Agenda item

Councillor Rory Vaughan welcomed joint presenters, Vanessa Andreae, Vice Chair of the H&F CCG and Lucy Rumbellow, Commisioning Lead – Immunisations, NHS England.  Vanessa Andreae explained that the membership of Immunisation Network Group was drawn from a number of local organisations and agencies including the local authority and H&F CCG, amongst others.  Councillors Lukey and Holder had attended events organised by the Group and updates on the service provided were available.

Lucy Rumbellow outlined briefly the programme which during 2015/16 offered flu immunisation for children of two and three years age, and also, school years 1 and 2.  A review of flu rates amongst primary school children had resulted in targeted practices in two or more cohorts, based on the view that a target of 40% would help ensure prevention, providing immunity for older members of the family by limiting transmission and thereby reducing rates in older people, concurrently.  Practices would make up to three attempts to contact parents and ensure that appointments are kept.  Practices were encouraged to develop action plans following national guidance. 

Vanessa Andreae explained that approval for a pharmacy pilot project was due to be signed off, with the aim of administering vaccines to a 1000 children, aged 3-5 years, in Hammersmith & Fulham.  Feedback from a children’s centres pilot project conducted in 2015 indicated ad hoc take up of vaccines from local pharmacies.  The CCG were exploring service led agreements with pharmacies and identifying training needs, although the timing of when this could be delivered needed further consideration.  They had initially identified pharmacies in convenient localities such as shopping centres and high streets. 

Councillor Vaughan touched on the fact that pharmacies had not previously been permitted to administer the vaccine to children and Vanessa Anderae clarified that this was more an issue relating to the porcine gelatine content of the vaccine as opposed to actual administration.  They were also consulting and working closely with community champions and faith leaders to address this.

Looking at the data from the Child Informatics Service (CHIS) reported to NHS England, Vanessa Andreae explained they were building in procedures to ensure that they could extract data indicating where a carer has been contacted three times, as this was also useful in developing a targeted approach. 

Janet Cree, Managing Director, H&F CCG expanded further and, parents residing on the bounderies of two boroughs, have had the benefit of living in one and obtaining services in another.  In terms of skewing data, Lucy Rumbellow confirmed that they looked at the resident population in the borough and that this was an issue that they were aware of, particularly in London.  This was one of the reasons why GPs were asked to record data on babies registered with the practice and updates records accordingly. 

Councillor Joe Carlebach highlighted the problem of capturing data, particularly from those obtaining treatment from private practice or “ghost patients”.  Vanessa Andreae acknowledged this was a complicated issue and that it was not possible to identify that particular information.  What was helpful to understand was that regardless of which borough, the data obtained through the NHS was captured and collated in the same way by practices.  Drawing on her own nurse practitioner experience, Vanessa Andreae acknowledged that her practice also saw patients registered in neighbouring RBKC.  She continued, explaining that one of the actions which arose out of the previous discussions was the intention to write to schools and include requests for a child’s immunisations record, as part of the application process on entering or registering for school. 

In the detailed discussion which followed this suggestion, Members of the Committee were broadly supportive of the idea of capturing such data at the start of the admissions process but acknowledged that the implementation, structure and delivery of this would need to be carefully developed.   Councillor Lukey, suggested that officers from Children’s Services were invited to attend future meetings of the Committee, in order to respond to policy questions that fall within service remit.

ACTION: Children’s Serivces / H&F CCG

Councillor Carlebach queried a possible conflict of guidance offered by GPs and schools, and the advice to keep children at home following infectious illness.  Some schools asked that parents provided a medical certificate from a GP following three days illness.  Vanessa Andreae clarified that it was now possible to self certify for up to five days and that school policies varied on this.  She also commented that if a child was off school for three days, they should see a GP.  It was noted that most surgeries offered a triage service with a phone consultation, assessing need over the phone, for example, febrile or not, and would be seen depending on the outcome of the assessment. Discussing the wording about the need for a medical note, as posted the LBHF website, it was acknowledged that this open to interpretation and could be further clarified.  Liz Bruce, Executive Director , Adult Social Care, commented that this had been raised previously with Children’s Service and the Director of Public Health and concurred that greater clarity should be sought. 

