Following negotiations between the Scottish GP Committee of the BMA, NHS Boards and the Scottish Government, a new GP GMS contract was agreed in effect from 1 April 2018. The contract purported to offer a refocusing of the GP role as an expert medical generalist, and in doing so agreed priorities for transformative service redesign over a three-year period.
These priorities were to include the provision of community treatment and care centres (CTAC) and community vaccination centres, and the provision of pharmacotherapy, physiotherapy, community mental health and link worker services within practices.1
Although the initial reaction to some of the proposed changes was positive the reality has not matched the aspiration. No-one could have predicted the COVID-19 pandemic, which has derailed much of general practice since 2020, however, it might have been prudent to ensure sufficient numbers of the health professionals promised.
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The entire contract has been dogged by a lack of staff, not least in the CTACs and vaccination centres, which has resulted in a blurred focus, not the sharp refocusing the contract promised. An ageing workforce; unrest in the ranks, resulting in early retirement; and reduced funding from the Scottish government have further exacerbated the issues the health boards face in providing these services.
A phased programme
The intention was for the Vaccine Transformation Programme (VTP) to be delivered as a phased programme, beginning with the childhood programme, moving to the national schedule influenza, pneumococcal and shingles vaccines and ending with travel vaccines, with the total immunisation programme being removed from general practice by October 2021. However, with the emergence of COVID-19, and subsequent nationwide vaccine roll-out, travel vaccines were not removed from practice until 1 April 2022.
The publication of The Primary Care (Vaccinations Transfer) (Scotland) Directions 2022, provided a framework for concluding the role played by most GP practices in delivering vaccinations, and stipulated that each of Scotland’s 14 Regional NHS Boards were responsible for the delivery of all vaccinations and immunisations.2
Due to the rurality of Scotland and variable population numbers throughout the country, each regional board has implemented the vaccine programme in the way they thought best served the population. This has resulted in a wide variety of clinics across the country ranging from multiple, small, local childhood clinics; to fewer, larger, more central adult clinics; to immunisation buses, for communities with limited transport options. In addition, circumstances requiring immunisation outside the UK national programme for example, post exposure tetanus or hepatitis B, has required to be developed, ‘ad hoc’, in what would appear to have been an afterthought.
Access to clinics remains a major factor, with the smaller, more local, child clinics being more popular than the fewer, larger adult clinics. In the author’s own area of practice in the south side of Glasgow there is only one adult immunisation clinic serving a socio-economically disadvantaged population with no access to their own transport and no direct public transport to the immunisation clinic.
This has resulted in those requiring vaccines travelling outside the area to other immunisation clinics with better public transport links, or in some instances, delaying appointments so they can attend alternative clinics with other family members.
However, some members of the public who have no transport, have been unable to access clinics and simply forego the protection of vaccination.This latter scenario is supported by research undertaken before VTP was introduced which indicated that accessibility was one of the key factors in people deciding to be vaccinated.3
Staffing and training
Pre-VTP, most regional boards would have had childhood and school immunisation teams in place, however very few boards would have had staff in place to step into the role general practice played in delivering vaccines. As boards recruited teams of immunisers to deliver the adult immunisation programme, the emergence of COVID-19 meant a national campaign was required.
The majority of those involved in delivering the COVID-19 programme had never previously administered vaccines, and NHS Education for Scotland (NES) was tasked with writing and rolling out training. As a result, the Turas website now has numerous immunisation modules available: both for registered practitioners, and also for health care support workers.4
Being able to record vaccines in one central repository, to which both primary and secondary care has access, may seem like an unachievable goal, but the Vaccine Management Tool (VMT) has begun that process. Introduced during 2020 it has expanded to incorporate the recording of adult vaccines anywhere in Scotland. Accessible from Turas, it imports vaccine data directly into general practice ensuring the most up to date record of vaccines is available to the primary care team. A single repository for all vaccines administered in Scotland is currently in development and is hoped will interface with primary and secondary care databases.
