Scotland’s independent think tank
Scotland’s independent think tank

Fixing vaccine delivery in the Highlands – Ross Jaffrey

My name is Ross Jaffrey and I am a GP principal at Croyard Road Medical Practice in Beauly and a Cluster Quality Lead (CQL) for a group of seven Practices across the Black Isle and Beauly surround. I also represent South and Mid-Highland as their CQL representative.

The CQL role has a remit to improve health care standards and my comments below reflect significant concerns in relation to the national Vaccination Transformation Programm (VTP).

  • That the current VTP model, particularly in NHS-Highland, is failing to provide effective vaccination uptake for children and eligible flu groups
  • That the current national VTP likely costs significantly more than the previous model
  • The IT system used for childhood vaccination does not record into the Primary Care record (we are blind to identify children requiring immunisation)
  • The VTP process is creating environmental harm and damage through additional travel and waste
  • The VTP model appears to be increasing rural-urban health inequalities.

BMA Scotland in negotiation with the Scottish government produced the “new GP contract” in 2018. This promised to improve the stability of Primary Care in Scotland, its vision was bold. GPs across Scotland voted in favour of this change. Highland GPs voted 75% to reject the contract due to significant flaws within the proposed new model for rural health care. Vaccination was identified by BMA negotiators as a work-stream, that if delegated directly back to Health Board control, would aid a reduction in workload to GP surgeries. It was my belief, that for some regions, this had potential to create real harms: cause a widening of health inequalities, have a greater impact on our environment through unnecessary travel and waste, lead to a reduction in both patient satisfaction and respect for their family doctor, and a larger cost to the taxpayer. In Highland the 2018 GP contract implementation has had an enormous destabilising effect.

I have been a long term advocate for vaccination within my community and the wider Highland region. I ran a grassroots Facebook Group during the COVID-19 pandemic providing pandemic information to the Highland population, and provided free hand sanitiser stations across a number of villages and towns. Primary Care in Scotland faced the COVID-19 pandemic challenge and assisted our transition back to “normal”. Without GP surgeries providing the early backbone of the COVID-19 immunisation delivery we would have struggled to do this rapidly across Scotland.

NHS-Highland was the last mainland Health Board to take back vaccination from Primary Care. In part, this was due to local GP pressure. Highland Practices last delivered vaccines to children in Feb 2023, our last seasonal flu involvement was the 2022/2 season. Health Board teams visited each Practice to remove vaccine stock. It was a sad day for our Practice affecting morale. I then had to watch uptake of childhood vaccination plummet. NHS-Highland childhood vaccine uptake figures dropped so badly our Public Health lead requested a peer review report from the national Vaccination and Immunisation division, led by Dr Sam Ghebrehewet. This visit occurred between 6th-14th June 2024. Their report produced 11 recommendations. An options appraisal group was created to look at alternative models. I was a part of this. Over 90% of Highland GP Practices were willing to take back vaccination. Since the review childhood vaccination continues to perform well below the pre-VTP standard. MMR uptake in children aged 6 has dropped off dramatically: 85.2% (previously >91%), uptake is only 71% (was 85%) in the most deprived, and dropped to 85% in the least deprived (formerly >96%). We are now open to historical long forgotten childhood illness. Record numbers of cases of whooping cough and Scotland’s first infant pertussis death since 2014 occurred this year. Preventable illness is causing harm. Polio is re-emerging in Gaza, measles outbreaks occur across the country and a number of Primary Schools with SIMD 1 and 2 (most deprived) are likely extremely vulnerable.

Seasonal influenza is a national emergency. Uptake trends are following the same pattern seen in the childhood immunisation programme. Uptake figures in “at risk groups” are down almost 50% from 2022/23. It has taken over 4 weeks longer to vaccinate the 1 millionth flu vaccination patient.

Hospitals across the UK are seeing huge pressures. I feel some of this was absolutely preventable. Through my direct interaction with patients, feedback from my Facebook posts and through discussion with peers, people are finding it more difficult to get a vaccine and have real confusion about how to arrange it. Some very vulnerable people are without protection, waiting for letters, digitally naive elderly struggle with an online booking, or find it physically difficult or too costly to travel far and wide to access their vaccine. This should not be happening. We used to vaccinate over 60% of our local population in 3 weeks through October. Surge population protection. We could target those most likely to benefit and made great efforts to do so. It took effort, it took purpose, and it took direct interaction with patients. All lost in the new system. People now feel anonymous and forgotten. Trying to book my own vaccine slot in early October faced a 3 month wait! Cancelled clinics, and little flexibility to change appointments makes access a challenge. Even the most motivated are finding this new process difficult.

Referencing the VTP cost makes for difficult reading. Despite directly asking on numerous occasions people are not keen to discuss this. I have done my own rough calculation. In 2018 GP Practices were reimbursed on average £8 per influenza vaccination, COVID-1 provided £12.58, Childhood flu £7.67, Childhood immunisations were for a brief period in 2022 reimbursed at £10.06. Through the options appraisal process for Highland I am aware current costs are now in excess of £6 million pounds, and this is like an underestimate.

In 2023/24 approximately 5900 childhood immunisations were delivered in Highland for the national vaccination schedule. Figures for seasonal influenza are not currently available to me. Using an estimated population proportion of 6.1% this equates to approximately 4000 pre-school childhood influenza completed so far in the 2024/25 season. GPs were not responsible for school age children (27000 vaccination). Using these numbers the total childhood immunisation cost for NHS-H using the previous GP payment schedule would have been £86000 (seasonal pre-school flu + national immunisation schedule) Adult costs for seasonal flu can be calculated in the same fashion. Using £8 as the baseline price gives a total of £592,744 (based on 74093 immunisations) and for COVID-19 using £12.58, a cost of £828,883.

The total vaccination cost approximated to £1.5 million. Other vaccines such as shingles, tetanus and other vaccines eligible under the NHS are not included. This would not be a majorly significant added component to costs.

NHS Highland use several locations for vaccination. 32 for Argyll and Bute and 51 for Highland. Not all run every day, each likely has some form of running cost. The “jewel in the crown” of Highland vaccination is the Highland Vaccine Centre based within the Eastgate Centre. NHS-H rents this unit. The Unit was refitted for health care use. The cost of VTP is not obviously visible in NHS Highland accounts. The central vaccine hub is located in Unit 67. A review online suggests the rental, rate and service costs are likely upwards of £200,000 per annum, based on an online review of commercial property adverts for units in the Eastgate. Running this venue alone, exclusive of staff, appears to cost upwards of 10% the previous total GP vaccination budget. I am not privy to the exact costings but merely use it as an possible example of VTP policy impacts the overall Highland NHS budget GPs in Highland are desperate to help our patients. Supporting Primary Care teams to deliver a sustainable and reliable model of vaccine delivery for those that want it appears a win-win situation for all involved. Please help stop the damage this is doing to our population and health care service.

Dr Ross Jaffrey is a GP

2 comments

  • John Sturrock

    It would be good to see this example used as the driver for practical changes straight away. I wonder how many other services would benefit from a similar analysis…?

  • Kenneth Ferguson

    How interesting and yet profoundly disappointing too. Another example of the failure to deliver the best public services to rural Scotland. Surely we can do better.

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