Last week I considered whether the impact of the vaccination programme might end up being too much for general practice, as a result of the financial and personal challenges that it has entailed.  One of the questions that this provoked was what would I have done differently given the chance to run the national programme?

Of course no one has the freedom to run the national programme.  Even our national primary care leads are constantly negotiating with (and directed by) their own political and NHS masters.  But even with that in mind the national approach could have been different.

The national approach has been characterised, I think it is fair to say, by control.  It started with the insistence that general practice sites were organised via “PCN groupings”.  Why was that?  Well in part it was because of the logistics of the Pfizer vaccine.  But this was never going to be the only vaccine, and the logistics were always likely to change, but there was never a commitment to work through individual practices.  PCN groupings were to be the delivery unit.

The fact is c1000 PCN groupings are easier to control than over 7000 practice units.  Supply can be controlled, delivery can be controlled, cohorts can be controlled.  While the vaccination service has technically been delivered via an enhanced service contract, in reality it has been managed as an NHS directly delivered service.  The daily requirements to provide information, the strict controls on what is and isn’t allowed, and the regular interventions from above into local sites are all testament to that.

This does feel like a taste of the future.  PCNs will increasingly be the ‘go to’ units of general practice, rather than individual practices themselves.  In part this is because it makes ‘integration’ between general practice and the rest of the NHS easier to achieve (e.g. the arrangements for mental health workers in next year’s ARRS scheme), but in part it is because it puts general practice more within the control of the NHS.

Could things have been done differently?  Or did the overriding requirement for speed and rapid mobilisation mean the approach built around national control taken was the only realistic one available?

I think things could have been done differently.  The approach could have devolved more control to local areas.  Local areas could have been given a clear set of outcomes to achieve within a set timescale and a set amount of funding, and could have been allowed to develop and implement tailored solutions for their local areas.   Each area could have created its own, joined up mix of PCN, practice, and mass vaccination sites (or indeed other types of site), that could have worked together to ensure whole population coverage.

We are in a situation where PCN sites, mass vaccination sites and pharmacy sites feel more like they are competing against each other than working together to achieve whole population coverage.  Separate national implementation teams has led to local confusion rather than a joined up approach. If local areas had been able to design their own mix of service offerings everyone could have understood their respective roles and worked together as a local team.

Local areas could also have tailored their approach according to their own local strengths and weaknesses, and challenges.  Rural areas could have taken different approaches to more densely populated urban areas.  Mass vaccination sites could have been targeted where PCN sites found it more difficult to mobilise.  Most importantly, sites within local areas could have actively supported each other, as different members of the same team.

I know it is easy to criticise, and am cognisant of just how successful the vaccination programme has ultimately been so far.  But we are on the verge of a shift in NHS policy towards integrated care systems.  The danger is that these systems, and PCNs within them, simply become different units through which central NHS exercises top down control.

For integrated care and these new ICS systems to really work they need to be locally owned and led, and freed up from top down imposition.  The concern the national vaccination programme highlights is that local freedom and true integrated working will remain secondary to top down national control.  The cost of that approach is things that do not make sense at a local level as well as an unsustainable level of pressure on individuals.