Haringey

CCG Governing Body

Immunisation and Screening Update

Report

May 2015

1

Aim of the report

• This report is an update for the Haringey CCG Governing Body on the

section 7a Immunisation and Screening Programmes currently

commissioned by NHS England.

• Section 7a is the NHS Public Health Functions agreement of the NHS Act

2006 and amended in Health and Social Care Act in 2012 that outlines

responsibilities for NHS England to commission specific public health

services aimed at improving populations’ health.

• It describes recent performance of the programmes at the regional and

local level.

• It includes local challenges, NHS England plans to address those

challenges and support that the local Public Health team is taking to boost

local performance.

2

Immunisation borough summary

• Overall, there has been some good improvements in achieving increased

immunisation coverage. However, there are still great variations across the

borough within specific areas and across different vaccination schedules;

• Hepatitis B vaccination data indicates that there are robust procedures in place

with a high completion rate of the 12 and 24 month cohorts;

• Trends for childhood immunisation coverage over the last three years suggest

overall improvement. However, fluctuations in performance between the quarters

still exists and is mostly due to data collection and data returns;

• Flu vaccinations this year in Haringey are comparable to the London average.

Thirty eight pharmacies in Haringey have been commissioned to offer free flu

vaccinations and PPV to eligible patients;

• Whittington Child Health Information System (CHIS) department has been

reviewed by NHS England and an action plan has been drawn up for

improvements.

3

Childhood and pregnancy immunisation

Child flu regional pilots

• London continues to be a national pilot site for the roll out of children’s flu vaccination in

primary school aged children in Havering and for the 2014/15 flu season the offer was

extended to Year 7 in secondary schools to maintain continuity.

• This winter NHS England also offered all special schools across London the opportunity to

take part to improve the uptake of flu in this cohort and to test the logistics for the flu

programme delivery moving forward into 2015/16.

• 2, 3 and 4 year olds

• GP practices are offering all 2, 3 and 4 year olds flu vaccines (using Fluenz nasal spray)

this year. Last year, where flu vaccines were offered to 2 and 3 year olds, uptake across

London was 33% and 30% respectively. Local data is not available yet.

Flu vaccinations in pregnancy

• Preliminary data for the London average coverage rate for flu vaccination in pregnancy was

38%, compared to Haringey’s 37.6%. This was an increase on the 25% coverage rate in

2013/14.

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Childhood immunisation

Hepatitis B vaccinations

• NHSE has identified that the flow of information from some maternity units to CHIS is not

always accurate. NHSE is working with PHE and Maternity Units to establish what recording

and data flow systems exist with a view to issuing a simple directive to ensure data flows

happen. CCGs contract the maternity unit via the Maternity Pathway Payment (MPP).

NHSE performance manage and oversee service developments of immunisation and ANNB

(Antenatal Newborn) Screening Programmes.

BCG

• Haringey currently delivers universal BCG at birth at North Middlesex Hospital and

Whittington Health deliver vaccinations in the community. Due to national data collection

suspension (KC50), there are currently no figures for BCG delivery.

5

HepB_da

ta_type12

m

Sum of

HBpos_12m

_

denominato

r

Sum of

12m_H

epB_%

HepB_

data_ty

pe24m

Sum of

HBpos_24m

_

denominator

Sum of

24m_H

epB_%

FULL

DATA 24 95.8

FULL

DATA 18 100.0

• Q1 2014/15 data shows that 23/24 babies

born to Hep B positive women completed

vaccination course by 12 months. 18/18

babies completed vaccination by 24 months.

Haringey 3 year childhood immunisation trend

Quarterly COVER data 2011/12 - 2014/15

7

Q3 14/15 versus Q3 13/14 childhood immunisation performance

National COVER data is still presented by PCT, and the borough reporting remains experimental.

School age vaccinations

HPV

• Achieving the 90% coverage target for HPV vaccinations remains a challenge

across London. 2013/14 data shows that HPV vaccination performance in

Haringey was lower than the England and London averages.

• From September 2014, only two doses of HPV are required to complete the

schedule, which should help to improve coverage rates. 2014/15 data is not

yet available.

