GP surgery teams identified limitations around engaging clinical risk groups with influenza vaccination and opportunistic delivery due to capacity. Patient groups and HCP reported that vaccination was rarely discussed or delivered in secondary care settings, and while delivery in secondary care was acceptable in theory, practical questions around feasibility remained.
Limitations on vaccine delivery in GP surgeries
Participants were aware that influenza vaccines can be accessed via GP surgeries and community pharmacies, and cited examples of convenient GP clinic arrangements (eg, evenings and weekends). The general view was that access was not a key issue:
It’s pretty easy to do, pretty easy to book, pretty easy to get and have. (P1_17_T2D)
Possibilities to have informed discussions about influenza vaccines or to be vaccinated opportunistically were limited:
When you go to the doctors, they go on the computer and say, “you do realize your due for your flu vaccine” And they don’t say, “well, I'll give it to you now.” They say, “make an appointment with the nurse.” This is what annoys me. (P1_26_COPD)
GP surgery teams described proactively offering vaccines opportunistically to patients with long-term conditions, though one practice nurse noted how limitations on orders during the winter season presented consequences:
This season just gone has been quite frustrating because we’ve just had the Saturday clinics. We’ve been told “right, don’t use any vaccines opportunistically to start off with because we need to know we've got all the vaccines for them booked in” […] But I think we missed out because you can get them opportunistically. (P2_PC15_Nurse)
More broadly, GPs described how limited capacity meant that they felt unable to consistently offer influenza vaccines opportunistically to eligible patients:
If you’re busy, and you’re running late, the last thing on your mind is to give a flu vaccine. They [staff] have to get through a whole host of things in that [annual] review. So, to add on to that? Would they have enough time to administer the vaccine? I'm not sure. (P2_PC5_GP)
Strained GP capacity during winter seasons then had an impact on the ability to ‘make every contact count’ and offer influenza vaccines opportunistically. Amidst these constraints, GP surgery teams reported being more likely to recommend influenza vaccination or offer vaccines opportunistically to patients in particular clinical risk groups:
I think the people with a respiratory diagnosis, you're much more likely to then stress the point about that for them, rather than diabetes […] And perhaps I think, for me personally, but I think otherwise in the practice, I've seen that as well, that fewer people would consider that immediately for diabetic patients. (P2_PC1_GP)
Acceptability of expanding delivery pathways
HCP signalled that there is significant potential to improve how the NHS engages clinical risk groups with the influenza vaccine programme, and how delivery is embedded in patient pathways.
Diabetes care teams explained various touchpoints where it would be acceptable and appropriate to engage patients with influenza vaccination, even if this was not current practice. The diabetes patient pathway includes primary care (regular GP appointments and an annual review), but also management through community care (annual diabetic eye screening appointment; possible engagement with a dietitian, podiatrist, dialysis centre; self-management and education programme). HCP cited how self-management and education services were important for patients with recent diagnoses, yet rarely recommended vaccination:
Well, they [vaccine conversations] don't [happen]. […] we have some patients who have only recently been diagnosed with diabetes, so they're only just getting grips to having diabetes and what that means for them, and what changes they need to make. They need to have had diabetes for three months to attend our courses. So, I'd say that population of patients, yes, might be more and less knowledgeable about how not having a vaccination impacts them and how the flu if they get it, for example, makes them more vulnerable […] I don't think there’s a barrier [to discussing vaccination], it’s just something that we haven't really done. (P2_PC7_DiabetesTeam)
Consequently, opportunities were missed to engage patients with the importance of influenza vaccination at a formative point in their care pathway. HCP consistently highlighted that discussing or delivering vaccines across patient pathways was not part of current practice but indicated the benefits of integrating vaccine delivery in spaces where patient demand for services was high:
We have a fantastic diabetic retinal screening programme […] most of our patients do attend for their retinal screening, but there is no mechanism for a patient to get their flu vaccination if they were attending that appointment. Because diabetic retinal screeners don't do flu vaccinations. (P2_PC6_Nurse)
People living with conditions linked to CLD are more likely to receive care from specialist hospital services, including 6-monthly ultrasound surveillance and tumour marker blood tests, clinical assessments every 6–12 months and outpatient clinic appointments. Hepatologists considered integrating influenza vaccine delivery in existing outpatient pathways to be feasible and strategic during winter seasons and suggested that this approach may help to reduce inequalities in vaccination among people from ethnic minority backgrounds:
Every 6 months, a patient with CLD should have an ultrasound scan as part of cirrhosis monitoring and liver cancer surveillance. So, by definition, one of those is going to be around the sort of time where it would not be unreasonable to have a flu vaccine. So that’s everybody with cirrhosis. That’s everybody with hepatitis B who has a family history of liver cancer. People who are, Asian men over the age of 40, Asian women over the age of 50, and all Africans over the age of 20. So that’s probably the best point of intervention. (P2_SC1_Consultant_Hepatology)
While secondary care HCP rarely discussed or recommended influenza vaccination with patients during outpatients appointments, they were conscious that COVID-19 vaccines were routinely recommended during roll-out in 2020–21:
It [influenza vaccination] doesn't come up. That’s the reality. Sometimes I get asked, should I have the flu jab? And I'll say, “Yeah, of course you should.” Certainly, when it came to COVID, we were absolutely recommending COVID vaccination. (P2_SC1_Consultant_Hepatology)
HCP had clearly set precedents by routinely recommending vaccines to patients with long-term conditions under their care. Participants in clinical risk groups were open to integrated delivery pathways, but what mattered most was convenience and being vaccinated by trained HCP:
