11 November 2020
As frontline GPs working in primary care we, like the rest of the country, are both excited and relieved that a vaccination for COVID-19 is in sight. Over the last week we have received some news regarding what a COVID-19 vaccine program may look like, and some primary care networks (PCNs) and GP surgeries are poised to take on this role and sign up.
Whilst this is brilliant news, the current offering from NHSE in terms of the Direct Enhanced Scheme (DES) falls short of making it feasible for many more GP surgeries and PCNs to deliver, with a huge number being unable to take up the offer. This will have significant implications for us all, and could threaten the success of the vaccine program as a whole. It is imperative that we act now and remedy these issues, in order to give us the best chance of defeating this virus.
We must understand the background and atmosphere in which we are rolling out this programme, in order to identify possible pitfalls and problems. Prior to the pandemic, the Health Foundation reported In March 2020 that workload pressures were growing across general practice. Despite a 2015 target for 5,000 additional GPs by 2020, the number of qualified permanent full-time equivalent GPs in the UK has fallen. There are now 1,700 fewer qualified permanent GPs than in 2015.
Recently, the DAUK ran a survey of almost 900 GPs in which 78% reported the pandemic has had a negative effect on their mental health. Additionally, only 1.8% of respondents felt well-supported by NHSE. Furthermore, the Medical Protection Society (MPS) found 1 in 3 GPs report being subjected to verbal abuse during the pandemic.
All of this is occurring against a background of rising health inequalities, and a stalling life expectancy. Currently, primary care is working at maximum capacity, dealing with issues as a result of the pandemic as well as ongoing routine work. This limited workforce, with a limited capacity, needs to be kept at the centre of any plans to roll out a vaccine whilst recognising the current issues we are facing.
Issues and recommendations
We welcome the introduction of a potential vaccine and believe primary care has an invaluable role to play in its delivery, having seen the innovation with which those working in general practice have managed to roll out this year’s biggest ever, seasonal flu vaccine. It is this expertise we need for the COVID-19 vaccine, but it is imperative that we set primary care up for success in the delivery of this.
Below we list the current limitations of the DES based on the information we have received so far, which means many practices are struggling to agree. We set out what the potential solutions are, which would ensure higher primary care take-up and thus a greater chance of success in our only way out of this pandemic.
Flexibility and further information
Without the full specifications of the program being released it is difficult to ask GPs to commit to delivering the vaccine. We need the full details of the DES to be released to GPs in a timely manner, in order to allow them to make a decision regarding whether or not they are able to take this on. If this is not possible, there must be flexibility to sign up at this preliminary stage, but if it proves difficult to safely deliver the vaccine alongside routine clinical care, there must be the option to step down from this responsibility.
On the current DES, all payments for the vaccine program will be made retrospectively. This is a huge undertaking and poses a significant financial risk to primary care, who will have to shoulder the financial burden. We cannot ask this of GPs when so much is at stake nationally. We need significant, upfront funding to allow surgeries to purchase equipment needed, pay for temporary staff, and make urgent renovations to their buildings in order to be able to deliver this vaccine safely. Additionally, primary care needs to fully cost this service. There needs to be a higher fee to acknowledge the huge ask and realistic costs of this programme.
Additional further funding is necessary to cover delivery of the vaccine to housebound and nursing home patients, as this will require higher time constraints.
Furthermore, we need clear guarantees that if a patient chooses not to attend for the second vaccine, payment will still be made. The time, logistics and practicalities of delivering this program will otherwise incur high costs that primary care cannot singlehandedly shoulder.
We have seen the significant funds that the government has pumped into other areas including the private sector, for services such as Track and Trace. The funding that has been allocated to this DES is hugely insufficient and significantly lower in comparison.
Working hours and logistics
The DES specifies practices must be open from 08:00 – 20:00, 7 days a week to deliver the vaccine. We believe more flexibility needs to be allowed. Each year, practices deliver successful flu vaccine programmes, dependent on the local needs of their respective communities. Some practices run late evening or Saturday clinics, whereas others provide it in hours; these decisions are influenced by local factors which GPs take into account in order to best serve specific communities. Practices need to have the flexibility to provide a service they feel confident they can provide, for a population they know well.
The information around the vaccine also states that we will need to reconstitute the vaccine, counsel the patient and have them be observed, socially distanced, for 15 minutes after having the vaccine. All of this has not been adequately taken into account within the PCN DES, setting unrealistic expectations of the numbers vaccinated each week. Workforce and time available within primary care need to be taken into account and funded accordingly.
Reduction in workload
In order to enable a maximum number of staff to be utilised for the vaccine program, we need to reduce workload by stopping CQC inspections, making appraisal voluntary and stopping other forms of bureaucracy. This vaccine programme represents a significant workload during a global pandemic, when GPs need to rightly be focussing on appropriate clinical care.
We need urgent clarification as to what other methods are to be employed in delivery. We recognise there are plans for additional support and mass vaccines centres, but this needs to be clear and set up alongside the PCN DES with primary care input, rather than separate to it.
Information around COVID Vaccine
We are already seeing appropriate questions from both the public and clinicians on the data behind these vaccines. To ensure good uptake, we need the research data to be available to clinicians in an appropriate timeline before full agreement to the PCN DES. Without this we, as clinicians who will be rightly asked questions around the vaccines by patients, cannot morally engage in this vaccination programme. We need time to absorb, discuss and question the data before fully signing up to the DES.
1) The research data needs to be released to clinicians with sufficient time to allow them to analyse the data and before signing up to the DES.
2) The PCN DES needs to be delivered in conjunction with, and not separate to, bigger strategies around mass vaccination centres and additional workforces.
3) Improved funding allocated for possible hiring of venues, hiring of more staff, improving current primary care estates, purchasing necessary equipment, transport for vaccinations and storage and that this funding is allocated upfront to allow proper planning for this programme.
4) Improved funding for the administration of this vaccine to take into account the complexity and time required.
5) No restriction of funding if the patient does not attend for the second vaccine
6) Funding to be increased for the administration of the vaccine to housebound and nursing home patients.
7) Flexibility over the time and days for these vaccine centres to be open under the PCN DES.
8) Flexibility over current workload and ask of primary care to recognise this huge task being allocated under this PCN DES.
In order to enable more GP practices to take up the DES we need to allow more flexibility and limit financial risks to individual GPs.
We hope that by making the above changes to the DES, aiming to reduce the risks in signing up to the program, this will lead to a significant improvement in the ability of primary care to take up vaccination delivery which will ultimately benefit the population. Primary care wants the vaccination programme to work and is rightly placed to deliver it. However, we need to ensure that the exit strategy is realistic and appropriately supported so that it is a success.
Dr Vinesh Patel
GP Partner, Sutton
Dr Lizzie Toberty
Salaried GP, Sunderland
Dr Kaveri Jalundhwala
GP Trainee, Thames Valley
Dr Zainab Najim
GP Trainee, Norfolk
DAUK GP Committee