ࡱ> JLEFGHI \bjbj hhR,h h @0$???P,?it(++sssssssv%ys]"s++2s<###B++s#s##fipVp+@7rF4?&lDs!tHitjly yVpyVpd#ss#ityh q:  PRIMARY CARE DEVELOPMENT 4.1.2 ENHANCED SERVICE SPECIFICATION FOR INFLUENZA AND PNEUMOCOCCAL IMMUNISATION FOR SPECIFIC AGE AND AT RISK GROUPS SERVICE OUTLINE 1.1 The purpose of the Directed Enhanced Service (DES) is to cover the provision of influenza and pneumococcal immunisation for those aged 65 and over and other at-risk groups. This is to reduce the serious morbidity and mortality by immunising those most likely to have a serious or complicated illness should they develop influenza or pneumococcal infection. This can avert the need for the patient to be hospitalised. In addition poultry workers are to be offered seasonal immunisation to reduce the slight risk of a poultry worker catching Avian (bird) flu and human flu at the same time. 1.2 This DES is subject to Directions (currently Primary Medical Services (Directed Enhanced Services) (England) Directions 2007) which may be updated during the year. 1.3 The influenza target for immunising those aged 65 and over is 70 per cent. No uptake target has been set for immunising those in the non-age-related at-risk groups, as reliable statistics on the size of this group are not available. For all at-risk groups, General Practitioners (GPs) should maximise uptake in the interests of patients. 1.4 In all cases, the final decision as to who should be offered immunisation is a matter for the clinical judgement of the GP, although we would encourage GPs to focus on the at-risk groups. 1.5 This scheme gives incentives to GPs to provide a proactive and preventative approach by adopting robust call and reminder systems for the patients on their list in the at-risk groups to receive immunisation. 2 AT RISK GROUPS 2.1 Based on the Chief Medical Officer (CMO) recommendation (please refer to Annex 2 of the CMO letter if further guidance is required), the current at-risk groups are as defined by the Joint Committee on Vaccination and Immunisation (JCVI), priority for vaccination may be indicated by the CMO during the year: Influenza infection all those aged 65 or over at the end of that financial year patients aged over 6 months in the JCVI recommended clinical risk groups (see Appendix 1 for CMO definition) those living in long stay residential or nursing homes or other long stay health or social care facilities (does not include prisons, young offender institutions or university halls of residence), or carers (see Appendix 1 for CMO definition) poultry workers (see Appendix 1 for Department of Health definition) Pneumococcal infection aged 65 or over at the end of that financial year patients suffering from chronic respiratory disease (not asthma unless so severe as to require continuous/frequently repeated use of systemic steroids) chronic heart disease chronic renal disease immuno-suppression due to disease or treatment chronic liver disease diabetes mellitus (requiring insulin or oral hypoglycaemic drugs) individuals with cochlear implants (NB important that immunisation does not delay the implantation, vaccination should be complete at least 2 weeks prior to surgery) individuals with the potential for cerebrospinal fluid leaks Asplenia or dysfunction of the spleen (this also includes conditions such as homozygous sickle cell disease and coeliac disease that may lead to splenic dysfunction) 2.2 The CMO has given guidance on which pneumococcal vaccines should be given to children under five years at risk please refer to the CMO letter 31March2005. 3 ELIGIBILITY 3.1 Payment arrangements under the scheme will apply to all at-risk patients who are immunised by 31 March in the relevant financial year. These include all of those patients who are or will be aged 65 or over on 31 March in the relevant financial year for influenza. For payment purposes the immunisation programme will operate from 1 August to 31 March in the relevant financial year. 3.2 The non-age related at-risk groups are described in Section 2. It is for each provider to identify the patients concerned from their records and this will be consistent with the registers maintained as part of the quality and outcomes framework. 4 SERVICE REQUIREMENTS 4.1 The requirements under this specification are extracted from The Primary Medical Services (Directed Enhanced Services) (England) Directions 2007 and may be updated if new directions are issued. The Provider must develop and maintain a register (its Influenza and Pneumococcal Scheme Register, which may comprise electronically tagged entries in a wider computer database) of all the at-risk patients to whom the Provider is to offer immunisation against influenza or pneumococcal infection (refer to Appendix 1 for the CMO definition). The Provider will undertake to: adopt/continue a robust call and reminder system to offer immunisations against those infections to those at risk patients with the aim to maximise uptake in the interests of at risk patients make that offer during the period from 1st August to 31st March in that financial year; but concentrate the immunisation programme during the period from 1September to 31 January in that financial year notify the Primary Care Trust influenza coordinator of poultry