whether they attended and if they did which vaccinations were administered. Practices should return completed immunisation lists to CH who then updates CHIS which is used in turn to produce the published NHSW immunisation uptake results Practices may return clinic lists late and there are no clear protocols/triggers for CH to actively follow up these practices. Practices not informing CH of administered immunisations leads to two adverse consequences. Firstly, children may potentially be left unnecessarily unprotected because whilst data on vaccine administration is outstanding CHIS suspends the child from the immunisation schedule and does not call them for further immunisation. Secondly, the calculated and published Worcestershire vaccination coverage is an underestimate of the true coverage. 5

6 Even if practices inform CH of immunisations undertaken there are anecdotal reports of the information not being uploaded onto CHIS in a timely manner This problem of under-ascertainment in CHIS may be a particular problem in ad hoc immunisations given outside of specific immunisation clinics. As there is no clinic list to be filled in, details should be filled in on a off schedule form. There is potentially more likelihood of an off schedule form not being returned compared to a filled in clinic list Financial targets and Public Health targets are not aligned GP practices are paid for pre-school childhood immunisations based on the coverage they achieve. A lower rate is payable if 70% coverage is recorded and a higher rate is payable if 90% coverage is recorded. These are nationally agreed contractual terms. These GP targets are not aligned with NHSW or Public Health targets in a number of ways - see and The financial targets are based on 70% and 90% coverage but the SHA targets for NHSW are set at 95% coverage. There is therefore no financial incentive for a practice to increase uptake from 90% to 95% The 70% and 90% GP thresholds are set nationally by the GP contract. DH is aware of PCT concerns but any change in these criteria would take at least two year of negotiations before changes were made in the GP contract The equation used to calculate GP coverage for payment is based on a subset of all childhood immunisation results that are different to the subset that make up NHSW immunisation targets set by the SHA. For example, MMR2 at 5 year of age is a NHSW target but these results are not used in GP payment calculations GP coverage for payment purposes is calculated from results submitted to the EXETER system whereas PCT coverage results are based on GP results submitted to CH. Therefore practices have a greater financial incentive to ensure EXETER data is complete compared to CHIS submissions. There is no simple way to link GP payment to results from CHIS due to a myriad of methodological issues Work is underway to incorporate immunisation targets into the Worcestershire GP Practice Performance Framework. Practices can be set individual immunisation targets based on a target that would correlate with a significant improvement over the previous year s results. Most practices however could not be set a 95% target due to the way the performance framework is set up Clinical issues There are some simple immunisation arrangements that all practices should implement to make immunisation clinics more efficient and increase uptake. Although most practices have implemented these, there is anecdotal evidence that all practices may not have done so Until recently, the national immunisation schedule stated children would have Hib/MenC at 12 months of age with PCV and MMR being given a month later at 13 months of age. Following new national guidance, children can now have all three immunisations at the scheduled 12 6

7 months of age immunisation session although parents have the option to have the immunisations over two sessions if they prefer. It is important that all practices routinely offer all three immunisations at 12 months of age as this could increase compliance and uptake. It would also reduce the number of clinic visits required which would be especially useful in practices with waiting lists The age of the pre-school booster was changed in 2009 from being given anytime between 3 years 4 months to 5 year of age to a new recommendation that it should be given to everyone at 3 years and 4 months of age. There is anecdotal evidence that some practices may still be delaying this immunisation till the child is 5 years old which would potentially leave some children unnecessarily unprotected Management of children who Do Not Attend (DNA) appointments CH has protocols in place whereby children who DNA an immunisation clinic appointment twice are suspended from being called from further immunisations until the Health Visitor (HV) reviews the case. These arrangements need to be reviewed to ensure that the protocols are robust and that children are not being suspended for longer than necessary See also Training issues Providers of immunisation services (GP Practice nurses and School Nurses) have a responsibility to maintain their immunisation skills and knowledge. Nurse and employers should be aware of their liabilities if working under Patient Group Directions. A self directed training package is available on local organisation websites and on NHSW website School Nurses (SN) have an organised programme of training provided by their employer relating to HPV immunisation The training provision for practice nurses has recently been reduced. In the past, NHSW organised training sessions for practice nurses that were free for attendees with some funding coming from vaccine manufacturers. These sessions have not been organised now for over a year as they were organised by the NHSW Practice Nurse Professional Facilitator but this post is vacant and there are no plans to replace it NHSW should assure itself that commissioned immunisers undertake continuing professional development. This could be done with a questionnaire to all providers asking for evidence of training attended during the last year. Alternatively, Public Health could take over organising immunisation training and set clear guidance to practices on attendance. This is the preferred option It would be difficult to charge practices for NHSW organised training sessions as some drug companies put on free training events for practice nurses. Although these are often useful, the information presented may not tally with NHSW policies. For example, they may advocate the use of a vaccine not supported by NHSW. 7

8 4.6. Teenage booster The teenage booster refers to the Td/IPV immunisation that is provided to children between 13 and 18 years of age Worcestershire has a legacy of a mixed model of service provision with GP practices being the main provider in Redditch & Bromsgrove and School Nurses the main provider in the rest of the county. The SN service only covers state schools and not private schools PCT s bordering Worcestershire may have a pure-school system, a pure GP system or a mixed system for delivery of the teenage booster. Each PCT is responsible for providing the teenage booster to its responsible population. This is any child registered to a Worcestershire GP practice or living in Worcestershire but not registered to any GP practice The main problem with the current system is that NHSW provision and NHSW responsibility for the teenage booster are not aligned. Some children that should be offered the teenage booster by NHSW are not being called for the vaccine (Table 4). Table 4: Summary of children not routinely called for the teenage booster immunisation in Worcestershire Area Delivery PCT responsible population who are not being called routinely for the teenage booster Redditch & Bromsgrove GP Practice Children resident in Worcestershire who are not registered to any GP practice South Worcestershire Wyre Forest School Nurses running sessions in state schools (except St John s Surgery) PCT responsible children going to a private school PCT responsible children going to a school in another PCT which does not have a school teenage booster programme PCT responsible children who are home schooled 4.7. Immunisation queries and incidents It is important that immunisers are able to access immunisation advice and support from Public Health. This is currently provided by a Public Health Consultant although there are no clear protocols or standards for this service Reviewing immunisation incidents are a valuable way of continually improving services. Protocols relating on reporting or handling of immunisation incidents require further clarification. 8

