The challenge to improve childhood immunisation uptake the Nottingham experience

1. The challenge to improve childhood immunisation uptake � the Nottingham experience Caroline Jordan Senior Nurse Public Health

2. What I will cover in this talk��� A bit about Nottingham Our performance Analysis of the issues Our actions supported by the DH Vaccination and Immunisation National Support Team (VINST) post visit May 2010 Next steps

3. Nottingham City Most deprived PCT in the East Midlands Surrounded by Nottinghamshire County c. 306,000 people resident in the City registered � an additional 14,500 over and above the census estimate About 32,500 people live outside the City but are registered with a City practice Overall rising trend in the population projected rise to at least 301,400 by 2013 and 309,600 by 2018. 10-year gap in life expectancy across the city

4. Nottingham City

5. Nottingham City PCT is co-terminous with the Nottingham City Council � a unitary authority Nottingham ranks 13 out of the 354 local authority districts in England using the average Index of Multiple Deprivation score (IMD 2007) High level of deprivation affects an extensive parts of city - 56 of the 176 Super Output Areas are within the 10% most deprived in the country and 106 in the worst 20%. 60% of residents live in the 20% most deprived areas of the country

6. Ethnicity Ethnicity � most are White British 19% from Black and minority ethnic (BME) groups - increasing & projected to increase to at least 25% by 2016 BME groups have a younger age structure than the overall population - account for 37% of Nottingham school pupils Mixed groups (46%) and the Pakistani group (30%) have the highest proportion of their total population aged under 16. Compares with 16% of White British people 19% of all pupils a first language that is not English - a rise of over 35% from 2005

7. Migrant population 20,000 people from abroad new to Nottingham city 2006 - 2008 7000 with refugee status, 800 asylum seekers plus 500 failed - most from Africa and Middle East Many migrants also from EU countries including commonly Poland, China, India, Pakistan, Jamaica, Nigeria, Zimbabwe

8. Population groups Largest population groups (Mosaic) Educated, young, single people living in areas of transient populations � NB. 2 large universities People living in social housing with uncertain employment in deprived areas Low income families living in estate based social housing

9. NHS Nottingham City Key contributors to deliver immunisation programme:- Public health team 62 GP practices CitiHealth � provider arm Primary care commissioning team Children and families commissioning team Child Health Information team Information analysts

10. % uptake DTaP/IPV/HiB age 1 April 2003 � Sept 2010

11. % uptake DTaP/IPV booster age 5 April 2003 � Sept 2010

12. % uptake 1st and 2nd MMR vaccine age 2 & 5 April 2003 � Sept 2010

13. Initial thoughts� No major outbreaks of vaccine preventable diseases Suspected that data reporting was key�.. Are there any differences between adjacent practices? Still need to keep promoting it to patients and the public Nottingham has practice based call/recall system � does that make any difference?

14. Understanding clinical variation Direct effect i.e. on the patient � no protection of the child increasing their risk of catching the disease and relying on others to be immunised to avoid becoming infected Indirect i.e. on others - public health risk as 95% herd immunity is not achieved meaning an increase in the number of people catching the disease increasing the risk of outbreaks occurring

15. Looking at variation more closely NHS Comparators 4/5 practices with highest % of registered children aged under 5 years had the poorest performance Using Mosaic Public Sector analysis Proxy for chaotic families - households with dependent children and none in employment Proxy for transient population � residency of 1-2 years Showed no relationship between transient population or chaotic families and MMR uptake when comparing adjacent practices

