HC Deb 27 October 1999 vol 336 cc972-9 12.30 pm
Liz Blackman (Erewash)

I am grateful for the opportunity to raise the subject of flu vaccine, with particular reference to southern Derbyshire, especially in flu awareness week.

We have just returned from our summer recess, but October is nearly over and we must start to consider the risk to a certain percentage of the population who may well contact flu and other associated diseases during the coming months.

On an average winter day, family doctors will write more than 100,000 more prescriptions than they do in summer. In December alone, the national health service expects 15 per cent. more emergency hospital admissions than in August and local peaks can be much higher, especially when people stay at home longer and have increased close contact with family and friends over the winter holiday period. This year, the situation could well be compounded by the millennium celebrations.

The Government are to be congratulated on their winter pressures approach and the substantial extra resources they provided last winter. My local health authority received £40,000 to enable primary care groups to use nursing home beds and thus reduce in-patient admissions and care for people in the most appropriate setting. That was most welcome.

The winter pressures initiative has developed considerably since its inception. In southern Derbyshire, which includes my constituency, managers have been incredibly proactive in addressing the issue. The winter pressures plan, requested by the Department of Health, is a collaboration between social services acute trusts, local general practitioners and primary care groups to plan for increased demand over the winter period. Southern Derbyshire, along with every other health authority, has identified the need to be better prepared in light of the millennium. It has linked the millennium planning process with the public sector relations group, bringing together many agencies to combat the projected problems.

Southern Derbyshire health authority, along with the Department of Health, has identified that targeting flu vaccination is a vital strategy in alleviating winter pressures. The virus has the potential of presenting as lethargy, a cold, a sore throat or wheezing, requiring a visit to the GP or chemist. The results can vary from minor disruption at home or work to serious, life-threatening epidemics which can have disastrous effects on the NHS, which attempts to treat sufferers and prevent the disruption of other services. Even in a non-epidemic year, the sector of the population whose resistance is poor can suffer numerous deaths as a direct result of flu and related complications. Rightly, that sector has been divided into high-risk groups: people with heart disease, lung disease, asthma, diabetes and immunosuppression; those in long-stay residential care; and those aged 75 and over, who the Government identified as a risk category in 1998.

Why do we regard the vaccine as effective in reducing flu in those groups? It is designed using the strains of virus closely related to those expected to be circulating in any particular year. The World Health Organisation co-ordinates global surveillance, which means that in most years there is a good match. The vaccines are 70 to 80 per cent. effective—they are not as effective as some, but they are pretty good.

It is also worth considering the cost of not vaccinating effectively. When I asked a parliamentary question last July, I learned that no figures relating to the cost of the flu epidemic last winter were available centrally. We must try to calculate the expenditure on treatment of this acute disease. We must consider the cost of suffering and lives when complications set in or flu exacerbates an underlying condition, and also the loss of wages and lifetime earnings due to morbidity and mortality.

So what is the cost of targeting groups at risk? Of course, there is the cost of the vaccine. According to the latest figures, it will cost between £5.07 and £5.70 per dose. There are also costs associated with administering the vaccine, treating any adverse effects and implementing the immunisation programme and health promotion. On Monday, at the press conference launching flu awareness week, an initiative sponsored by the Association for Influenza Monitoring, the Public Health Laboratory Service and the Royal College of General Practitioners, the chief medical officer and the Minister agreed that immunisation of high-risk groups is their best defence against flu. So we are all saying that prevention is better than cure.

So is this effective measure a success? Apparently, the take-up is not as good as it could be. In southern Derbyshire, estimated target population figures for those in high-risk groups requiring the influenza vaccine have been set at 140,000, yet last winter just over half that number—73,000—were given or claimed the vaccine. However, it is impossible to say what percentage were in the high-risk group. According to Dr. Van Tam, a senior lecturer in public health medicine at Nottingham medical school, who is regarded as something of an expert, the figure could be as low as 12 per cent. or as high as 25 per cent. That is not particular to my area. An article by the Public Health Laboratory Service in 1997, which gave information on the uptake of the influenza vaccine in high-risk groups, noted that the overall uptake was estimated to be low—about 23 per cent.—and was particularly poor in younger members of the group. About 44 per cent. of those aged over 65 and 13 per cent. of those aged between 34 and 49 were estimated to have received the vaccine.