If they’re all trained healthcare professionals, no I’d have no issues with them doing it in any of those environments. (P1_17_CLD/T2D)
Feasibility of embedding vaccination in patient pathways
HCP viewed expanding influenza vaccine programme delivery in community care pathways such as retinal eye screening favourably, but questions around feasibility were raised due to limitations on space and capacity to administer vaccines to patients:
There is time for vaccination to be done, whilst they [patients] are waiting. I think it’s a very good and opportunistic approach to do it. The main issue here would be the space—where is it going to be done? Because usually there is minimal waiting area, there is minimal room available. Everybody is struggling for a little room. (P2_PC9_DiabeticEyeScreening)
The perceived feasibility of embedding vaccine delivery in non-primary care settings depended on an assessment of the most appropriate delivery points and who would have responsibility for vaccination. HCPs acknowledged that there were systems-level limitations which prevented them from vaccinating patients admitted to hospital but did not necessarily feel that delivery via wards was the most feasible or appropriate point to offer vaccination:
It’s been a constant frustration that you can see a patient who’s in your hospital, who’s not vaccinated, and to not actually have the means to vaccinate them. But it would be much better done at discharge. They're more aware of the conversations. Having a conversation where you're slightly out of it on the wards isn't going to necessarily stay with you. (P2_SC14_Consultant_InfectiousDiseases)
Acceptability and feasibility were, therefore, not always aligned. However, a respiratory consultant described in patients as a feasible site for delivery due to the authority of ward staff to prescribe and administer a range of pharmaceuticals:
The doctors prescribe and the ward nurses administer—they have been trained to, and are very used to giving other treatments, including injections, so you don’t need a specialist nurse or roving ‘vaccinator’ to come and do it—it just happens as part of “treatment” rounds. (P2_SC15_Consultant_Respiratory)
Offering influenza vaccination at the point of discharge in hospitals was considered by HCP to be most the most appropriate time, as patients were perceived to have improved since admission and were waiting to return home:
When we admit a patient, it might be for something quite trivial. If they’re really ill, it’s not the right time to vaccinate somebody. But many of them could be vaccinated opportunistically at the point of discharge. (P2_SC8_Consultant_Hepatology)
Outpatient clinics were perceived to be effective settings to reach a larger number of eligible patients with underlying long-term conditions due to back-to-back appointments:
If you had someone doing flu vaccines in our outpatient clinic, we have clinics running all the time, every day of the week, morning and afternoon, sitting doing flu vaccines. I'm sure you would catch quite a lot of people. Again, with the inpatients, we can certainly offer it, but again, if patients are in or such a short time, we would normally just send them to their GPs. I think outpatients would be a good place to catch patients if you wanted to administer it to them. (P2_SC7_Pharmacist)
HCP also perceived it feasible to have their patients signposted to vaccine clinics stationed by outpatient services and vaccinated before or during appointments:
If we had a vaccine clinic running alongside our clinic, so I could just say to the patient, “look, I really think you should go and get vaccinated. Pop in now before you go home,” or while they were waiting to see me somebody could have approached them and offered it would have made a world of difference. (P2_SC10_Consultant_Hepatology)
While delivery via hospitals was considered by programme managers to be costlier compared with primary care, participants recognised that integrated delivery approaches offered an opportunity for reducing expenditures by preventing hospital admissions:
It would be quite expensive compared to the number of vaccines you give. And that’s the problem here, isn't it? We're rewarded by volume. But actually, we said this the whole way through COVID, it’s crackers, because the one patient that you might get who’s got lots of co-morbidities, who was most likely to trip into a hospital bed if they get flu or COVID, that patient has value, should be valued at hundreds of pounds. (P2_VCM4)
Perceptions of feasibility then need to be understood in relation to the design of appropriate targets and incentives which focus on reducing inequalities in the immunisation system.
Enhancing vaccine recommendations
Outpatient clinic letters and summaries were rarely used by specialist clinicians as an opportunity to recommend influenza vaccination. Just one HCP included a checklist about vaccination status in clinic letters, which primary care teams could review with the patient:
So, my I have a clinical summary at the top of every letter, one of the items will be “had annual flu vaccination every year” or “doesn’t have,” or “has been recommended to have,” “has had Pneumovax up to date with COVID.” Every single clinic letter, and in the text, which is a letter written to the patient, there will be a discussion about vaccination either saying “you're fully vaccinated’ or ‘respect your wishes not to, however, as you know, would have been strongly recommended. (P2_SC15_Consultant_Respiratory)
GPs were positive about including vaccine recommendations in specialist clinic letters, which might reinforce recommendations in primary care and offer condition-specific information about risk:
It highlights the importance even more if the consultant is saying it too […] as extra evidence that it’s important they have it. (P2_PC13_GP)
Such letters might also offer a prompt for community pharmacy teams to discuss vaccination with people in risk groups:
As Commissioners, we can also send out communications to say, “if you receive a letter from a consultant the patient presents, please consider them for this option.” (P2_LP7_PharmacyAdvisor)
However, a secondary care HCP was concerned about the additional administrative burden and described the need for a pro forma that was simple to implement:
If there had been an automated rubric that I could just click and it would have appeared or had been automatically on the letter, yes, that would have made a big difference […] I would. But I would have seen it as being worthwhile, if it had been facilitated, because the text was already there. And it was just another click as opposed to going to have to type “I've mentioned to this patient, and they need that they would benefit from flu vaccination.” So, to say, “on the basis of their liver disease, they would benefit from flu vaccination and I recommend that they come and talk to you full stop.” (P2_SC10_Consultant_Hepatology)
