SERVICE SPECIFICATION Service Childhood Immunisation Service Commissioner Lead Sarah Darcy Provider GP Confederation Mary Clarke Provider Lead Period 1 April 2018 to 31 2019 Date of Review December 2018 1 Population Needs City and Hackney Clinical Commissioning Group (CCG) commissions health services for the population of two inner London boroughs; City of London and Hackney. It is an ethnically diverse population with only 55% identifying as White (of which over one-third are not White British) and almost 40% of the population are born outside of the UK. The London borough of Hackney is the third most densely populated London borough with the Office for National Statistics (ONS) estimating 263,000 people including 20,400 children under five years of age (mid-2014). Greater London Authority (GLA) Population Projections forecast this to rise to 282,000 people with 20,900 children under five by 2020. The City of London has a relatively small resident population of 8,100 found in densely populated pockets, with only 370 children under five years of age (mid-2014 ONS estimate). GLA Population Projections forecast this to rise to 9,300 people with 600 children under five by 2020. The childhood immunisation programme for children includes a series of vaccinations given at 8, 12 and 16 weeks and at 1 year and 3 years 4 months of age. See table below 8 weeks 12 weeks 16 weeks 1 year 3yrs 4 months 5in1* 5in1* 2 nd 5in1* 3 rd dose dose Pneumococcal (PCV) Rotavirus Pneumococcal (PCV) 2 nd dose Pneumococcal (PCV) 3 rd dose Rotavirus 2 nd dose Men B Men B 2 nd dose Men B 3 rd dose Hib/Men C** Measles, Mumps & Rubella (MMR) Measles, Mumps & Rubella (MMR) 2 nd dose 4-in-1 pre-school booster *5-in-1 vaccine a single jab to protect against: diphtheria, tetanus, w hooping cough (pertussis), polio, Haemophilus influenzae type b (Hib) and Hepatitis B **Hib/ Men C vaccine - a single jab to protect against meningitis C (first dose) and Hib (fourth dose) The above schedule requires infants to have 7 injections by 1 year and 4 injections between 1 and 2 years of age. With the exception of rotavirus all the vaccines are by injection. 1
The aim of the national childhood immunisation programme is to protect children who receive the vaccine and reduce the risk of infection to others. Currently the uptake of childhood immunisations in City & Hackney is well below the level (95%) required for herd immunity. The uptake reported by official COVER data for 2015/16 was: 83% of 5in1 uptake at 12 months. There have been a number of service changes that have impacted on the decrease in immunisation uptake. In 2015 the commissioning of Health Visiting was transferred to Local Authorities / Public Health. In many areas a new model of HV has been introduced and immunising children is no longer within the remit of HV. Health visitors provided between 20-40% of childhood Immunisations across C&H until April 2016. The exact volume is difficult to quantify as reported data does not capture details of the immuniser, rather the location e.g. GP practice. Prior to April 2016 the call and recall (i.e. invitation and reminders) element of Childhood Immunisation was provided by the Child Health Information Service (CHIS) which sat within the Children s services at HUHT. The CHIS sent an individualised letter to all new parents prior to the start of the immunisat ion programme with the dates when their child is due. Reminders were also sent prior to immunisations due at 12 and 40 months of age. The Immunisation call recall function provided by CHIS officially ended in 2016 and NHSE centralised all CHIS functions from April 2017. The aim of this contract is to increase primary care capacity and enable wider access to childhood immunisation. It will provide additional nursing resource to operate flexible clinics tailored to the needs of the population. Through improved co-ordination and data monitoring, resources will be mobilised and targeted to areas of particular need to ensure optimum uptake of immunisations. It is recognised that year one of the contract (2017/18) delivered low levels of immunisations, but the establishment of clinical protocols, review of call and recall across practices, engagement work with practices, and the establishment of hub delivery across north and south Hackney by 2018 is expected to enable a significant escalation of activity from April 2018. 2 Outcomes Vaccination is one of the most cost-effective health interventions available, saving millions of people from illness, disability and death each year. The primary aim of immunisation is to protect the population from vaccine preventable diseases and reduce the associated morbidity and mortality. NHS Outcomes Framework domains & Indicators Of the NHS Outcomes Framework the following will be supported through this contract. 1 Preventing people from dying prematurely 2 Enhancing quality of life for people with Long term conditions 3 Helping people recover from episodes of ill health or following injury 4 Ensuring people have a positive experience of care 5 Treating and caring for people in safe environment and protecting them from avoidable harm 2