Since 1998, when those aged 75 and over were identified as a high-risk group, new figures should show a substantial increase in the uptake of the vaccine. However, many are still falling through the safety net of adequate preventive provision by way of a simple flu vaccine. The statistics are estimates as the data count the number of vaccinations given or claimed for. There is no routinely collected or available data showing which people in which risk group have been vaccinated.

Individual practices should keep details of who has been given the vaccine and when, but they are not required to report this information. Does the Minister agree that a more coherent and co-ordinated way of collecting, recording, analysing and reporting data would ensure a better understanding of the national picture. Could such a body as the Public Health Laboratory Service be resourced to monitor coverage and uptake of vaccines in risk groups?

Undoubtedly, however, the uptake of the flu vaccination by the target group could be improved. The Department of Health does not currently set targets for increasing the percentage of people in risk groups receiving influenza vaccinations because of the difficulty of accurately assessing denominators for the risk groups. Will the Minister look again at the issue of target setting and consider whether it is possible to set targets, especially in the 75-plus age group and for those in long-term care?

At the heart of flu awareness week is the crucial role that GPs and other health professionals are expected to play. That is the expectation of the chief medical officer, the Government and local health authorities and the overall message of the flu awareness campaign. They rightly focus on the key role of GPs because patient surveys show that the single most important factor affecting whether an individual is immunised or not is whether the doctor or nurse recommended it. However, practice in my constituency varies, as I am sure it does across the country.

Some GPs target the high-risk groups in a rigorous way, as they would if they were calling in women for smears. Others rely on posters or leaflets, or both. Some practices have the information technology and resources to identify the risk groups, but others appear not to have them. The ability of IT to identify and target risk groups is variable. Sometimes the data may be on the system, but not in a way that they can be used. There are also training needs to be considered.

Does my hon. Friend the Minister see any improvements that could be made to ensure a more consistent approach? There is no national target payment, although I understand that payments are made to GPs in some regions for giving out the flu vaccine. Would she consider incentivising GPs to vaccinate at-risk groups?

I noted that one London practice had a very good take-up rate because of a more co-ordinated approach by all the health professionals: doctors, nurses, health visitors and pharmacists. Is my hon. Friend aware of GP practices or health authorities that have a better success rate and would she consider disseminating their best practice?

Is there an opportunity, as the focus widens in health action zones, to incorporate some of those related issue into their remit? Health promotion is a vital part of increasing uptake, and there needs to be an on-going process. There is a timing factor involved in when the flu vaccine is administered, but the overall message about prevention and year-on-year uptake needs to be continually reinforced, as is done in child immunisation programmes.

I applaud the Government's tremendous efforts to be proactive with their winter pressures policy and their endorsement of flu awareness week. The local public health co-ordinator for southern Derbyshire has been publicly very positive about the campaign and the progress being made with the Government's support. I accept that much of the framework for monitoring, targeting and co-ordinating the flu vaccine is historic: we have inherited it.

Given the known effectiveness of the vaccine in the target groups, will my hon. Friend consider the issues that I have raised and whether there is any scope for reconsidering the rationale behind the 75-year-plus group? Will she consider the many countries that target people over 65 on the basis that that broader group contains the majority of at-risk people? Risk groups overlap, especially in the higher age range. Perhaps she could consider the percentage of deaths attributed to influenza in that category.

The World Bank has described targeted immunisation as one of the most cost-effective public health interventions. Is there scope for further improvement in our approach in the United Kingdom? I look forward to hearing my hon. Friend's views and thoughts.

12.42 pm
The Parliamentary Under-Secretary of State for Health (Yvette Cooper)

I thank my hon. Friend the Member for Erewash (Liz Blackman) for her excellent timing in raising the topic of flu immunisation during flu awareness week and for her interesting speech and informed points. She is certainly right to say that there is scope for improvement.

This is the time of year, ahead of the winter, when those patients for whom flu can be a serious illness should be getting their jabs from GPs. For most people—those who are otherwise fit and healthy—flu is unpleasant but not serious. The doctor's advice is usually to stay home, stay warm, drink plenty of fluids and look after oneself. For others, however, it can be very serious. As many as 3,000 to 4,000 people, mainly elderly, are estimated to die from flu each year, even in years when flu has been relatively mild.

In the last severe epidemic, in 1989–90, as many as 26,000 deaths over and above those expected were recorded during the epidemic period. Flu is not a subject that we take lightly and it is important that we do everything that we can to prevent flu among those likely to suffer most.

