Stricter targets will see a number of GP practices lose tens of thousands in income from child immunisations – including one practice set to lose £66,000, Management in Practice’s sister title Pulse has learned.
The 2021/22 GP contract saw vaccinations and immunisations become an essential service with item of service fees set at £10.06, and four new indicators covering vaccinations and immunisations added to the QOF, replacing the childhood immunisation DES.
However, it also removed exception reporting at the same time as insisting on practices hitting 95% uptake, which has led to a number of practices losing out on tens of thousands of pounds.
GP leaders told Pulse the new rules are too strict, and disproportionately affect practices with a high number of migrant families who either have been vaccinated overseas to a different schedule, or are less likely to have vaccinations.
As part of negotiations with NHS England on the 2022/23 GP contract, BMA GPC England had asked for a reform of item of service fees and the QOF, with ‘additional support for childhood immunisations’ within QOF to enable practices to ‘deliver more for their patients without being financially penalised’. However, this was rejected.
Childhood vaccination payments
Item of service fees
The item of service (IoS) payments of £10.06 now apply to each dose administered (except Covid).
If fewer than 80% of children have the jab then practices may face a clawback equivalent to half of the cohort, although this is at the discretion of the CCG. As a result, there is a potential big jump in payments when you get to that 80% threshold.
Importantly, the thresholds will now be measured at the end of the year, rather than quarterly as they were previously.
DTP: Three points are awarded at 90% achievement, with the remaining 15 points going up gradually until 95%. Indicator measures uptake in infants at eight months. After eight months, infants will no longer be eligible for the QOF indicator, but will still attract the IoS payments.
The single MMR vaccination: Seven points are awarded at 90% with the remaining 11 points gradually awarded as you get to 95%. Indicator measures uptake in children who reached 18 months old in the preceding 12 months, who have received at least 1 dose of MMR between the ages of 12 and 18 months.
Completion of both MMR doses and DTP booster at five years: Seven points at 87% increasing to the full 18 at 95%. Indicator measures uptake in children who reached 5 years old in the preceding 12 months, who have received a reinforcing dose of DTaP/IPV and at least 2 doses of MMR between the ages of 1 and 5 years.
Source: Pulse Intelligence
Lancaster PCN clinical director Dr Kirsty Hagan said her practice missed out on payments of up to £66,000 after achieving 91% uptake for diptheria, 90% for the single MMR jab and 90% for both MMR doses and DTP booster.
She said: ‘We would reach the 95% if they allowed us to include people that have had their immunisations late…. they have actually been vaccinated, we’ve done the whole course, but we don’t get paid anything for them because it’s not within the schedule.’
These delayed vaccinations are due to Covid, she said, with cancelled clinics if staff are sick, or when isolation rules were in place, or people didn’t want to bring newborns into the surgery.
She said: ‘For us, because we’re quite a big practice, [we’ll lose out on] £66,000. It’s a lot of money.’
This might mean the practice not replacing a nurse who is retiring, she said, adding: ‘That means that in the following year, we definitely wouldn’t hit the targets, we would be one nurse short.’
Dr Hagan said that another PCN clinical director’s practice ‘had actually made the target and then they registered a refugee family’. She added: ‘[That is], of course, absolutely is the right thing to do. But it meant that then they lost all of their indicators. That’s because the children were out of schedule, which is just ridiculous.’
Peterborough PCN clinical director and GP federation chair Dr Neil Modha said his practice, Thistlemoor Medical Centre, is set to make a net loss of almost £45,000 from the IOS element of childhood vaccinations, due to lower coverage rates on some of the vaccine indicators.
Despite an increase in uptake through running a Saturday drop-in clinic for patients, his practice has achieved ‘nothing close to the level of QOF points or to even avoid the 50% clawback of item of service costs built into the current commissioning arrangements’.
The federations’s analysis showed practices in Peterborough that served the most deprived and challenged populations – especially where the makeup of the population are from migrant backgrounds or there are language challenges – had the lowest uptake. Other practices in the town have projected QOF money losses over £30,000, £20,000 and £15,000.
Gateshead and South Tyneside LMC chair Dr Paul Evans said that because of one child registering with his practice within the last month, who was fully immunised in their country of birth, they will lose all their points for the single MMR indicator despite having given the catch-up dose of MMR.
Dr Evans said his 6,620 patient practice will lose just under a potential £10,000, adding: ‘We’re looking at half an HCA, or we’re looking at three weeks of GP locum cover that we’re just not going to have the money for now.
‘The practices being disproportionately hit with this are those who’ve actually made it easy for migrant children to register with them. Essentially, if practices who are happy to take “no doc” migrants without question, will be hit with this the hardest for doing the right thing.
The GPs missing out on tens of thousands of pounds
A number of GPs have told Pulse they are missing out on funding.
