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A closer look at the impact of this autumn's flu and Covid vaccine programme

Last-minute changes to the Covid and flu vaccination schedules were so exasperating, they led to Community Pharmacy England describing the situation as shambolic. So what happened and why?

On August 30 the DHSC announced that the autumn Covid-19 and flu vaccine programmes in England would start on September 11, rather than the originally planned date of October 2, as a “precautionary measure” following the identification of the Pirola Covid variant, BA.2.86. 

The DHSC said the change followed a risk assessment by scientists from the UK Health Security Agency (UKHSA), which examined the BA.2.86 variant – first detected in the UK on August 18 – and found it to have a high number of mutations and to have appeared in several countries in individuals without travel history.

The latest UKHSA Covid surveillance report showed that Covid-19 activity had increased across most indicators. The World Health Organization (WHO) is currently tracking several SARS-CoV-2 variants, including three variants of interest (XBB.1.5, XBB.1.16 and EG.5) and seven variants under monitoring (BA.2.75, CH.1.1, XBB, XBB.1.9.1, XBB.1.9.2, XBB.2.3 and the aforementioned BA.2.86). 

The Pirola variant has attracted particular interest as it has 36 more mutations than the XBB.1.5 variant recommended for vaccination.

While BA.2.86 was not, at the time of going to press with this issue, classified as a variant of concern, the UKHSA advised that speeding up the autumn vaccine programme would “deliver greater protection, supporting those at greatest risk of severe illness and reducing the potential impact on the NHS”.

“There is limited information available at present on BA.2.86, so the potential impact of this particular variant is difficult to estimate,” said UKHSA chief executive, Dame Jenny Harries. “As with all emergent and circulating Covid-19 variants – both in the UK and internationally – we will continue to monitor BA.2.86 and to advise government and the public as we learn more.”

The Pirola variant has been described as “the most concerning” since Omicron first emerged. 

According to the DHSC, the decision to move the date forward means those most at risk from winter illness – including people in care homes for older people, the clinically vulnerable, those aged 65 years and over, health and social care staff, and carers – will be able to access a Covid vaccine earlier than originally planned.

The news was greeted with dismay by sector leaders. “This has been a shambolic start to the winter vaccination programme,” said Alastair Buxton, director of NHS services at Community Pharmacy England. “It simply isn’t efficient for pharmacies or other providers to work to a seemingly endlessly changing timetable.”

Tase Oputu, chair of RPS England, agreed. “The short notice changes to the start date for the winter vaccination programme have created confusion for pharmacy teams trying to make plans, and for the public. The Government must plan ahead more decisively next year to avoid such uncertainty.”

Flu vaccinations

The annual flu vaccine will be made available at the same time as the Covid vaccine wherever possible, to ensure the relevant groups are protected with both vaccinations ahead of winter. Adult care home residents and those most at risk will receive the vaccines first.

Vaccination start date saga...

NHS England initially announced a change to the flu service specification, which meant the start date for the pharmacy vaccination scheme was set for some point in October, rather than September 1 as in previous years. 

NHSE subsequently contacted pharmacies and GPs to say that flu vaccinations (and Covid jabs) could commence for
care home residents and staff from October 2, and for all other eligible patient cohorts from October 7. 

Then, on August 30, following guidance from the UKHSA, the Government asked NHS England to bring forward the start of the Covid autumn/winter booster programme to September 11, leaving community pharmacies to deal with the confusion and subsequent difficulties in preparation and obtaining stock. 

Eligible flu groups

The number of flu vaccinations administered by community pharmacists under the NHS Advanced service grew by 3.2 per cent in 2022/23 compared to the previous year – according to NHSBSA data – with 5,007,578 administrations being claimed by the end of March 2023. 

However, even with the new September 11 start date, this year’s flu vaccination season may well struggle to meet, let alone beat, this figure since people aged between 50 and 64 years old are not eligible for a free NHS jab this 2023/24 season. 

Eligible groups are:

  • Those aged two and three years on August 31
  • Eligible school-aged children (reception to year 11)
  • Those aged six months to under 65 years in clinical risk groups
  • Pregnant women
  • All those aged 65 years and over
  • Those in long-stay residential care homes
  • Carers, those in receipt of a carer’s allowance or main carer of an older or disabled person
  • Household contacts of immunocompromised
  • Frontline health and social care staff.

Other specifications

NHSE has said that pharmacy owners must use a NHS-assured point-of-care IT system (e.g. Sonar Informatics and PharmOutcomes) to make their clinical records for the service and to submit payment claims to the NHSBSA’s Manage Your Service platform (automatically via an application programming interface). 

As last year, the PGD will be able to be used by an appropriately trained practitioner to provide the Advanced service, which will allow pharmacy owners to use other healthcare professions listed in the PGD to provide the service under the supervision of a pharmacist. 

A national protocol is also available, which can be used by pharmacy owners as an alternative to the PGD, where they are able to make use of the skill mix flexibilities allowed by the protocol to administer the vaccine (e.g. by pharmacy technicians. Clinical supervision of the service must still be provided by a pharmacist.

Something else that hasn’t changed for the 2023/24 season is the service fee, which remains at £9.58 plus the cost of the vaccine (and an allowance for VAT on the cost of the medicine).

Does Australia lead the way?

Many look to Australia’s flu season as a possible indicator of what the UK can expect in its winter — but as the UKHSA points out, Australia is one of many countries from which flu may arrive in the UK, so it is “not possible to reliably predict” the implications for the following northern hemisphere season. As a result, Australia’s influenza activity “has no bearing on the local persistence of influenza in the UK in our inter-seasonal period”, the agency says.