Councillor Vaughan asked whether parents were expected to report flu absences to the school or to the GP practice and it was understood that it was acceptable for a child who had been sick for 3 days to the GP.  It was observed that it was not a case of using up valuable appointment time to simply obtain a flu diagnosis, for the benefit of proving an authorised school absence.  Councillor Vaughan commented that parents were expected to evidence and report absences in some cases, implying again a grey area, given the option of self-certification.  Councillor Vaughan took the view that there should be greater clarity so that parents clearly understood what they were expected to do.

ACTION: Childrens’s Services

Patrick McVeigh referred to page 99 of the report and the 40-60% target for immunisation rates amongst 2, 3 and 4 year olds.  Lucy Rumbellow explained that there was evidence to show that the target was sufficient to reduce the spread of infectious diseases.  Each new roll out for younger children would add another year group each year.  Two, three and four year olds would be picked up by GP’s, and the cut-off point would be where the child’s 5th birthday fell after 31 August. 

Councillor Hannah Barlow referred to the top five and bottom five performing GP practices, what common factors identified them and what the mechanisms were for sharing learnings amongst the better performing practices.  Vanessa Andreae confirmed that the top five performers were also larger practices, located in affluent areas.  The bottom five were single partner practitioners, serving a less affluent demographic.  The lower performing practices were co-operating with the CCG to explore ways in which target rates can be achieved, without resorting to more formal methods to facilitate improvement.  Operating on the basis of centralised hubs, practices that did not have a dedicated nurse practitioner were able to book immunisation appointments accordingly.  Although lower performing practices would be accountable if rates showed no sign of improvement, Members acknowledged that parents too, had a responsibility to follow up appointments. 

Councillor Natalia Perez enquired about Meningococcal B vaccine for under two’s and the Meningitis ACWY vaccine for university students, particularly, the wider availability of the vaccine.  Dr Mike Robinson, Director of Public Health, explained that the Department of Health co-ordinated the introduction of new vaccines.   Meningococcal B was introduced as a new vaccine for babies born on or after 15 July 2015, and its restricted expansion included certain age groups.  Data spikes in young children and young adults indicated that a targeted approach was warranted but that it was not cost effective to vaccinate everyone. 

Vanessa Andreae explained that it was important to stress the wider community benefits of the vaccination programme as it contributed to the overall reduction of this strain of meningitis.  It was also explained that GP’s cannot charge for administering vaccinations available on the NHS, from their own practice without breaching their terms of service.  Most parents would not be able to cover the cost of paying for vaccinations and it was further explained that Department of Health guidance stated that single vaccines would not be available on the NHS, due to their lack of efficacy when administered individually.  It was accepted that parents would be anxious but in light of the current working being undertaken, the outlook was much improved compared to the previous year.  It was noted that parents who were thinking about private vaccinations or vaccinating abroad should ascertain the origin and quality of the vaccines being administered. 

Councillor Brown queried whether the data received was a reliable indicator of immunisation rates, highlighting the difference between practice figures and figures from NHS England.  Dr Robinson took the view that the figures were a true representation and it was noted that data could be slightly skewed, given that they precluded vaccines administered in private practice or abroad.  Councillor Vaughan queried some of the data which had declined significantly over a three year period (MMR – 24 months 80.8% to 73.4%).  Lucy Rumbellow speculated that there were local issues around GP System One TTP data in in different practices.  She outlined the complex process undertaken to extract and cleanse the data by the Child Health Informatics Service (CHIS), which was then submitted to NHS England for analysis.  Data for Quarter 1 2016/17 was yet to be published and it was noted that there was a recognised concern that London cover data is lower than the data that is reported.  It was also recognised that there were discrepancies between the system models, for which there was no available solution therefore they should be looking at both.

ACTION: H&F CCG / NHS England

Councillor Carlebach responded that it would be helpful to look at data from other boroughs, referring to the high number of private, paediatric GPs in RBKC and drawing comparisons with for example, Ealing.  Vanessa Andreae confirmed that there was a high number of private practices in RBKC so the data was not available, noting that in parts of Europe such as Italy, vaccination was mandatory. It was recognised that that there was no pan London schedule to monitor if these figures improved.  Outer and inner London figures were mixed together, with the outer London boroughs tending to record higher rates of immunisations.  They were optimistic but clear about the significant amount of work required to meet target rates.