School Leavers booster

• School leavers booster is delivered in schools by the school nurses. Due to

the suspension of the national data collection (KC50), there are currently no

figures for school leavers booster delivery.

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Area

Coverage by dose 2013/14 academic year cohort 11 (year 8)

Dose 1 Dose 2 Dose 3

England 91 90 87

London 85 84 80

Haringey 81 79 76

Adult vaccinations

Seasonal flu

• Provisional data for week 52 shows that 65.4% of over 65s have been

vaccinated in Haringey, compared to 66.7% vaccinated across London; and

45.6% in clinical risk groups received vaccination in Haringey, compared to

47% across London. This is an improvement in performance compared to

2013/14.

• Flu vaccination uptake for all staff in direct contact with patients at the

Whittington Hospital was 82.7%, 46.5% at the North Middlesex Hospital

and 29.5% at the BEH MHT.

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Challenges and next steps

• Some data quality issues with the Cover of Vaccination Evaluated Rapidly (COVER) reporting system

managed by Public Health England are reported across London. NHS England has secured COVER

reporting and the CHIS provider is submitting on time and passes through the internal NHSE quality

assurance process.

• Haringey CHIS (the Whittington) has been reviewed by NHS England and an action plan for the

Whittington CHIS has been drawn up to ensure the delivery of the agreed Service Specification.

• Flu vaccinations were lower at the beginning of the season and NHS England has worked with Haringey

CCG to increase uptake, particularly with the pregnant women cohort and offering access to flu

vaccination within pharmacies.

• Staff flu vaccination was lower at the NMH and BEH MHT. The CCG should request from the Trusts

action plans to improve the uptake for the next season.

• Training needs have been identified and fed into a national scoping exercise. Availability of training for

immunisers has been identified as a national barrier and workshops are taking place with PHE to resolve.

• Co-commissioning of school nursing team with local authority to deliver immunisations is taking place.

The local immunisation group has been re-instated and met on 1st June 2015.

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What is NHS England doing to improve uptake

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Objective One

To improve uptake and

coverage

Objective Two

To reduce inequalities

Objective Three

To improve patient

choice and access

Vision

Empowering Londoners to eliminate vaccine-preventable diseases from London

Improving the information systems

Data cleansing

Data linkage

Improving patient choice and widening access

Embedding immunisations in the maternity and

neonatal care pathway

Targeting specific communities

Introducing new immunisation programmes with new

technologies

Roll out children’s flu programme

Improving coverage through provider recovery plans

• People registered with GP

• People who struggle to access mainstream

Contributing to the management of vaccine-

preventable outbreaks

Measured using the following success

criteria Nationally published vaccine uptake data

Increased range of access points

Reduced outbreaks and incidents

Clinical audit of pathways

Overseen through the following governance

arrangements

Overseen by the London Immunisation Board

National Public Health Senior Oversight Group

Three patch Immunisation Quality Improvement

Boards

On-going engagement with Health and

Wellbeing

Boards

High level risks to be mitigated

Information governance and systems

Stakeholder and user engagement

Inadequately trained immunisation workforce

Vaccine supply

Screening borough summary

• Sickle cell and thalasemia screen at 10 weeks and completion of family origin

questionnaire is low;

• Cancer screening programmes coverage and uptake have increased over the

recent years but they are all still performing below the national standards in

Haringey;

• Bowel Cancer Screening uptake is lower in those who were never screened

(approximately 40%) compared to those who have been screened before (84%);

• Diabetic Eye Screening performance is currently not available for each borough -

data is still presented by the screening centre.

• NHS England has a number of actions in place to improve screening coverage and

uptake across all programmes.

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Antenatal and newborn screening

13

KPI Q4 2013/14

Trust FA1 -

completi

on of

Down's

Request

Form

ID1 - HIV

Coverage

ID2 - Hep

B

Referrals

ST1 -

Sickle

and Thal

Coverage

ST2 -

Sickle

and Thal

screen by

10 wks

ST3 -

Completi

on of

FOQ

North

Middlese

x 97.10% 99.60% 78.30% 99.60% 10.10% 83.20%

CHRD /

Hearing

Screening

Unit

NB1 -

Bloodspot

Coverage

NB2 -

Bloodspot

Avoidable

Repeat Rate

NB3 - Bloodspot

Timeliness of

Results (17 day)