16. The challenges Population issues Persistent late or non-attenders at appointments Vaccination is not seen as a priority for parents despite practices� repeated calls Parents� difficulty in understanding requirements of NHS immunisation schedule - may be different to home country Parents consider that children have already had all their immunisations in their home country High levels of immigrant population with language problems Need for interpreters Delays due to checking immunisation status from home country Population issues Persistent late or non-attenders for immunisation and vaccination appointments Vaccination is not seen as a priority for parents despite practices� repeated calls via letter, telephone and face to face. Parents� difficulty in understanding requirements of NHS immunisation schedule which may be different to their home country. Parents consider that children have already had all their immunisations in their home country. High levels of immigrant population with language problems - difficulty in accessing information leaflets in other languages; Need for interpreters to attend with patient at consultations or spend time with practice(s) telephoning patients etc. Delays due to checking immunisation status from home countryPopulation issues Persistent late or non-attenders for immunisation and vaccination appointments Vaccination is not seen as a priority for parents despite practices� repeated calls via letter, telephone and face to face. Parents� difficulty in understanding requirements of NHS immunisation schedule which may be different to their home country. Parents consider that children have already had all their immunisations in their home country. High levels of immigrant population with language problems - difficulty in accessing information leaflets in other languages; Need for interpreters to attend with patient at consultations or spend time with practice(s) telephoning patients etc. Delays due to checking immunisation status from home country

17. The challenges Services are not always accessible and flexible to meet the demands of service users and this affects uptake including GP Practices not having the capacity to allow their Practice Nurse to do domiciliary visits Practice Nurse not having the confidence to vaccinations in patient�s homes Some practices having rigid clinic arrangements Practices not understanding the different reporting requirements i.e. HPA COVER and DES payments

18. The challenges continued� Issues from practices Health visitor role � can they immunise Domiciliary visits � capacity issues Call/recall � practice based � variable robustness Information/reporting issues Health visitor related issues Health visitors not required to be hands on immunisers Allocation of health visitors on a geographic patch based allocation instead of practice attached - difficulty in contacting health visitors and breakdown in once close relationships. Domiciliary visits Need for domiciliary service provided from either the practice (capacity allowing) or through the provider arm Call/recall Call/recall of patients is done by practices � no central system Lack of robust practice call/recall system Late reminders to patients � either too late to vaccinate before reporting dates or after reporting dates Variable use of text or telephone prompts just prior to appointment. Information/reporting issues Practice not aware that family had gone abroad Immunisation not reported or reported late (reasons unknown). Practice information system difficulties delaying monthly submission of data to Child Health Information System (CHIS). Child immunised after the reporting period. Child registered with practice after the reporting period. Health visitor related issues Health visitors not required to be hands on immunisers Allocation of health visitors on a geographic patch based allocation instead of practice attached - difficulty in contacting health visitors and breakdown in once close relationships. Domiciliary visits Need for domiciliary service provided from either the practice (capacity allowing) or through the provider arm Call/recall Call/recall of patients is done by practices � no central system Lack of robust practice call/recall system Late reminders to patients � either too late to vaccinate before reporting dates or after reporting dates Variable use of text or telephone prompts just prior to appointment. Information/reporting issues Practice not aware that family had gone abroad Immunisation not reported or reported late (reasons unknown). Practice information system difficulties delaying monthly submission of data to Child Health Information System (CHIS). Child immunised after the reporting period. Child registered with practice after the reporting period.

19. Actions � on-going and new Try and understand the issues � population and practice Immunisation Strategy � thank you Salford Immunisation Action Plan � thank you London Implement DH VINST recommendations Strategic and working groups Feedback and visits to individual practices Top tips from well performing practices Discuss provider arm role following paediatric nurse immunisation pilot - 84% of children referred were immunised � explore potential for focus on children on High Support/Safeguarding files

20. Actions � on-going and new Having a workforce that is well trained and up to date and able to inform the public and deliver vaccines. Have robust contracts � primary care and provider arm Service providers to understand what is needed to deliver the contract Having robust performance management of commissioned contracts Inputting data correctly � not late, not entered and not lost Having accurate practice lists with no �ghost� patients on the list

21. Top tips from well performing practices Each practice has a:- Designated Lead(s) for immunisations � ideally a GP Champion supported by an operational lead A robust practice call and recall system including call up patients early, use letters and telephone calls, flag up need on childrens� and parents� records A flexible system for giving immunisations including booked appointments, opportunistic, domiciliary Have strong links with their named health visitor Pro-actively use the Interpreting Service or Language Line

22. Still more to do�. Maintain on-going actions Work with NHS Nottinghamshire County on joint initiatives including a local communications campaign and conference for practices Develop more systematic feedback to practices

24. Thank youAny questions? caroline.jordan@nottinghamcity.nhs.uk 0115 8839441