Nottingham GP Dr Marcia Chamberlain said: ‘Our practice is going to lose at least £7,200, but this could easily rise to £11,200 if even one family now registers and declines vaccination of their child. One of the other practices in the PCN stands to lose £27,000.
‘This change to QOF then surely does not achieve their aim to help improve health inequalities but rather does the opposite.’
Reading GP Dr Aparna Balaji said: ‘We have a few families who have refused it despite counselling and some who have missed the deadlines and delayed. We have a large number who are born abroad and move in as well whose schedule is out of sync with us.
‘We are at 92%, 90% and 88% for the three childhood vaccination indicators so we will lose almost 50 points.’
Norwich GP Dr Ed Turnham said on Twitter: ‘Our practice, serving a deprived multi-ethnic population, is losing all funding on one vaccine indicator (£1,700) this year because ONE family got their jabs late.’
Sunderland CCG clinical vice chairman Dr Fadi Khalil said his practice will lose 34 QOF points out of the total 54 because they are at 91% achievement rather than the target of 95%: ‘That’s approximately £4,000 of funding lost to the practice, at a time of rising costs and trying to support practices with pay uplifts and NI and pension rises.’
Fylde and Wyre CCG chair Dr Adam Janjua said: ‘We’ve done 86%, 88% and 87% of the work. The remaining people that are on the list are people that are not going to come in, they are children whose parents are refusing to vaccinate them. They’ve had ten appointments even and then they just don’t show up.
‘In the past you used to be able to say [that] you’ve invited them twice, they haven’t come and then they’ll be taken off the list. But this year, apparently, it’s not going to work like that.
Dr Janjua said his practice manager estimates their 6,000 patient practice will lose around £12,000.
Mid Mersey LMC medical secretary and GP Dr Ivan Camphor said his practice could lose out on £10,000: ‘In my practice, there are only three unvaccinated patients, and we’ve sent God knows many letters, emails, text messages, phone calls, saying please can they come and have it done, and the parents are refusing to have their [child’s] MMR jabs or their booster doses.
He said that for small practices, losing around £10,000 is ‘a huge amount of money, especially when you can demonstrate that you’ve actually done the work, you’ve actually contacted these patients and we can show that there’s been communication and people have rung and sent letters and so on and so forth. I’ve raised this several times but we’re making no progress.’
Swindon GP and QOF expert Dr Gavin Jamie said: ‘On average, practices are actually slightly better off under the new system, but it’s hugely variable between practices because there’s a completely new system.’
Dr Jamie said the amount QOF points are worth will vary with practice size and how many children are on the list, adding: ‘Potentially, between 90% to 95% of those patients, each child is worth hundreds of pounds for one vaccination. That one child that kicks you over into 90% is going to be worth seven points and potentially, for doing one vaccination, you’ll get paid £1,400 pounds. There are huge leaps.’
Deputy chair of BMA GPC England Dr Kieran Sharrock said: ‘GPs and their teams already feel undervalued, and NHS England’s decision to push ahead with reinstating QOF, without recognising the pressures that practices are already facing, will only exacerbate this.
‘NHS England must not only listen to the needs of practices and by extension their patients, but also remember that we are still mid-pandemic, and that asking practices to return to blanket former ways of working without proper consultation to accommodate individual practice need is both unrealistic and for many, simply unfair.’
NHS England did not respond to a request for comment from Pulse.
Recent childhood vaccination figures prompted UK public health officials to call on parents to ensure children have had their MMR vaccines – as uptake fell to the lowest level for a decade.
And the health secretary has proposed a ‘national vaccination service’ to relieve GPs of doing immunisations.
Meanwhile, RCGP chair Professor Martin Marshall said the QOF system for GP payments should be scrapped altogether, as the current system ‘doesn’t make sense whatsoever’.
Adjustment for lower coverage
The payments are grouped in three tiers:
– Practices achieving less than 50% coverage of a vaccination will not be able to retain the Item of Service fees (IoS). In previous arrangements there would have been no payment until the practices reach 70% coverage for MMR and the 6-in-1 vaccine, and in other childhood vaccines a lower payment generally applied.
– Practices achieving more than 80% coverage of a vaccination will retain all of the IoS fees for all the vaccinations they administered.
– Where practices are achieving between 50 to 80% coverage on the routine childhood vaccines (MMR, 6-in-1, rotavirus, PCV, Men B, Hib, Men C) then a repayment of a proportion of earnings will be triggered according to the following formula: value of the IoS fee x 50% of eligible cohort size.
– A practice may very occasionally demonstrate extenuating circumstances, and therefore be exempt from the repayment. In this situation the practice would need to demonstrate that the core contractual requirements had all been met and that they had made appropriate efforts to improve the vaccination rate before a commissioner could consider it. This is expected to be applicable only in small number of circumstances.
This story was initially published on our sister title Pulse.