NH1 - Newborn

Hearing

Screening

Coverage

(within 4 weeks)

NH2 - Newborn

Hearing Timely

assessment for

screen referrals (4

weeks)

Haringey 96.60% 100.00% 97.4% (NCL) 86.5% (NCL)

North

Middlesex 3.05%

Source: Published data UK NSC - North Midd Maternity Unit

Source: UK NSC - Haringey CHRD and NCL Hearing Programme

Antenatal and newborn screening

actions for improvements

• ST2 – Sickle Cell & Thalassemia - timeliness of test. The maternity

booking system is under review to facilitate earlier booking

appointments (10 weeks gestation).

• ST3 – Sickle Cell & Thalassemia – completion of Family Origin

Questionnaire (FOQ). The booking blood request form is under

review to improve completion of FOQ.

• NB2 – Newborn Bloodspot Screening – avoidable repeat tests.

New system implemented to triage all cards centrally for quality

and accuracy.

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Trends in screening uptake since 2006: Breast, cervical and

bowel cancer screening

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Cervical cancer screening actions for

improvement

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• The North Middlesex Hospital (NMH) cytology laboratory relocated to new premises in

November 2013 as part of planned reconfiguration of services to achieve a minimum

of 35,000 samples reported each year. This affected the 98% turnaround time

standard for delivery of results until September 2014. These issues have now been

resolved.

• There is an action plan in place to resolve waiting time issues for colposcopy at NMH.

This includes appointment of administrative staff , implementation of partial booking

and SMS text reminders.

• There are a number of specific actions targeting improving the coverage such as

Cancer Research UK primary care facilitators and the NHS England coverage and

uptake technical group that will critically appraise proposals for initiatives, produce

evidence of best practice and provide trajectories for improvement of screening

programmes to the London Screening Board. This work will inform NHS England

commissioning of coverage and uptake initiatives across London.

Breast cancer screening actions for improvements

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• An uptake CQUIN has been agreed with the North London Breast Screening

Service (NLBSS) for 2014/15; this aims to achieve 3% increase in the uptake by

year end through the implementation of an agreed evidence-based initiative.

Plans for the CQUIN are monitored through the performance board on a quarterly

basis.

• Barnet and Chase Farm Trusts have been acquired by the Royal Free Hospital

(RFH) Trust which has had an impact on the availability of the data.

• NLBSS report that the RFH Trust management is supportive and do not

anticipate a negative impact on the breast screening programme. Technical

Recall (TR) rates for NLBSS increased in May 2014 to 2.4% (national target

< 2%). The radiography department is conducting an audit and will be

considering purchasing equipment to reduce the 'blur' and improve on TR rates.

Bowel cancer screening issues and actions for

improvement

• The most significant factors affecting uptake for bowel cancer screening are age,

sex, deprivation and recent migration.

• Uptake is lowest for prevalent screens, i.e. those who have never ‘completed a

kit’ before (40.6%), while in incident screens, i.e. those who have previously

‘completed a kit’, uptake averages 81.3%.

• The London Hub contract for 2014/15 includes a CQUIN to improve uptake in the

NHS Bowel Cancer Screening Programme (NHSBCSP) in London by

• sending pre-notification lists (PNL) to GPs

• sending GP endorsement letters with screening invitations

• forwarding of reminder letters (at one month after invitation) to GP practices

to enable timely follow up of non-responders.

• Haringey’s Public Health Team has implemented a local enhanced service for

bowel cancer screening and 10 practices have taken up this service.

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Diabetic eye screening

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Performance for the NCL Screening Service

Diabetic eye screening

• The NCL Programme cited capacity issues in clinics as their main challenge and

they have introduced out of hours clinics where uptake is reported to be good.

• The programme has recently acquired a screening van to screen patients at GP

surgeries and other venues.

• The uptake in quarter one was 77% (3% lower than the previous quarter) because

23% of patients (15 out 66) referred with active R3 during the reporting period did

not attend the offered appointments.

• The programme is auditing the DNA rates at Hospital Eye Services across the five

main referral sites to ascertain if the problem is more prevalent at any particular site

in the patch and will then formulate targeted strategies to address issues that arise.

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