workers known to the Provider by the end of September in that financial year, this is to enable the ordering of the vaccine for this part of the programme to record the information that it has in its Influenza and Pneumococcal Immunisation Register using any applicable national Read Codes have appropriate resuscitation equipment on site in case of anaphylactic reaction, including appropriate doses of adrenaline (an algorithm for anaphylaxis) and a telephone in case of an emergency. Immunisation should only be undertaken where there is another health professional on the premises in case of emergency meet any public health targets in respect of such immunisations HEALTH RECORD AND CONSENT 5.1 The Provider will take all reasonable steps to ensure that the lifelong medical records held by an at-risk patients GP are kept up-to-date with regard to his immunisation status, and in particular include: any refusal of an offer of vaccination where an offer of vaccination was accepted: details of the consent to the vaccination or immunisation (where a person has consented on an at-risk patients behalf, that persons relationship to the at risk patient must also be recorded) the batch number, expiry date and title of the vaccine the date of administration of the vaccine where two vaccines are administered in close succession, the route of administration and the injection site of each vaccine any contraindications to the vaccination or immunisation any adverse reactions to the vaccination or immunisation 5.2 Please see Section 9 regarding the significant event and incident reporting requirements. TRAINING Administration of vaccines may be undertaken by registered nurses using a Patient Group Direction (PGD) for the individual vaccine developed for this purpose. Registered nurses must be assessed as competent to use the PGD and have undertaken the training in Section 6.2. The Provider must ensure that any health care professional who is involved in administering a vaccine has: any necessary experience, skills and training with regard to the administration of the vaccine as outlined in the national minimum standards published by the Health Protection Agency (HPA) training with regard to the recognition and initial treatment of anaphylaxis, including immediate access to adrenaline training with regard to potential drug interactions (e.g. anti coagulant, anti epileptics and theophylline) evidence of the training should be kept for each practitioner 6.3 Assessment of competencies and compliance with this section will be via evidence kept by the provider with regards to training for each member of staff carrying out immunisations. 6.4 Where the Provider is considering employing healthcare assistants to carry out this work this must be discussed and agreed by the Primary Care Trust in the first instance. STORAGE All vaccines must be stored in accordance with the manufacturers instructions and with regard to Chapter 3 of the 2006 Department of Health guidance, Immunisation against Infectious Diseases (also called the Green Book) available at HYPERLINK "http://www.dh.gov.uk/greenbook"www.dh.gov.uk/greenbook. All refrigerators in which vaccines are stored must have a maximum/minimum thermometer. Readings from the refrigerator thermometer(s) should be taken on all working days and temperature recordings should be recorded and documented. The Provider should refer to vaccine manufacturers instructions if the refrigerator is not performing consistently. Disposal should be via an approved sharps container. 8 INFECTION CONTROL 8.1 Providers must have infection control policies that are compliant with national guidelines, which include: disposal of clinical waste needle stick incidents environmental cleanliness standard precautions, including hand washing AUDIT/MONITORING The Provider must supply to the Primary Care Trust any information it may reasonably request for the purposes of monitoring the Providers performance of its obligations (this includes the quarterly enhanced services returns plus monthly data inputted onto the Health Protection Agency website between October and January). The Provider will monitor the uptake of flu vaccination by poultry workers separately to the standard call/recall for at risk patients, this data will be provided to the Primary Care Trust when requested. 9.3 National Read Codes are available and examples in use are shown below. These will be standardised as part of the UK approach to having agreed Read Code definitions. If providers store information on computers, they should ensure that all staff enter the same Read Code to indicate influenza or pneumococcal immunisation has been given or offered. The current codes are: 9021 letter invite to screening 65E..% influenza vaccine given 68NE no consent to influenza vaccination 68NI. medical contraindication to immunisation 14LJ influenza vaccine allergy 9OX5 influenza vaccination declined 9N4q did not attend flu vaccination appointment OC57 food and drink processors/poultry dresser O6D7 manager poultry farm OB3D stockman/ poultryman 6572 pneumococcal vaccination 68NX no consent pneumococcal immunisation 14LR pneumococcal vaccine allergy 9.4 Parents/guardians should be encouraged to record immunisations within the Personal Child Health Record to prevent an immunisation being given twice. 