The Joint Committee on Vaccinations and Immunisation identifies the risk groups as people with underlying diseases such as chronic respiratory disease, chronic heart or kidney disease or diabetes; and people whose immune systems are impaired by disease or through treatments such as cancer therapy or steroids. They have a higher risk that a bout of flu will lead to serious illness such as bronchitis or pneumonia.

Although the elderly are more at risk, people of any age with those conditions are at increased risk and that risk increases further when an individual has more than one of the underlying problems. The Department of Health recommends, on the basis of the committee's recommendations, that people in those circumstances should get a flu jab before the winter begins. The Department also recommends that people in long-stay residential accommodation should also be vaccinated, because flu, once introduced there, can spread very rapidly. From last year, everyone aged 75 or more has also been recommended to be immunised.

My hon. Friend asks whether we will consider extending that to everyone over 65. Further investigation and analysis are taking place. The Joint Committee on Vaccinations and Immunisation is examining the question and will make recommendations according to the evidence of what impact there will be on different groups.

As my hon. Friend says, we have increased the number of vaccinations in the past few years. Last year, more than 7 million doses were given, compared with only 6 million doses three years ago. This year, we have more vaccine than ever available—more than 8.5 million doses; but she is absolutely right, we could do better. The most recent national data point to low uptake rates, especially among younger people in the risk groups. Ultimately, it is up to patients to decide for themselves whether they want to be vaccinated but we must ensure that they are fully aware of the options and the risks when they make that decision.

My hon. Friend is also right to say that the data that we have are not adequate to tell us exactly what is going on and what we should be doing about it. I want to explain in some detail the data that we have at the moment and the direction in which I believe we should be moving. For a start, we know from the manufacturers how much vaccine will be available in advance of the flu immunisation programme. Manufacturers also give the Department of Health a weekly update at this time of year on the number of doses distributed and what is still available should there be additional need.

We have some idea of the use of vaccines by GPs. Like the analysis given by my hon. Friend today, we can use prescription data to show the number of vaccine doses that GPs are delivering, but she is absolutely right to say that they do not tell us whether an individual GP is targeting the vaccine to those most in need—those identified as belonging to high-risk groups.

Before last year, reliable national estimates of flu vaccine uptake in our targeted groups were not available. Last year, that gap was partly plugged. The Public Health Laboratory Service calculated the national uptake rates using the general practice research database: records from a representative sample of general practitioners throughout the country. That analysis has allowed us, for the first time, to make an assessment of the recent performance of the NHS in delivering flu vaccine policy, as it enables us to track the health condition of those who are vaccinated.

Only by using such analysis can accurate figures be produced for uptake of flu vaccine in the recommended groups. The latest figures from the database show that in the winter of 1996–97, 23 per cent. of the high-risk population were vaccinated and 44 per cent. of those over 75 with high-risk conditions. That was before the aim to include all people over 75 was introduced.

The figures also show that half the total vaccinations given went to people not considered to be at high risk. We plan to use that system from now on to monitor uptake regularly and as a basis for reviewing the implementation of the programme in future and determining what further improvements can be made. That is a major step forward, but we still lack any information on how individual GPs, rather than a sample of GPs throughout the country, are managing to reach their target groups.

The flu immunisation programme is delivered largely by general practitioners and practice nurses. GPs should identify their targeted population through whatever methods are available to them: most can do it through their computer systems; others have chronic disease registers or can identify patients through repeat prescriptions for particular medicines. GPs then need to order their vaccine early in the year so that supply can be assured.

Vaccine is delivered to practices in September to October, when patients need to be contacted to attend an immunisation session or other arrangements are made.

My hon. Friend is right to say that we have very limited information on how far individual GPs are achieving that and how wide the variations are across practices in different parts of the country.

Given the Department's commitment to reducing health inequalities and to making sure that people's treatment from the NHS is not dependent on where they live, we consider this matter to be important. However, we are putting in place changes which should make the process easier in future. We are developing standards for electronic patient records and we plan to have comprehensive coverage by the year 2002. This, together with new systems, should enable us to tie together the information available and to examine individual practice level data. It should give us considerable scope to identify best practice across the country, and give us the opportunity to spread that further in future.

