With covid-19 booster vaccinations likely in the near future, now is the time to consider how to create a sustainable, long term infrastructure for vaccine delivery, say Simon Hodes and Azeem Majeed
By mid-June 2021, the UK had administered over 70 million doses of covid-19 vaccines; with the majority (estimated around 75%) delivered by primary care-led vaccination sites. Since the start of the vaccine programme in December 2020, the UK has offered a variety of locations for covid-19 vaccination; GP led sites, mass vaccine sites, community pharmacies, and hospitals. The rollout of covid-19 vaccination is a major and much needed success for the NHS, and there are many positive lessons to be learned and taken forwards. However, we must not be complacent. We are still in the midst of a global pandemic, with covid-19 rife in many countries; and with new, more infectious variants of SARS-CoV-2 continually emerging. It is essential for the UK to maintain its vaccination momentum, as well as consider extending the vaccination programme to older children; and being prepared to offer booster doses to adults if these are required to maintain immunity. We must also focus on vaccine hesitancy, which is a major global health risk in its own right.
General practices in the UK are very experienced at mass vaccination programmes; being largely responsible for administering seasonal flu vaccines with support from community pharmacy sites. In 2020, the cohorts offered flu vaccines were extended to include household members of high risk patients, and all people aged 50-64. The same extended groups will be targeted for a flu vaccine next winter. General practices are embedded in their communities, are local and trusted, have health compliant regulated premises, rigorous cold storage systems, resuscitation equipment on site, hold full electronic patient records, and have long standing knowledge of their patients. For all these reasons, when the covid-19 vaccines became available, it was primary care teams nationwide who were able to quickly step forward and deliver the majority of vaccinations.
The initial cohort for the covid vaccination programme—people aged 80 and over—were not easily reached by email or text messages, are sometimes not technically literate, and many needed phone calls to book their vaccination appointments. The amount of time and effort this took was considerable and it is a credit to overstretched primary care teams nationwide (with special praise for practice managers, receptionists, care co-ordinators, link workers, nurses, volunteers and other support staff) that our most vulnerable patients, including nursing home, housebound and clinically extremely vulnerable patients received their initial injections so quickly and efficiently.
As we moved to the “lower risk” cohorts, the range of vaccine sites quickly expanded, and without any consultation central recalls were sent out, resulting in many unnecessary queries, much confusion, and unnecessary travel for patients. The logistics around the storage and handling of the mRNA Pfizer BioNTech vaccine precluded the use of community pharmacy sites, but the Oxford AstraZeneca (like seasonal flu vaccine) has been widely administered in community sites. The more recent changes by the MHRA allowing up to 31 days storage in a vaccine fridge for the Pfizer vaccine has the potential to further expand the range of suitable sites for its use.
In England, GPs have been working in primary care networks (PCNs) since July 2019, representing groups of practices typically covering 30,000-50,000 patients. Primary care networks are ideally placed to offer population based health services including covid-19 vaccination. Some primary care networks have offered covid-19 vaccinations in house by reorganising their services, while others have worked with other primary care networks to use large sites such as sports centres, entertainment venues, and village halls. Many primary care networks have also offered “pop up clinics”—for example in homeless shelters, community centres, places of worship and hostels—with great success, to increase uptake in marginalised groups who are typically at higher risk of infection, serious illness, and complications from covid-19; and thereby help to reduce health inequalities.
There has been great commitment from both the existing primary care workforce and volunteers to deliver the covid-19 vaccination programme, with many retired staff coming back to help, primary care staff being redeployed, and volunteers acting in roles such as marshals, data entry clerks and car park wardens. In addition to all the administrative workload in booking appointments, there are huge numbers of queries from patients about their vaccines both before and after the event. This hidden work is also being carried out, unfunded, and largely unrecognised, by primary care teams. Each time there is a change in policy by the government or a health scare in the media, primary care teams are inundated with calls, and this workload and its importance in ensuring the continued high uptake of covid-19 vaccines needs to be recognised by the government.
The UK government has recently announced that they may offer a covid-19 booster in the Autumn 2021 and, with new variants emerging, this is likely to be a key health policy to protect the NHS over the winter. Hence, now is the right time to appraise the various options for vaccine delivery. Having a mixed range of sites able to offer mass vaccination in theory should speed up the process, but it has been clear throughout the vaccination programme that the limiting factor is actually vaccine supply, not capacity to vaccinate.
We recommend that NHS England publish data on the respective costs of delivering vaccines via primary care networks (general practice sites) versus mass vaccine centres. Any such calculations must include set up costs, running costs, and also explain where the clinical staff are coming from—knowing that staff shortages are already running at over 10% across the NHS. The work in dealing with queries from patients also needs to be factored into this evaluation—this is currently largely being directed at primary care teams, who are often left to deal with the most complex patients. We would also request an official breakdown of the percentage of vaccines given in each setting thus far, so that there is full transparency and also an appreciation for the huge efforts made by GP teams nationwide.
By using primary care sites for the vaccination programme, there is the potential to invest in and strengthen our infrastructure for local healthcare delivery, which will assist in the covid-19 NHS recovery plans, and leave a legacy for the future. By contrast, there is a risk that mass vaccine sites—like the Nightingale hospitals—will eventually be dismantled. Policy makers need to carefully evaluate the use of mass vaccine sites versus GP led sites, along with the desire of patients to receive their care closer to home and in a familiar setting. However, there must be adequate resources attached for this work, so that routine care and timely access to other primary care services is not compromised by delivering the covid-19 vaccination programme.
We know that many GP teams are at breaking point, and must be fully supported if they are expected to provide mass covid-19 vaccination in addition to their core work. Investment in primary care led vaccination sites, supported by local pharmacies, is likely to be the most cost-effective option for ongoing mass vaccination, as well as being the option that is preferred by most patients. It is essential therefore for the government and NHS managers to work with primary care teams, giving them the resources needed to put in place a sustainable, long-term infrastructure for vaccine delivery.
Simon Hodes, GP Partner, Watford, UK, Twitter @DrSimonHodes
Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed
Competing Interests: None declared
Acknowledgements: AM is supported by the NIHR Applied Research Collaboration NW London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.