A GP posted this message on twitter last weekend:

“Prediction for GP in England. It will deliver on the vaccination demands. Delivered for most partners at a loss because of the awful NHSE and GPC ES. Once the pandemic is over many GP partners, PCN CDs and practice managers will resign, broken.” (you can find it here)

It is an interesting prediction.  I would say general practice is currently divided into two groups.  There are those sites that have a vaccination model that is working well, has a team that is functioning effectively and are not only delivering the vaccine but also deriving huge satisfaction from doing so.

Sadly this group do not seem to be in the majority.  The second (larger) group are those who are both struggling to make the vaccination model work financially, and personally finding the whole process physically and emotionally exhausting.

The financial challenge noted in the tweet comes for a number of reasons.  The Pfizer vaccine is much more expensive to deliver (because of the need to dilute the vaccine, to put a 15 minute observation period in place for those receiving the vaccine, and to staff clinics at incredibly short notice).  There is no additional payment that takes this into account.

The housebound patients simply cannot be vaccinated within the £12.58 available.  Even if the team delivering the vaccinations can be funded (not possible if a GP carries them out), there is no way of funding all of the additional work required such as carrying out the training, gaining consent, validating the Pinnacle records etc etc.

Then there are all of the unseen costs.  Finding staff to book patients at short notice, even on the day of clinic and while the clinic is still running.  Bringing staff in on a Sunday because of an insistence that all of this week’s vaccines are used this week.  Managing the complaints because of the national control-freakery that is being applied to any messaging.  Communicating with practices and GPs who are not crazy enough to engage with WhatsApp groups that spew hundreds of messages a day, but are the only way of finding out what is going on.

Et cetera, et cetera.

If it does come to pass that, once all of the housebound and elderly are vaccinated and the Oxford AZ vaccine is much more widely available, primary care sites are stepped down for other sites, it will genuinely be one of the most galling financial kicks in the teeth general practice has ever experienced.

However, the personal loss for many of those leading the vaccinations is far greater than any of the financial challenges.  It is hard to overstate how all-consuming leading the vaccination process has become for many.  It is 7 days a week with no respite.  There is the weekly wait to find out what vaccines will be arriving, with painful recent scars reminding these leaders not to book anything until national confirmation is received.  Then there is the mad scramble to staff rotas and find patients for the clinics.  Then there is dealing with the inevitable change or late delivery, and having to absorb all of the local patient and staff unhappiness this creates.

For many vaccination leaders their life is on hold.  On top of the clinic challenges, there come new challenges every week – changes to the second vaccine regime, delivering to care homes, to the housebound, changes to Pinnacle, the emergence of a local mass vaccination centre (etc) – all topped with constant pressure from above to do more, faster, better.

The staff they are leading struggle with the pace, but the leaders have to push forward.  The local practices who are not involved push them from the sides.  It is the leaders who bear the brunt of the blame for national rules that don’t make any sense but can’t be broken, like which cohort can be done when, and why vaccine can’t just be given to local practices to administer themselves.

These leaders are PCN CDs, GP partners, PCN managers, practice managers.  They are our local leaders of general practice.  And if not already then certainly at some point soon they will need a break.  Many will simply not want to return.  They won’t stop until the job is done, but I understand a message that says once we get there enough will be enough.  And what then?  Who will pick up the pieces?  What state will general practice be in?  Will it all have been too much?

We are at a difficult stage of the vaccination programme.  Some sites started in December, and have been able to largely complete the vaccination of cohorts 1 and 2 (care home residents, those aged over 80, and frontline health and social care workers).  Others have only just received approval for their local site to begin vaccinating, and are only now able to make a start on these priority cohorts.

The challenge is whether the sites that have completed the initial cohorts should carry on with the next cohort (the over 75s), or whether they should be stopped while other areas catch up?  By the time you read this the next cohorts are likely to have been announced, but at present strict national rules mean any area that has completed cohorts 1 and 2 is experiencing heavy pressure not to make a start on cohort 3.

The Joint Committee on Vaccination and Immunisation (JCVI) is clear that the priority for the vaccination programme is the reduction of Covid-19 mortality and morbidity, and the protection of health and social care staff and systems.  The age based strategy in place has been selected as the best option for preventing morbidity and mortality in the early phase of the programme, because “Current evidence strongly indicates that the single greatest risk of mortality from COVID-19 is increasing age and that the risk increases exponentially with age” (p4).

The strategy is clear.  So if the constraint in the system is the supply of vaccine it makes perfect sense that the supply should now be prioritised to those areas that are catching up and still have over-80s to vaccinate.  It is up to the national team who decide who is receiving supplies to ensure it goes to those sites.

The complexity comes when the constraint is not supply but delivery capacity/capability.  If a site has completed cohorts 1 and 2 and receives a supply what is it to do?  The national mandate is that this site must now help other sites to deliver cohorts 1 and 2.  This is sensible, but there are two problems with this.  One is geography – how practical is it for the over 80s to travel to an area that is further away to receive the vaccine; and the other is logistical – the Pfizer vaccines have to be used within a very short number of days, and so delays in booking patients leads to a much higher risk that the vaccines will be wasted.