The second important strand in my hon. Friend's argument concerns how we spread best practice. First, the Government are promoting immunisation policy at a national level. Tips on how to run a successful programme are published in the Department of Health's memorandum "Immunisation against infectious disease"—the GPs immunisation bible. In that advice—entitled "Increasing the uptake of influenza vaccine"—the memorandum points out clearly that

the single most important factor in patients accepting influenza vaccine is that their doctor recommended it". Doctors and nurses are encouraged to maintain registers of their patients who should be immunised. On top of this, the chief medical officer writes to GPs each year, reminding them further of the need to target the risk groups.

The Department of Health works closely with the Association for Influenza Monitoring and Surveillance in the build-up to flu awareness week. The purpose of the week is to get the message to the public that if they think that they may be in a risk group, they should see their doctor and arrange to be immunised. Flu awareness week is a highly successful campaign. It is launched through a press conference—chaired by the chief medical officer—to which my hon. Friend referred. Hon. Members may have heard the chief medical officer on "Today", ITN and other media on Friday promoting the message that flu vaccine can save the lives of those at risk.

Flu awareness week is supported by Help the Aged, the British Diabetic Association, the British Lung Foundation, the National Asthma Campaign, the Royal College of General Practitioners and the Royal College of Nursing. Both Help the Aged and the British Lung Foundation have produced flu leaflets to help promote the uptake of immunisation in the risk groups.

Separately, the Department of Health and the NHS have this year run extra activities to raise public awareness of flu vaccine. In September this year—for the first time—as part of the winter planning round, health authorities were provided with a briefing pack, including a press release suitable for local use to support local activity around flu awareness week. The Department of Health has produced leaflets and posters which are available free.

Health authorities should be able to see whether an individual GP is prescribing broadly too little or too much vaccine, given the number of patients he has on his list.

GPs should be able to identify best practice locally. Using these data, health authorities should support those GPs who are not giving sufficient priority to the immunisation needs of their patients. They should encourage them up to the levels of the better GPs.

All practices should be able to identify risk groups and should be able to identify their own level of performance. Health authorities should be promoting good practice across their GPs. Prescribing advisers are employed by health authorities to help promote good prescribing practice, including flu immunisation.

The introduction of primary care groups should increase the peer pressure to follow better prescribing practices, and make the best use of resources to support the health needs of their populations. Clinical governance offers a framework within which primary care groups can work to improve and assure the quality of clinical services for all patients. In addition, we are currently looking at broader accountability and service issues within the GP contract, as is the General Medical Council. The GMC is looking to revalidate GPs and all doctors on the basis of the quality of service that they provide. Together, these new structures should provide a series of routes by which we should be able to increase the uptake of flu vaccine in recommended groups. However, we will continually monitor and examine this matter as progress is made.

Finally, my hon. Friend asked if we would consider introducing targets. I can tell her that I will certainly look closely at the points she makes. It is true that the Department does not at present set national targets for the uptake of flu vaccine. We have aimed at year-on-year increases. This has reflected the historical lack of good estimates of vaccine uptake. As I have mentioned, it is difficult to introduce targets when we do not have adequate information about who exactly is receiving the vaccine in the first place. However, we do now have estimates of flu vaccine uptake on a national level, and the equivalent data at a local level should be a matter for local planning.

Due to the difficulty in accurately estimating flu vaccine uptake, those health authorities which have looked at setting local targets on flu vaccination have focused on the percentage of over-75s being immunised. That is easier to quantify. Nevertheless, age on its own is not the most important risk factor. We must ensure that we do not divert attention from the need to maximise the uptake among everyone with these underlying risk conditions, whatever age they happen to be.

I can assure my hon. Friend that we will now be looking carefully at how targets could be used in the future to ensure that we achieve higher uptake without distorting the priority groups. We will review the latest data in the light of additional information from the general practice research database, and we will look at the direction in which the figures are moving in the future.

I would like to thank my hon. Friend once more for raising this timely and important subject, and I commend her on providing the information on what southern Derbyshire is doing to improve flu vaccination and preventive measures. Obviously, the more we can do to prevent the serious nature of the disease, the better it would be, rather than to place additional burdens on the NHS. Delivering flu vaccine in such wide numbers is something that the NHS must plan around—it cannot be delivered easily and quickly. Individual GP practices and health authorities should make adequate plans to make sure that they reach the target groups.

This is a vital public health measure. I will be looking to see what improvements we can make before next year's winter flu awareness week.

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