Covid vaccinations

In August, NHSE opened an expression of interest (EOI) process for pharmacy owners wishing to take part in this autumn’s Covid-19 vaccination service. This was seen as a positive move as it meant more pharmacies would be able to choose to participate than had previously been the case.

Pharmacy owners who do wish to participate in the service at their pharmacy must show they meet the minimum requirements, which include:

  • Providing the Flu Vaccination Advanced Service until March 31, 2024
  • Being able to offer at least 100 Covid-19 vaccinations per week
  • Being ‘in good standing’ from a regulatory perspective with the NHS and other organisations such as the General Pharmaceutical Council.

Pharmacy owners will not be required to administer all vaccinations from the pharmacy, but must also vaccinate eligible housebound/care home patients if requested by NHSE and may also provide outreach services if agreed with NHSE.

Owners were also invited to express an interest in providing the service from a location away from their pharmacy, although NHSE said it would “usually only approve requests to operate services in the vicinity of the pharmacy where there is a population need”; for example within the same integrated care system. 

Eligible patients

In early August, the Government accepted the final Joint Committee for Vaccination and Immunisation (JCVI) advice for the Covid-19 autumn 2023 seasonal campaign. This narrowed the groups to be offered a Covid-19 booster vaccine to:

  • Residents in a care home for older adults
  • All adults aged 65 years and over
  • Persons aged six months to 64 years in a clinical risk group, as laid out in the Immunisation Green Book, Covid-19 Chapter (Green Book)
  • Frontline health and social care workers
  • Persons aged 12 to 64 years who are household contacts (as defined in the Green Book) of people with immunosuppression
  • Persons aged 16 to 64 years who are carers (as defined in the Green Book) and staff working in care homes for older adults.

The JCVI also advised that people in the above cohorts who have not had any previous doses should be offered a single dose of Covid-19 vaccine during the campaign period.

It is anticipated that updated versions of the Moderna, Novavax and Pfizer boosters are in the pipeline, in order to offer better protection than existing vaccines against the new Covid variants.

Acute respiratory infections

New NICE draft guidance on the initial assessment and management of suspected acute respiratory infections (ARIs) says that more people could be treated out of hospital in the NHS’s new respiratory hubs and virtual wards.

The draft guideline covers diagnosing and managing suspected ARIs, including pneumonia, respiratory viruses and flu in adults. It does not cover people with Covid-19. 

Covid fee adjustments

Despite widening the potential number of pharmacies that could join the Covid vaccination programme, NHSE had initially decided to reduce the fee paid for jabs by 25 per cent, to £7.54 – to widespread condemnation. However, following the announcement of the revised start date, NHSE said it was putting in place “interim financial arrangements” to support acceleration of the vaccination programme, “recognising the additional administrative, organisational and delivery costs which pharmacy owners will incur”.

Pharmacies commissioned to provide Covid vaccinations will now be eligible to claim:

  • An additional acceleration payment of £10 (in addition to the item of service (IoS) fee) for each Covid vaccination administered to care home residents between September 11 and October 22
  • A separate one-off additional payment of £200 for each completed care home by midnight on Sunday October 22 that is confirmed to the commissioner by the submission of a live time survey no later than midnight on Sunday October 29.

To support the acceleration of Covid-19 vaccinations to other eligible cohorts:

  • An additional £5 acceleration payment (in addition to the IoS fee) will be paid for each Covid vaccination administered to eligible people between September 11 and October 31 (excluding care home residents, housebound people, and any health and care worker vaccinations commissioned under the NHS Standard Contract). “The acceleration payments for early vaccinations will make it more financially viable for some pharmacy owners to take part,” said CPE’s Alastair Buxton. The negotiator had repeatedly warned NHS England that the previous fees were too low, he added.

Private jabs

Thirteen million people who had a Covid jab last year no longer qualify following the Government’s decision to exclude the majority of 50-64-year-olds from the clinical risk group this autumn.

Although the UKHSA has confirmed that it will not restrict the private sale of Covid vaccinations – private jabs are not expected to be available until next year – media speculation has suggested that a possible cost of around £100 per jab puts them way out of reach for many people. 

This is in contrast to the relatively affordable cost of a private flu jab in the UK. These range from between £10-£20, although Superdrug was quick to announce what it called “the UK’s cheapest private flu vaccination service” priced at £8.79 for its health and beauty card members, or £16.99 for non-members.

Dr Avinash Hari Narayanan, clinical lead at London Medical Laboratory, says the Government should consider subsidies for people who want a Covid jab but are unable to afford it.
He describes the decision to not vaccinate the majority of 50-64-year-olds this autumn as “questionable”. 

“Our European neighbours such as Germany, Italy and Holland are at least giving boosters to everyone aged 60 and over. If the UK had opted to follow suit, that would have ensured almost 4 million more people would be eligible for a top-up,” he said.

“Perhaps uniquely, the Covid vaccine is not [just] about individual protection as much as it is about group protection. It succeeds by increasing the level of immunity across the community.”

Don't forget add-on sales

“Customers are more likely to test for illnesses since Covid-19 and also wear masks to protect others, so keeping tests and masks in stock will help to maximise sales,” says Karen Baker, pharmacist for Care at Thornton & Ross. “There are now also flu testing kits available, which may be popular this winter. Other linked sales items to keep near the tills include hand sanitiser and tissues.”

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