Eight PCN clinical directors joined Pulse editor Jaimie Kaffash on Microsoft Teams to discuss how the Covid vaccination scheme has progressed
Dr Tom Rustom, Clinical director (CD), Hawley PCN, East Surrey
Dr Robin Harlow CD, Gosport Central PCN, Hampshire
Dr Partha Ganguli CD, South Ribble PCN, Preston and Chorley, Lancashire
Dr Monica Alabi CD, Titan PCN, Bedfordshire
Dr Reshma Syed Joint CD, Sittingbourne PCN, Kent
Dr Tom Holdsworth CD, Townships PCN, Sheffield, South Yorkshire
Dr Helen McAndrew CD, Abbey Health PCN, St Albans, Hertfordshire
Dr Sanjoy Kumar CD, North East London PCN, Waltham Forest, London
Rollout
Jaimie: Let’s first discuss the problems with the vaccine rollout. How do you think things could’ve been done better?
Monica There could have been a lot more communication to start with. There could have been a lot more trust placed in the hands of the GPs…and more notice given. GPs have been doing [vaccines] for many years, we don’t have any problems [with it].
We should be allowed to request vaccines as we need them. For instance, for Titan PCN in Luton, we had a delivery of vaccines in January and a month later we’d had no more.
Reshma Vaccine delivery is a major problem. We don’t know when the vaccines are going to come to the various sites, deliveries are very erratic and there hasn’t been the opportunity for other sorts of practices to get involved. So, PCNs have been given this cool contract but obviously there are separate contracts for other providers and individual practices have not been given the ability to also provide vaccinations. Vaccination could have been ramped up a fair bit if practices had been allowed to do it individually.
Helen In terms of vaccine supply, I think it’s been split into too many different models of delivery. I suspect that primary care probably wasn’t supposed to be involved in this programme from the offset. My cynical side thinks that there is still a strong push for mass vaccination sites to be delivering this but general practice has proved it has the means, expertise and the access to patients and relationships to deliver it and has far exceeded what any government expected us to do. Now there’s a situation where there aren’t enough vaccines to spread around all these different models of delivery. But there’s a very successful service in primary care that can’t easily be stopped.
Robin There were concerns about resilience, longer term. Yes, we’ve done this, and it’s fantastic, but what services have we not delivered because we’ve been delivering vaccinations as a priority? Most of our staff have done [vaccinations] as additional hours – and yes, we’ve brought in volunteers to help support that – but still, that is additional work for our staff.
Jaimie When we talk about supply issues, is this simply a problem with lack of supply from Pfizer and AstraZeneca or is it a problem with logistics in NHS England?
Tom H My honest feeling is we don’t know. The transparency is really difficult. I’m not completely against mass vaccination centres. I think the issue is about the communication and the working together. At times, it feels the system’s working in silos rather than working together. Sometimes the level of communication is that we [first] hear [about] things in the press and that’s really bad.
Helen Our CCG on the surface seemed to be really supportive of the fact that we would have a mass vaccination site imposed [on us]. They openly admit that there are thousands of vaccines in the fridges of our local pharmacists and our local mass vaccination sites and that people aren’t currently going to them because of the cohorts they’ve [set up].
Yet we have more than 10,000 people in cohort six that I can’t vaccinate because I haven’t got any supply. We’ve tried the mutual aid route of asking for that vaccine to be moved to us, [which would] also let us go out and get some of the health inequality and vulnerable groups. Last night I vaccinated 20 homeless people. But I couldn’t vaccinate the other 50-60 because I didn’t have enough vaccine.
Location
Jaimie: Why do you think the mass vaccination centres are being pushed instead of the PCN groupings?
Helen Using this area – St Albans – as an example, GPs could successfully deliver 15,000 [doses] a week. We’ve proved this by doing 2,000 in a day – easily – on the odd occasion that we’ve had vaccines. But a mass vaccination site is still going to be put in the city, even though there is not the vaccine capacity. I think you’ve got to question why. We suspect it’s to do with the May elections and the headlines that [might result from] mass vaccination sites.
Partha We actually have written to our integrated care system (ICS) vaccine team [saying] that we don’t need the confusion created by mass vaccination and whatever workforce they are planning to use, asking them to give it to us to run the service much better. That was turned down. [The reply was]: ‘We want to preserve your working capacity’.