For those of us consulting with travellers, the idea that travel health should sit under the VTP was an uncomfortable thought. After all, ‘travel health is not all about vaccines’. However the CMO letter circulated in March 2022 stipulated that, ‘The redesign and implementation of vaccination delivery includes travel health advice and travel vaccination services. Our aim is that this will ensure a localised, improved and consistent travel health service delivery model is implemented across Scotland.’ 5
Unfortunately, as with the remainder of the VTP programme, each regional board implemented this guidance in their own way. Some offered the service to pharmacists; some to their own, in-house immunisation teams; some established a, ‘hub and spoke’ model: utilising one central specialist centre with multiple less specialist clinics. One board put the service out to tender and awarded the contract to a commercial company, and others utilised a combination of all of the above.
The Scottish Government, aware of the potential for variances in practice, offered training from an external provider: Travel-related Health & Education (TREC). The author was one of two trainers who delivered training to 120 travel health advisors from all regional boards during 2022. The second phase of training is a new e-learning module, commissioned and provided by NES, on the Turas website.
Under VTP, each regional board should provide as a minimum the recognised NHS vaccines (tetanus, diphtheria, polio, hepatitis A, typhoid and cholera). But must include a full travel risk assessment and consultation, and if appropriate signpost for malaria chemoprophylaxis and non-NHS funded vaccines, such as hepatitis B, meningococcal meningitis, rabies, tick-borne encephalitis, and yellow fever.5
Some pharmacy-run clinics are able to operate a, ‘one stop shop’, which offers both NHS and non-NHS provision which would appear to be the most beneficial to the traveller, but it is important to note that many pharmacy-led services had been successfully operating in rural areas of Scotland for many years, long before VTP.
The first year of VTP Travel has not been smooth sailing. It was apparent during the delivery of Phase 1 training that there was a wide range of expertise and many trainees were inexperienced in the field of travel health. Many registered professionals who attended the training were familiar with the concept of immunisation, and even of risk assessment, but not the depth of information and advice required during a travel consultation. The Good Practice Guidance for Providing a Travel Health Service document, published by the Faculty of Travel Medicine in 20206 was a timely resource for both Scottish Government and the Phase 1 trainers were able to align the existing TREC 2 day course with both the FTM document and also the current RCN Travel Health Competencies.7
The great paradox is that although general practice is no longer able to administer NHS vaccines, they are still able (if they choose) to advise and offer non-NHS vaccines and services including malaria chemoprophylaxis; and the management of long term conditions for travellers has remained with general practice, as has post travel assessment and treatment.5
The introduction of the VTP programme offered a unique opportunity for Scotland to, ‘get immunisation right’, and it many ways it has delivered: in respect of the excellent NES training modules, the centralised appointment system and the VTM recording tool. But in many areas it has been found wanting. Vaccine accessibility for all should not be a privilege, and should not depend upon access to private transport.
One of the main complaints about immunisation within general practice was the lack of access to appointments.3 It is an area that has not necessarily improved with the advent of the VTP. With no evidence of an impending review, how and when the public will be invited to evaluate the service in their area is open to speculation.
Margaret Umeed is a senior GPN/ANP Trainee working in Glasgow.
1.Scottish Government. GMS Contract 2018. 31 November 2017. https://www.gov.scot/publications/gms-contract-scotland/pages/2/ (Accessed: 1 May 2023)
2. Scottish Government Directorate for Primary Care General Practice Division. 11 August 2022 https://www.sehd.scot.nhs.uk/pca/PCA2022(M)13.pdf (Accessed: 1 May 2023)
3. Bishop, Miller & Suphi for NHS Health Scotland. Exploring public views of vaccination service delivery. Feb 2019.
4. https://turasdashboard.nes.nhs.scot/ (Accessed: 1 May 2203)
5. CMO Directorate. Vaccination Transformation Programme - Travel Health Services. 31 March 2022 CMO(2022)13.pdf (scot.nhs.uk) (Accessed: 1 May 2023)
6. Faculty of Travel Medicine. 2020. Good Practice Guidance for Providing a Travel health Service. https://rcpsg.ac.uk/travel-medicine/good-practice-guidance-for-providing-a-travel-health-service (Accessed: 2 May 2023)
7.Royal College of Nursing. 2018. Competences: Travel health nursing: career and competence development. https://www.rcn.org.uk/Professional-Development/publications/pdf-006506 (Accessed: 2 May 2023)