Councillor Sue Fennimore, Cabinet Member for Social Inclusion acknowledged comments that the data around childhood vaccination indicated an increased impact on educational attainment and stated that she would welcome joint initiatives to ensure that communities will benefit.  H&F CCG welcomed the offer of support to help improve performance and suggested that information could be included in council literature to raise flu awareness, highlighting the need to expand this across all forms of council communication.  Vanessa Andreae suggested a change to school policy to include a request to provide dates and information about immunisations on registering for school or an admissions form.  This was not normally requested on local authority adminssion forms but there was a need for a robust front door policy when children commenced school.   Whilst it was acknowledged that some countries operated mandatory MMR immunisation, this was not likely to be endorsed as feasible in the UK.  It was important for parents to retain freedom of choice and a corresponding responsibility to ensure they were well informed. 

Councillor Vaughan referred to the four pilot sessions held in two local schools in 2015.  It was acknowledged that whilst the pilot was effective, there were financial and resource implications that needed to be considered.  Although the model of consent was harder to achieve in different age groups, the process administering vaccines in schools must be made more robust. 

Councillor Vaughan enquired if the specific learnings acquired from the pilots had been taken forward.  Vanessa Andreae stated that there was a sharing of best practice arising from the pilots.  The Pan London Steering Board was an excellent forum for discussion and helped to avoid ‘reinventing the wheel’.  She reported that LBHF was one of four boroughs that were well regarded and that there was a lot of interest in the collaborative work currently being undertaken.  Communication of the message about the importance of vaccinating was a challenge and it was explained that the schools programme had been given to a newly appointed provider.  This meant that there was no historic information to compare with year on year.  Vanessa Andrea suggested that headteachers could be included to help facilitate the programme.  There were year on year increases in rates of flu immunisation and this in turn, had resulted in a corresponding effect on younger siblings.  Children were vectors in terms of their capacity to transmit infections, particularly to young, vulnerable or elderly family members. 

Councillor Vaughan reiterated an earlier point, enquiring what might be a suggested approach, mandating schools to capture data at the point of admission, sharing the information with the Department of Health or Education.  Liz Bruce outlined the whole system approach taken in Children’s Service and expressed support for the concept.  She suggested that some pilot work be undertaken to explore the possibilities further.  Responding to the question of how LBHF could best support this work, Vanessa Andreae outlined how the collecting of information and communicating the message to parents that this information was important contained on a form or application was an excellent starting point. 

Acknowledging that whilst parents were aware of need for immunisations, it was noted that many parents forget or are unorganised about appointments, so strategic incentives or prompts at certain milestones, which ensure that the conversation with a parent about the message has taken place, could be effective.   During the discussion which followed, the logistics of implementing a mechanism for collecting immunisation data at a single point of admission highlighted issues around the design of the form, local authority schools (it was noted that private schools already request this information), transfer dates and how parents sourced the details.  It was agreed that this could be explored further by the Children’s and Education, Policy and Accountability Committee (CEPAC).

ACTION: HASCSIPAC

Continuing the discussion about what the Council could do to support this work, the Committee discussed the eligibility criteria for NHS flu immunisation.  It was noted that those who were fit, healthy or on low income are not eligible for free flu vaccinations.  The eligibility criterion was linked to long term chronic illness, being homeless or carers.  GP’s had discretion to offer the vaccine to anyone else that might benefit and the practice will absorb the cost.  Dr Mike Robinson commented that the policy was data based and the list of the eligibility criteria was regularly reviewed. 

Councillor Fennimore, whilst broadly supportive of the idea, expressed doubts about collecting the data at a single point of admission and how this would work in practice, given the requirement for a single, pan London admissions form, which operated between September and March. She speculated that it could be included in the information given to parents about the admissions process.  In theory, it was possible for parents to provide the information when, for example, they register their interest in a particular school.  This was an identifiable “nudge point” but Councillor Fennimore was keen to ensure that any further discussions include officers from Children’s Services, particularly to avoid adding further to existing bureaucracy. 

Bryan Naylor expressed broad support for the report findings, which he felt had been well presented.  He welcomed an approach which advocated the wider community benefit for older people, to encourage better take up of the vaccination by parents. 

Councillor Vaughan indicated that he was very encouraged by the collaborative work being undertaken and welcomed the fact that shared learning was a significant factor in the improved rates.   He reiterated that the Committee broadly supported the idea of exploring with schools, data collection at a single point of admission and anticipated that officers would take this forward, in addition to referring the suggestion to CEPAC.  A further report was planned for May 2016, with a possible update in either January or February. 

RESOLVED

1.      That a further report is considered in approximately May 2016, with an update to be scheduled for early 2017; and

2.      That the report be noted.