We are going beyond our capacity to do the job and at the end of the day I think our uptake is much better than uptake at a mass vaccination site.
Tom R I think that PCNs are really showing their worth with all of this because they’ve shown that they’re the right size of footprint to be able to deliver a vaccination programme like this. So it would be a real shame if [vaccinations] did move out of PCNs from local sites to mass sites. We’ve got clinical directors who have built relationships with their practices over the last two and a half years. I think in most places the clinical directors are taking a lead with the vaccination sites. And we’ve proved that it’s working.
Sanjoy The work streams to set up mass vaccination sites are completely separate [from PCNs]. We weren’t told about the mass sites originally and how they would affect our area or that they’d be within half a mile of a PCN centre that’s doing particularly well. We weren’t told about the fact that someone else would be given the easiest cohorts which are in and out in three seconds.
We weren’t told about the supply problems. We weren’t told about the fact that if you do particularly well, NHS England will take your vaccine supply and give it to somewhere else that is perhaps making more noise about not having the supply.
We’re all being treated like children here, but we all have a significant amount of experience in general practice. We give 20 vaccinations to every child in our practice from the time they are born to the time they go to school. We are the experts at giving vaccinations. It should be a ground-up [service]. This is actually a top-down service – the exact opposite of the way you should set up a service.
Jaimie: Does anyone here think that mass vaccination sites have been a support at all in your task of vaccinating your populations?
Partha Before we divided up the cohorts 65 to 70 and cohort six, in our network we and our CCG got in touch with our local mass vaccination provider – which is the acute trust. They were quite supportive of us. We wanted to involve the pharmacists to divvy up the patient group because there is no point in fishing in the same pond. We decided we would aim for one cohort and they would aim for another. But we weren’t told at the time that we could go down to [cohort] six. And then, some of [the patients] shared the link with patients who are quite young…younger than 50. Nobody is checking at the mass vaccination site which group anyone is in. By contrast, we are being monitored so closely, with distrust.
Reshma We’re getting a lot of complaints from patients who have noticed other cohorts or lower cohorts have had their vaccinations done at these mass vaccination sites. We’ve heard this constant argument:
‘I should be getting my vaccination before that person’, and so on. [This inequality] between patients causes a bit of distrust and a contradiction between what’s put out in the press and what we’re doing.
Robin Letters were being sent out to the public that weren’t clear about their offer. We were part way through the campaign and patients were being offered an option [of where to get a vaccine], but it wasn’t clear it was an option. So [this] increased the workload that we had in practices. That goes back to problems with communications. I also don’t think there was clarity at the start about process – [or the] trust in GPs to undertake this.
Jaimie: Do you feel the mass vaccination sites have been allowed to be more flexible with cohorts than PCNs have?
Monica The way it’s being carried out is not right and they definitely have more flexibility. NHS England is gentler with them.
Reshma The cynical side of me thinks that basically the mass vaccination sites had this plan all along to do the easy cohorts of patients and leave GPs to do all the difficult ones, like care homes and patients who were housebound.
Deprivation
Jaimie: In our quick poll of you all, deprivation seems to be the biggest barrier to patients getting the vaccine. What are the reasons behind that?
Tom R We can’t underestimate, actually, the damage this whole pandemic has done to the worst off in society. I don’t think we can talk about it enough, really, because we’ve seen domestic violence go up, we’ve seen job losses. If somebody gets invited for a vaccine but they’re a single parent and their kids aren’t at school and they haven’t got enough money for a taxi or they haven’t got a car, how are we supposed to vaccinate them? I think that those people get lost.
That’s where the local vaccination sites can be quite useful. Initiatives like [the vaccination bus in Sussex] don’t happen because someone’s told us we have to do it, they happen because we’re GPs and we care about our patients and it’s the right thing to do. Local vaccination sites are best placed to pick up these pockets of deprivation. We know about the guy that sleeps outside the supermarket across the road from the practice. We know about the families that struggle, the child safeguarding families.
Tom H One of the things that needs to be thought about more is matching vaccine supply with areas of greatest deprivation. NHS England has done a particularly bad job of that in Sheffield, which has caused a lot of upset.