The national immunisation programme is interdependent on Public Health strategy and this contract will support improvements in the following Public Health outcome domains: health protection preventing premature mortality (by addressing preventable ill health). Improving the uptake of Childhood Immunisations has been identified as a CCG priority in our sustainability and transformation plans. It is also a priority shared with partner agencies (i.e. local authority, public health and provider organisations), is reflected in the priorities of the integrated Children, Young People and Maternity Services workstream, ( strengthening of the early years offer ) and is articulated in our 5-year locality plans. We are committed to achieving the World Health Organisation (WHO) target of 95% herd immunity for childhood Immunisation uptake by April 2019. 3 Scope of Service The GPC will ensure that practices provide a robust co-ordinated system to manage the invite and recall of children registered with a GP in City & Hackney for immunisations. They will ensure there is improved access by delivering additional ( mop-up ) clinics across the borough, providing greater choice and flexibility for families falling behind with Immunisation. To evaluate and monitor performance the GPC will work with the CEG who will provide technical support (e.g. data reporting, production of monthly performance dashboards, call / recall lists). This will be carried out by the GPC by working with practices to; ensure timely delivery with optimal coverage of the target population ensure the service is safe, effective and of a high quality ensure the service is delivered by trained, competent and qualified staff who participate in recognised on-going training and development delivers, manages and stores vaccines in accordance with national guidance ensure staff are familiar and have access to the latest edition of the green book and encourage staff to register to receive vaccine updates https://www.gov.uk/government/organisations/public-healthengland/series/immunisation-against-infectious-disease-the-green-book 3.1 Service model The immunisation service is available to all children registered with a City and Hackney GP and is delivered by local GP practices supported and monitored by the GPC who will ensure practices have the following; A robust system is in place to call children for their immunisation appointments, and recall system for children who do not attend. Improve access for hard to reach families by providing parents with drop in sessions and/or arranging additional (mop up) clinics across the borough to provide greater choice and flexibility Record details of the immunisation on EMIS templates, ensuring that data is uploaded within 2 working days of the vaccine being administered at practices or mop-up clinics. Invite newly registered children aged 0 to 5, for immunisation check (within one month of registering). Record immunisation details in the children s red book 3
Specifically target the following groups of children at risk of not being fully immunised: Those who have missed previous vaccinations Looked after children Children with physical or learning disabilities Those not currently registered with a GP, including those who are homeless, through facilitating practice registration and offer within two weeks of a practice based / mop up clinic appointment Younger children from large families Children who are hospitalised or who have chronic illness Children from some minority ethnic groups, exploring the barriers to timely vaccination in the Charedi community and work to overcome these barriers to increase the proportion of children who are up-to-date with the schedule. Children from non-english speaking families Vulnerable children, such as those whose families are travellers or asylum seekers 3.2 Care Pathways GP registered children will be offered services under the contract and this will be coded by the GP practice. The service is supported by searches created by CEG and EMIS templates to prompt and record activity. Practices will notify families and invite children for an immunisation appointment. Practices will offer families a range of options for accessing immunisation clinics and recall children who have not attended and or are behind with their immunisation schedule. Children who have missed vaccinations are not only at risk of particular infections, but may be at greater risk of having other health and social wellbeing needs, including neglect. Practices will liaise with other health professionals e.g. Health Visitors to follow up and track families who fail to bring children to be immunised. 3.3 Structural Support The GPC is commissioned to ensure that all practices engage with the aspiration to improve childhood immunisation outcomes by improving access and increasing the vaccine uptake to 95% by April 2019. The GPC will support practices to deliver the service and oversee quality and governance. Where the volume of immunisations are lower than expected the GPC will be asked to produce a report, calling on the assistance of the CEG if needed, outlining what action has been taken to improve the situation. The GPC will embed the work undertaken on call and recall in year 1 and will provide assurance of the systems in place at each practice by the end of Quarter 2. 4 Applicable Service Standards - NHS National Immunisation programme - Public Health Strategy - World Heath Organisation - City & Hackney 5 Year Joint Locality Plan 4