Many sites have been scrambling around for patients to ensure that vaccine isn’t wasted at the end of a session.  There are reports that some sites have not been able to use all their vaccine because they have not been able to find people from the right cohort in time.

To an outsider this seems strange – surely no one would let any vaccine be wasted?  But there is heavy system pressure applied to sites about not vaccinating outside of the allowed cohort, even after Pfizer vaccine has arrived on site and the clock has started ticking.  Threats are made that sites supplies will be cut off if they go outside the cohort.  So some vaccine has been wasted.

There needs to be a balance between striving to achieve the strategy of delivering the vaccines in priority order and a pragmatism of applying this goal so that we make the most of the vaccines we have.  The JCVI itself advised that,

“Implementation should also involve flexibility in vaccine deployment at a local level with due attention to… vaccine product storage, transport and administration constraints… JCVI appreciates that operational considerations, such as minimising wastage, may require a flexible approach, where decisions are taken in consultation with national or local public health experts.” (p11)

It does not feel like we have got that flexibility in the system right yet.  As ever, the top down nature of the NHS is resulting in local inflexibility when flexibility is required.

If supply is not the constraint and some areas can go faster, and cannot for geographical and logistical reasons help other areas, surely it makes sense to let them vaccinate their local population as quickly as possible (in cohort order)?  Holding back supplies so that we all move at the pace of the slowest does not feel like an appropriate response to the crisis we are all currently in.

This is only the first time we are moving from one cohort to another; there are many more such movements ahead.  General practice has stepped up and is doing an amazing job of mobilising and responding to the call.  The numbers already vaccinated is  a testament to this response.  Let’s not let system bureaucracy impede the incredible effort that is underway.

Last week, on the 7^th January, the national primary care team wrote a letter to practices entitled, “Freeing up practices to support COVID vaccination”.  There is no question GP practices are struggling right now, so how helpful was this letter, and does it go far enough?

The letter follows a previous letter written at the start of the second lockdown in November, which headlined with an announcement of £150M of additional primary care funding.  The core message of this letter was that, unlike the first wave of Covid, GP practices are very much expected to stay “fully open” this time round.  The additional funding was to enable “expanded capacity”, and to be able to deliver (on top of day to day work), extra work including:

• Supporting the establishment of a Covid oximetry at home model
• Identifying and supporting patients with long Covid
• Supporting clinically extremely vulnerable patients and maintaining the shielding list
• Making inroads into the backlog of appointments including for chronic disease management and routine vaccinations and immunisations

As a result the £150M has been primarily deployed to support additional work in general practice, rather than to provide any extra support for the work currently being carried out.

Two months later we are at a point where the pressure of the pandemic has significantly increased.  Practices are having to juggle staff sickness and isolation alongside skyrocketing demand.  At the same time the pressure is on from all sides for practices to carry out an extremely challenging Covid vaccination programme, as well as well as completing the biggest ever flu vaccination programme.  This is before getting started on the list of extra work from the November letter.

And so it was into this context that last week’s letter landed.  There is no question that the financial protections it contains were very much needed.  The minor surgery DES, the QOF QI domains and the 8 prescribing indicators in QOF are all now income protected until the end of March.  I think just seeing something that recognised the need for additional support prompted an initially positive reaction from many.

Non-essential locally commissioned services are suspended, although there is no guarantee of income protection.  Instead “budgeted payment against these services should be protected to allow capacity to be redeployed”, which undoubtedly will mean some CCGs interpret this as local income protection while others make additional requirements of practices against it.

PCN CD funding is (rightly) increased from 0.25 WTE to 1 WTE in recognition of the complexities of the Covid vaccination response.  This can “be flexibly deployed by PCNs” – it will be interesting to see how this works where one PCN is leading on behalf of a number of PCNs.

The other main announcement was that extended access funding won’t be shifting to PCNs before April 2022.  You would think that “repurposing extended hours and access capacity to support the vaccination programme” would actually be easier once the funding moves across to PCNs, but given everything currently happening I can see that many PCNs would struggle to put effective new arrangements for extended access in place any time soon.

My sense is that when you dig into the detail of the letter it does not acknowledge the reality of the additional pressure currently on practices as a result of both managing Covid patients and the demands of the vaccination programme.  If the national aim is really to free up practices to support Covid vaccinations, I would suggest what is also needed is:

• The £150M announced in November is distributed to practices to enable them to manage the current demand rather than to create additional work for practices
• There is a national mandate that the income from locally commissioned services is protected for practices by CCGs
• PCNs are allowed to flexibly deploy the ARRS underspend to staff vaccination centres. The requirement for six month minimum contracts limited to the staff roles identified in the ARRS list feels like such a wasted opportunity.
• National financial commitments are made to practices that go beyond March. The vaccination programme will take at least six months (and longer), so surely arrangements need to be put in place now that reflect that.

The ask of primary care is really significant at present, and practices up and down the country are going above and beyond to meet these challenges.  But practices remain independent businesses faced with unprecedented operational and financial upheaval, and my sense is more active support for practices needs to be provided to go alongside the demands being made of them.  Without it the current situation may not be sustainable.