They should recognise some of the problems deprived populations will have [such as] very large cohorts like cohort six, and the huge amount of multi-morbidity. Understand that we have to have translated consultations, that some people are not going to be able to use the technology to book in. Also we must flip this idea of hard-to-reach populations. Actually, a lot of these populations are not hard to reach, they’re underserved and that’s been built in over the years.
Partha When you’re looking at anti-vax campaigns, [they] sort of come together with [health inequalities] where there is not enough information given to these people. Also, there is a significant inequality in these groups. We work in a city centre area and there are people who don’t have a phone. Some of them only come in to see us in person. These things are not being taken care of, and there is no extra effort put in for these groups of people separately to approach them. There needs to be flexibility. In terms of the BAME issue, I personally had to phone a lot of patients who speak Punjabi, Bengali or Urdu and convince them, because they didn’t have the information. They all agreed to the vaccination. That’s something we need to look at, it’s GPs’ time but I think it’s worth spending.
Helen Last night I and my fellow clinical director personally did our local open door homeless shelter after hours, when [everyone was] there. No one else was going to do it. And there was a proportion of [people] who had been told by a local pharmacy that the vaccine wasn’t safe. So that made our job harder. We had to convince [people] without having relationships and they did actually all come round. There is no recognition that that is what primary care brings. That is a significant funding issue and we’re just all going above and beyond as we normally do.
Jaimie: Is there anyone here who feels this should have been delivered on a practice basis from the very start and not at PCN level?
Monica We decided to have a hybrid model because we are in a deprived area and many of our patients said they will not under any circumstances go to the main [vaccination] site. We were able to get support from NHS England, support from our LMC although our CCG was very cross about it. And now all we do is we deliver AstraZeneca vaccines from the practice for our most deprived patients and Pfizers when we get them from the main vaccination site. But that option and that flexibility should have been built in and that should have been organised via the PCNs.
Tom R I think there were practical issues that would have made delivering [the vaccinations] from individual practices very difficult. Not everybody’s got the same access to estates. [Also] we’ve got other patients coming in for other problems, [who would mix] with the most vulnerable people who are coming in for their vaccinations. We’ve potentially got heart patients coming into practices so I think there would be a lot of complications about trying to deliver [vaccinations] at practice level only. Also, I think the Pfizer vaccine would have been particularly difficult to deliver from smaller practices. But it would be nice, as we have now, to have [had] the flexibility to take a few vaccines from the [main vaccination] site to the practices to deliver them.
Funding
Jaimie: At the start of the programme, vaccinating vulnerable groups was probably costing more than you made. Did you expect to claw some of this money back once you started vaccinating younger, healthier patients, and has this happened?
Sanjoy All of our set-up was cost neutral. We hoped that when we started doing the 16 to 60-year-olds, we would then pay off some of the things [we purchased]. Now, though, GPs will be left out of pocket because now it’s payback time, we are not getting those [patient] cohorts. So it is unfortunately going to leave some GPs out of pocket.
This is a huge funding issue. GPs are not supported by the NHS England model and again, as my colleagues have said, they haven’t joined up the thinking with the pharmacy model. So there are so many people getting vaccinated at sites that will [result in] a complete financial loss to certain groups.
Partha When we are talking about loss and profit, we need to think about the time and effort the PCN group clinical directors have given. I don’t think that that’s being evaluated or valued at all. As a whole, we don’t expect to make a profit, which we should as a business. We are all worrying now that we might have a loss if we are actually taking into account the time we have spent.
Helen When you bring up the argument of not having access to the lower cohorts we’d financially accounted for, it’s been used against us as a reason why general practice [shouldn’t] continue to deliver the service.
Tom H Sometimes we’re stuck because we’re trying to operate like a business but at the same time we’ve got to do the right thing and that makes it really difficult.
And yet again, it comes back to transparency and communication. The initial question was ‘Can you deliver a vaccine service? But you’re not going to have any of the details of it or [only] very bare bones. Can you say yes or no by next week?’ What would you need, if you were a proper business moving forward? Well I’d like to know how long this would go on for. What’s the funding? Yes, there’s extra funding for management up until March, what happens after that? Without these details it’s so difficult.
So, yes partly [the problem is] the model but also it’s the lack of clarity and the difficulty with the communication.