9.5 Where patients fail to attend for vaccination it is recommended that they are followed up to ensure that their needs are reviewed to ensure the call/recall system is working effectively. 9.6 Providers should review uptake rates annually to identify any possible reasons for change or ways in which the Provider may look to raise existing achievement. This will be reviewed by the Primary Care Trust alongside the evidence of training. 9.7 Providers may be asked to audit the monitoring of fridge temperature. 10 SIGNIFICANT/ADVERSE EVENTS 10.1 The Department of Health emphasizes the importance of collected incidents nationally to ensure that lessons are learned across the NHS. A proactive approach to the prevention of recurrence is fundamental to making improvements in patient safety. 10.2 The Provider should be aware of the various reporting systems such as: the National Patient Safety Agency National Reporting and Learning System the Medicines and Healthcare products Regulatory Agency reporting systems for adverse reactions to medication (yellow card system), and accidents involving medical devices the legal obligation to report certain incidents to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 10.3 In addition to any regulatory requirements the Primary Care Trust wishes the Provider to use a Significant Event Audit system (agreed with the Primary Care Trust) to facilitate the dissemination of learning, minimising risk and improving patient care and safety. 10.4 In addition to their statutory obligations, the Provider will give notification, within 72 hours of the information becoming known to him/her, of all emergency admissions or deaths of any patient treated by the Provider under this enhanced service, where such admission or death is or may be due to the Providers treatment of the relevant underlying medical condition covered by this specification. Notifications are to be sent to the Director of Nursing and Patient Safety with a copy to the Senior Primary Care Commissioning Manager for the specific locality. 11 PRICING 11.1 Payment will be at the rate of 7.56 per immunisation, until such time as a stock order system is in operation across the UK. The same rate will apply for under 65s at-risk as for the over 65s. 11.2 The Provider is entitled to the item of service fee described above in Section 9.1 plus a Personal Administration fee under the Statement of Financial Entitlements. 11.3 The Provider is not eligible for the Personal Administration fee if the patient receives a prescription but the vaccine is not supplied and administered. Flu vaccination cannot be provided as a private treatment to any of the Providers registered patients. Providers can refer patients to another provider for a private vaccination, but no financial adjustments between Providers should be made. Where a patient is not in the high risk group, the decision to immunise is based on the GPs clinical judgement. There would be no item of service fee on this basis, but if the Provider supplies and administers the vaccine the Personal Administration fee would apply. 11.4 It is expected that, as is normal procedure, influenza immunisation will be concentrated in the period 1 September to 31 January of the relevant financial year. However, immunisation given at any time between 1 August and 31 March of the relevant financial year will qualify under this scheme. 11.5 Pneumococcal immunisation may be given at any time during the financial year, however if the provider is planning to immunise a large amount of patients towards the end of the financial year this should be notified to the Primary Care Trust to enable budgetary planning. 11.6 In addition to the influenza and pneumococcal vaccinations the Primary Care Trust will fund (at the same rate per immunisation) Hepatitis B for those at risk (i.e. short term foster carers, people who may be at risk via drug use/partners drug use, NOT for travel). 11.7 Responsibility for immunisation for occupational staff rests with employers and should be provided by occupational health services. Health and social care staff should not routinely be referred to their GP for their immunisation unless they fall within one of the recommended clinical risk groups, or a local agreement is in place for this service. 12 PAYMENTS 12.1 Payments will be made on a monthly basis via the Exeter system using a budget based on the previous years out turn position. 12.2 Reconciliations will be completed after the end of the financial year by the Primary Care Trust. 13 PATIENT AND PUBLIC INVOLVEMENT 13.1 The service will conform to professional and legal requirements especially clinical guidelines and standards of good practice issued by the National Institute for Clinical Excellence (NICE) and professional regulatory bodies, and legislation prohibiting discrimination. It is anticipated that for the majority of enhanced services translated information will be available via the Department of Health. If a patient wishes to communicate via a language that is not covered via these leaflets please let the Primary Care Trust Equality and Diversity Lead know and use the commissioned interpretation and translation service (Applied Language Solutions) to facilitate the consultation and provision of information to the patient. Use of the interpretation/translation service should be recorded in the patients lifelong medical record including confirmation of the first language of the patient. 