9 4.8. Immunisation waiting lists Childhood immunisation waiting lists are a persistent problem in a small number of practices in Worcestershire Children should have their childhood immunisations as soon as required based on the national immunisation schedule. If children are due for immunisations but there are an inadequate number of immunisation slots at their GP practice, the child is placed on a waiting list called a QLIST Most GP practices in Worcestershire have never had and currently do not have a QLIST. In June, 18 out of 68 practices had QLISTs and the total numbers of children that could not be appointed in a single week were 471. Nearly all affected practices had QLISTs of less than 30. The five practices with the largest waiting lists made up almost three-quarters of the total immunisation waiting list size in the county Waiting lists often do not significantly affect reported uptake but QLISTs are a quality and clinical governance issue as children are potentially left unnecessarily unprotected whilst waiting to be called for immunisations. 9

10 5. ACTION PLAN Interventions When? Who? 5.1. Increase awareness of immunisation issues The Worcestershire /12 Immunisation Report to be disseminated widely to key stakeholders including GP practices, paediatricians and councillors. Sept Presentation of the Worcestershire /12 Annual Immunisation Report at NHSW Board and Worcestershire County Council (WCC) Board meetings. Oct 5.2. Improve alignment of public health and financial targets Incorporate immunisation targets into the Worcestershire GP Performance Framework Complete /LD Lobby SHA and DH for change in GP contract to align public health and financial targets Ongoing 5.3. Increase comprehensiveness of CHIS Short-term Dissemination to GP practices of clearer protocols for submission of details of vaccines administered to CH. Details of all vaccines administered should be reported to CH within two weeks of the date of administration Design protocols for CH to follow up of practices that do not return data on time including non-returned clinic lists All quarterly submissions to DH to be signed off by PH before submission by CH to DH Practices will be provided with quarterly non-anonimised practice level data on uptake results for childhood immunisations for all practices in Worcestershire. Practices will be able to inform PH of any gross errors in the data so that these can be investigated and amended before the final NHSW annual results are submitted Sept Sept Sept Sept Medium term A project plan is being developed for a PH led review of CH. Alternative systems for scheduling/appointing children (e.g. using GP systems) for immunisations and possible line management of CH by PH will be explored as one strand of this work. TBC LA 5.4. Provide PH support to practices The quarterly practice level uptake reports to practices will help practices compare their performance with other practices including ones nearby serving a similar socio-economic and demographic population. The results could help facilitate low uptake practices learn lessons from high uptake practices. Sept 10

11 Public Health can help individual practices with low uptake through further analysis of their data and systems and through targeted media and social marketing campaigns. From Sept PF SL 5.5. Improve management of DNAs See Review CH DNA protocols to ensure that children are not being inappropriately suspended from future childhood immunisations Review HV specifications to ensure they are in line with CH protocols for management of children who DNA Sep Oct LA 5.6. Increase clinic efficiency Encourage practices to provide three immunisations at the scheduled 12 month immunisation sessions wherever possible Encourage all practices to provide the pre-school booster at 3 years and 4 months of age Sep 5.7. Improve handling of immunisation queries and incidents Develop protocols and standards for the handling of queries. Practices would generally be expected to submit queries to PH by and responses would be provided within 48 hours unless further specialist advice needed to be sought from the HPA. Sep Develop a protocol identifying which incidents must be reported to the PCT (e.g. use of expired vaccines, cold chain failures) and how such incidents should be investigated so that lessons can be learned and future problems avoided. Oct 5.8. Improve immunisation training NHSW to organise two free training sessions per year for immunisers. Jan PH to produce timely production of professional briefing sheets around key issues e.g. MMR Ongoing SB 5.9. Eliminate waiting lists Review current CH QLIST protocols to ensure that practices are adequately alerted to problems with waiting lists A simple protocol will be developed to help assist practices tackle waiting lists. Practices with significant waiting lists will be asked to produce action plans to eliminate them. The PCT will emphasis NICE guidance that waiting lists are unacceptable. Sep Sep TW Teenage booster interventions PH to send a letter to all Year 10 children in private schools in Worcestershire urging them to contact their GP practice to check if they need the teenage booster Work with schools and CH departments in PCTs bordering Worcestershire to ensure that all PCT responsible children are alerted when they need a teenage booster and are told how they should get it. Sep Oct 11

12 PH to work with the County Council to ensure that parents of home educated children in Wyre Forest and South Worcestershire understand that they can receive the teenage booster via their GP practice Oct In the longer term, the options to move to a GP delivery system across the county will be considered for the 2012/13 academic year. This would align delivery and responsibility more closely. By Sept 2012 = Ash Banerjee, LD = Lynda Dando, LA = Liz Altay, SB = Sue Bosworth, TW = Trudi Wylde, PF = Peter Fryers, SL = Selina LaVictoire Produced by Dr Ash Banerjee Public Health Consultant NHS Worcestershire September ashis.banerjee@worcestershire.nhs.uk 12