5 Key Performance Indicators City & Hackney CCG and the Children, Young People and Maternity Services workstream, are aiming to achieve the World Health Organisation (WHO) target of 95% herd immunity for childhood Immunisation uptake by April 2019. Uptake of 6in1 immunisation in City and Hackney at 12 months is currently 75%. Achieving herd immunity will require a 20% increase in uptake and will require approximately 900 more children to be immunised over the remaining twelve months of the two year period-year period. For the term of this contract - April 2018 to 31 2019 the GP Confederation is commissioned to ensure that practices immunise an additional 900 children to achieve a 20% increase in year two. This position reflects the underperformance against plan in year one, when service delivery did not start until the end of Quarter 2, and was initiated only in NE Hackney where there is greatest need for the service. The delivery plan for year 2 is challenging but is underpinned by roll out by end of Q4 17/18 of service delivery across an additional three sites in City and Hackney, in addition to initiation of a domiciliary service. Achievement targets for the contract term are set out in the tables below. The baseline is derived fr om data provided by CEG. Quadrant Uptake of 5in1 @ 12 months Baseline Sept 2016 (%) Target by 30 Sept Target by 31 2018 (%) Baseline Dec Target 31 2019 (%) NE 60 65 70 55 TBC NW 84 89 94 84 TBC SE 74 79 84 87 TBC SW+C 83 88 93 89 TBC All 75 80 85 75% TBC Quadrant Uptake of 5in1 @ 24 months Baseline Sept 2016 (%) Target by 30 Sept Target by 31 2018 (%) Baseline Dec Target 31 2019 (%) NE 74 79 84 70 TBC NW 77 82 87 87 TBC SE 77 82 87 89 TBC SW+C 79 84 89 88 TBC All 77 82 87 82% TBC Uptake of MMR @ 24 months 5
Quadrant Baseline Sept 2016 (%) 6 Reporting Requirements Target by 30 Sept Target by 31 2018 (%) Baseline Dec Target 31 2019 (%) NE 66 71 76 63 TBC NW 76 81 86 80 TBC SE 72 77 82 80 TBC SW+C 75 80 85 83 TBC All 72 77 82 75 TBC The contract and performance will be monitored via contract monitoring meetings and quarterly reports provided to the CCG. The reports will demonstrate increased staffing resources, clinic availability and increased immunisation uptake by quadrant. Uptake data will be available from information captured on clinical templates and monthly performance dashboards developed by CEG. Reporting/Performance Requirements Frequency Indicator/Milestone Number and %of eligible children immunised by practice and by quadrant Quarterly 80% in Q1 85% in Q2 90% in Q3 95% in Q4 Weekly clinic capacity and activity by site Monthly Weekly domiciliary capacity and activity against practice Monthly hard to reach lists Summary of engagement work with under -performing Monthly practices Open book reporting of nursing and administrative Monthly N/A recruitment. The transfer of imms data onto the EMIS record within 2 working days 5% sample size audited by GPC x2 p.a Q2 and Q4 95% 7 Financial and Procurement Summary The total budget available is 167,000 for the contract term 1 April 2018 to 31 2019 (this is an all-inclusive price which includes Confederation overhead costs). Practices are supported to enhance their GMS contract income through this service, and do not receive direct practice payment. Outcomes based payments are therefore not aligned to this service. The funding is provided on a non- recurrent basis for this second year of a two-year improvement initiative. Any future funding will be subject to recommendation of the children, young people and maternity services workstream and subsequent governance approval. The funding is intended to provide additional nursing resource in primary care, a senior nurse adviser and part time administrative support. Payment will be made on a monthly basis from April 2018 and the GPC will provide open book reporting. Payment will be withheld for any period where the posts are not filled, immunisation clinics are not operating or the post holders leave and the posts remain vacant. 6
Indicative budget value ( ) 100,000 Activity expectation Expected outcome Aligned payment Minimum 1,200 immunisations Herd immunity Open book reporting Nurse workforce 22,000 Clinical management and general management / administration Clinical / managerial and administrative support Evidence of engagement and targeted work with all practices Evidence of targeted engagement where underperformance is identified Open book reporting Assurance of call and recall (reported at end of Q2) 23,233 Other costs 21,785 Confederation overheads Facilities / consumables / travel Based on GPC intention to deliver across a minimum of 5 sites and domiciliary service Improved access (both across sites in the north and the south, and at times appropriate to the age group and local populations) Open book reporting - - Open book reporting 8 Proposed Contractual Terms Type of contract proposed: NHS Standard contract Service Commencement date: 1 April 2018 Initial term of service is: One year Is there an option to extend the initial term? If so, on what basis?: 7
This is dependent on the outcome of service delivery and subject to a recommendation from the children, young people and maternity services workstream. Details of proposed sub-contractors: GP practices in City and Hackney Contractual interdependence with other existing services/providers: 1) GMS service delivery 2) CCG contract with the Clinical Effectiveness Group (CEG) Centre for Primary Care and Public Health; via this contract the CEG will: - Run baseline immunisation audits - Further develop (as necessary) and produce monthly dashboards that include both the COVER reporting requirements and the monthly uptake reports. Dashboards will show activity at practice and quadrant level, total GPC activity, and achievement and progress against the agreed baseline - (Monthly dashboards will be run on the 1 st of every month) - Templates and protocols for practices - Searches for practices above and beyond anything GPC apply to support identification and targeting of cohorts - Support with reconciliation of Childhood Imms data - Health intelligence profiling e.g. looking at factors affecting uptake 8