13.2 Practices should encourage, consider and report any patient feedback (positive and negative) on the service that they provide and use it to improve the care provided to patients, particularly if there are plans to alter the way a service is delivered or accessed. 14 REFERENCES 14.1 GREAT BRITAIN. 2008. CMO Letter 31 March: The Influenza Immunisation Programme 2008/09. DH gateway reference 9570 The Primary Care Trust Flu co-ordinator will contact the list of poultry premises and approved poultry slaughterhouses and local Animal Health Divisional offices of the State Veterinary Services (SVS) within the Primary Care Trusts responsibility to inform them that eligible employees who want to be immunised can go to their GP practice to get immunised. 14.3 GREAT BRITAIN. 2005. CMO Letter 31st March. The Pneumococcal Immunisation Programme for Older People and Risk Groups. Also see Immunisation against infectious disease ("The Green Book") page 301, Table 25.1. Gateway 4330. 14.4 For example from the National Resuscitation Council 14.5 Refer to the Mental Capacity Act if necessary to ensure consent is appropriately obtained Local PGD available from Primary Care Trust intranet site. 14.7 HEALTH PROTECTION AGENCY. June 2005. Standard number: Standard year National Minimum Standards for Immunisation Training. Place of publication and name of publisher (separated by a colon). 14.8 The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections, The Stationary Office, updated 2008. Email contact point for influenza vaccine uptake enquiries is HYPERLINK "mailto:influenza@hpa.org.uk"influenza@hpa.org.uk APPENDIX 1 CHIEF MEDICAL OFFICER definitions 1 CLINICAL AT RISK GROUPS FOR INFLUENZA IMMUNISATION Clinical risk category Examples (decision based on clinical judgement) Chronic respiratory disease and asthma that requires continuous or repeated use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission  chronic obstructive pulmonary disease (COPD) including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD) children who have previously been admitted to hospital for lower respiratory tract disease Chronic heart disease  congenital heart disease hypertension with cardiac complications chronic heart failure individuals requiring regular medication and/or follow-up for ischaemic heart diseaseChronic renal disease  chronic renal failure nephrotic syndrome renal transplantationChronic liver disease  cirrhosis biliary artesia chronic hepatitis Chronic neurological disease  stroke transient ischaemic attack (TIA) Diabetes  Type 1 diabetes Type 2 diabetes requiring insulin or oral hypoglycaemic drugs diet controlled diabetes Immunosuppression  immunosupression due to disease or treatment patients undergoing chemotherapy leading to immunosuppression asplenia or splenic dysfunction HIV infection individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mgs or more per day (any age) or for children under 20 Kgs a dose of 1mg or more per kg per day. some immunocompromised patients may have a suboptimal immunological Individual consideration by GPs with regard to the risk of influenza infection exacerbating any underlying disease that the patient may have, as well as the risk of serious illness from influenza itself. individuals with Multiple Sclerosis and related conditions or hereditary and degenerative diseases of the central nervous system Carers 1.1 Those who are in receipt of a carers allowance, or those who are the main carer for an elderly or disabled person whose welfare may be at risk if the carer falls ill. This should be given on an individual basis at the GPs discretion in the context of other clinical risk groups and priority of health need. (Gateway reference 9570, The Influenza Immunisation Programme for 2008/09). Poultry Workers 1.2 The CMO has adopted the HPA definition of a poultry worker: Workers employed at or regularly visiting registered poultry units who: routinely access enclosed poultry rearing or egg production areas perform initial sorting of poultry eggs if the sorting area is an integral part of the production unit catch or cull poultry within enclosed poultry rearing or egg production areas perform the final clean down of poultry sheds following depopulation of a poultry house collect or remove poultry manure or litter from within enclosed poultry rearing or egg production areas of poultry premises catch or handle live birds kill or eviscerate birds cleanse or disinfect areas and equipment contaminated by poultry faeces  See reference 14.1.  See reference 14.2.  See reference 14.3.  See reference 14.4.  See reference 14.5.  See reference 14.6.  See reference 14.7.  See reference 14.8.  See reference 14.9.  Orange book with regard to these services is available at  HYPERLINK "http://www.somersetpct.nhs.uk/how%20we%20do%20things" www.somersetpct.nhs.uk/how we do things PINs for accessing this service have been given to each provider.      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