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Season to be cheerful?

17 November 2010

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Consultant Editor, MiP

In my experience, the flu cycle begins way before the operational element kicks in. Time spent planning through operational meetings is key to ensuring a smooth operation and a safe, efficient and financially viable service. Involving everyone in the team at an early stage, however small their input may be, is also crucial to the success of the campaign.

The aim of the programme is primarily to reduce the morbidity and mortality from flu by vaccinating those patients most likely to develop severe or complicated illnesses as a result of their suffering with flu. Allied to that of course are the financial rewards that a successful flu season brings in the form of QOF points, reimbursement for the purchase of the vaccines from the prescriptions pricing authority (PPA) and enhanced services payments from your PCT.

Placing your order
Flu orders are often placed before the previous campaign has ended, with reps keen to encourage managers to commit to their supply with promises of earlier selected delivery dates.  There are important considerations to make that influence the supplier I choose:

  • 1. How much profit will I make if I buy their vaccine (note maximum profit doesn’t necessarily mean you purchase your vaccines from the cheapest supplier). Maximising profit is about negotiating discount, and at times generally the vaccine that attracts the highest NHS list price where you pay a reduced price due to the discount you have negotiated will bring you the most income as the PPA will reimburse your vaccine and dispensing costs (for GMS practices).
  • 2. How reliable has their delivery been? Some suppliers have not been able to manufacturer enough vaccines to deliver to schedule. If you are let down and have advertised your dates you are in trouble. Use a reputable company.
  • 3. What support can they offer me? Will they help with postage and stationery, will they help with publicising the campaign, will their rep support us during the programme and be on hand to answer queries?
  • 4. Will their finance office allow extended credit terms, essential to allow cash to flow? Many flu suppliers offer 90-day credit terms, which allow PPA payments to begin coming through (as they are paid two months in arrears) before you have to pay their bill.

The support process
While waiting for delivery of your vaccine, there is an opportunity to ensure your internal processes that support the flu campaign are robust and current. To date this year, we have had three operational meetings and add the flu campaign as a regular agenda item at our weekly management meetings.

Your clinical computer system can be your best friend during the flu campaign. It can also be your worst enemy if information is not fed in correctly. Having suffered a considerable amount of lost income through incorrect information being applied to a computer system, I have learned the hard way that the attention is in the detail.

Your IT system will manage your FP34 reimbursements as a result of the prescription generated if you have bought your vaccines in of course. Do ensure you have the right vaccine, and the right supplier of that vaccine fed into your system. Our practice didn’t do that and therefore had not claimed back the appropriate revenue from the PPA. We did manage to recoup some of the costs, but the sleepless nights could have been avoided if our IT team had known what the finance team knew. A case of incompetent incompetence I am afraid was very costly, a simple oversight that cost thousands. Hence now the whole team hears the same thing in the same meeting and reads and helps write the same policy.

Your IT system will also manage your enhanced services claims. Therefore a good template that includes all of the related QOF codes is essential, as again when entered correctly this will influence your payments received. As a general rule of thumb, enhanced services payments will be pulled across from your clinical system into a central database, which your PCT will use to action your payment.

This is very similar to the way QOF works – transferring data from the clinical system into QMAS to calculate your end of year QOF payments, which will include your flu uptake.

Stock Control
In a practice with 25 clinicians, not to mention additional community staff, it’s not easy managing our stock. I would suggest being anal is the only way to do this and that every vaccine taken from your fridge is recorded.

Review your systems before the campaign starts to ensure that they are robust and be prepared to reconcile your stock with your claims at the end of every day. One lost vaccine is more or less equivalent to your nurse’s hourly rate of pay. Insure your vaccine too – overstocked fridges tend to ice up, beware insurance and store appropriately (advice again as a result of experience).

With a large list size, deciding on which approach to take for advertising is a major decision. Ensuring all of your patients receive the necessary information while keeping an eye on the cost is not always easy.

Again, from experience I would advise that you plan your advertising campaign well beforehand. Your regulars will be ready to roll up at the door on “opening night”, but those approaching 65 who are newly eligible to receive the vaccine may not be aware of their entitlement. We have chosen to write directly to them. We keep costs down on postage by using direct mailing companies – this saves our staff time and reduces the outlay by at least 50%.

In addition to this, we apply the usual internal poster campaign, advertise on our internet site and on the right hand side of repeat prescriptions. We also advertise in a local free newspaper. However, last year this was only to find out that receipt of the particular paper was hit and miss and was dependent upon whether there was a paper boy or girl willing to pick up the round! We have therefore extended our advertising to additional free leaflets that we are assured go through every door in the area. We will also try text reminders this year, providing our patients consent of course!

Crucial to the success of any venture is having appropriately trained staff to do the job.

Nurses will work to a patient group directive and provided they have had their annual vaccination training update they can work relatively independently so long as a doctor is on the premises. Healthcare assistants are relatively new to administering vaccinations and have to be qualified at NVQ level 3 before being allowed to do so. We have to notify our PCT annually of our HCAs’ qualifications and offer assurances that they have the appropriate medical defence cover in place and that they have the support of the doctors. They are only allowed to work under patient-specific directions, which, as suggested, means the vaccine must be administered on a named patient basis. This takes a little planning but is not insurmountable.

CPR updates and anaphylaxis training are also a must for everyone involved.

Getting started
Our advertising invites patients in alphabetical sections. With 5,000 patients to vaccinate we need to have a small element of crowd control and a degree of organisation.

It’s all hands on deck – the main structure of our flu vaccination programme centres around two “flu weeks”; all other clinics are put on hold during those weeks. Annual leave is banned for all doctors and staff. We have to have the full support of the whole team as everyone has a part to play.

Doctors support the nurses after their morning surgeries and then it’s open house for the rest of the day. We compare our surgery during flu week to Macdonald’s Drive Through on a hectic day: sign in, sleeves up, quick jab, coat on and on your way! Oh, and don’t forget to ask consent! We get through around 500 on an average day, and after a while it becomes a little robotic for the staff involved.

Feedback, however, is very positive. The patients love it – they are in and out in five minutes. Yet many people appear to be in the queue before them, jostling for places (and I am not kidding).  

Once the hard work of the two main flu weeks is over, we target the housebound and action the home visits while mopping up opportunistically in surgeries or other QOF clinics throughout the flu season.

With PCT targets this year requiring us to vaccinate 75% of our over 65s, we don’t find the campaign easy. Although we have a high elderly population we cannot claim deprivation, but suburban middle England brings its own problems too as many patients exercise their right to say no. We have just managed to tip the 70% mark over the last few years – this year will be much harder. One can only hope that our operational meetings have prepared us well and the financial reward will follow early in the new year and that the spread of flu among our patients is contained. We will then appreciate that it’s a worthwhile service, despite taking a year to complete.

Finally, offer your staff the vaccination too. You can’t claim an enhanced service payment, but it may save you some money in sick pay further down the line!