Fifty primary care trusts distributed the survey invitation to a total of 2896 practices. Responses were submitted by 569 practice managers, 335 nursing staff and 107 GPs, representing 795 practices (27.5% of those invited to contribute). These practices serve a total of approximately 5.8 million patients, among whom over 1.5 million are eligible for influenza vaccination. The distributions of flu vaccination rates in the surveyed practices were well matched to national patterns (). For the majority of eligible patients (ie, those aged 65 years and above), our findings indicated that the variation between practices' flu vaccination rates was not influenced by differences in the ethnicity or affluence of their patient populations, whereas Quality and Outcomes Framework summary scores showed highly and significant positive correlations with vaccine uptake achieved in both age groups (supplementary table 1). The univariable logistic regression results referred to throughout this section are shown in supplementary table 2.
Figure 1 Box and whisker plots showing the range and distribution of influenza vaccination uptake rates for patients aged 65+ years (blue boxes and bars) and at-risk patients aged under 65 years (red boxes and bars). The distribution of uptake (more ...)
Having a lead member of staff for arranging the practice flu vaccination campaign was associated with increased flu vaccine uptake rates in both 65+ and <65 age groups (p=0.001 and 0.004, respectively). Nominating a staff member with responsibility for identifying eligible patients was associated with increased uptake of vaccine in older age groups (p=0.038), but this trend, although present, did not reach significance in under 65s (p=0.218).
A plot of the number of vaccine doses ordered for 2011–2012 versus vaccines used in 2010–2011 shows a tight correlation (). On average, practices were found to have ordered vaccines based on the number of doses given in the previous season, with an average uplift of 8.8% (95% CI 4.3% to 13.3%; n=568). As vaccines are ordered as a total, these data could not be differentiated into doses intended for vaccination of patients aged over or under 65 years old. However, the data showed that only 78.3% of responding practices would have been able to vaccinate at least 75% of their at-risk patients (in accordance with the CMO recommendations) ().
Figure 2 (A) Relationship between reported total number of vaccine doses ordered for the 2011–2012 season and actual number of doses administered in 2010–2011 (n=568) and (B) plot showing the maximum average achievable vaccination rates for the (more ...)
Using personal invitations, either alone or in combination with general publicity, was significantly associated with higher rates of vaccination. The use of personal invitations for all patients (not just those who did not respond to an initial general publicity campaign) was associated with the highest vaccination rates in the larger 65+ age group (p=0.003), although a similar association did not reach statistical significance in the under 65s. Using both letters and telephone calls was not associated with significantly different vaccination rates than using either letters or phone calls alone (p=0.721 for patients aged 65+; p=0.852 for patients aged <65).
Identifying eligible patients
Programmes for identifying eligible patients from the practices' IT system are usually issued by the software providers. Modifying the IT supplier's standard search or creating a separate in-house search was associated with significantly higher uptake rates for patients aged 65+ years than using an unmodified IT supplier's search (p<0.001 and 0.027, respectively). A similar trend for under 65s did not reach statistical significance, perhaps due to insufficient power. As older patients are identified simply on the basis of their age at a certain date, which should not require a complicated search strategy, these findings suggest that creating or modifying a system search reflects that the staff in these practices are more motivated and/or experienced to use their IT system to try to achieve their flu vaccination targets.
Offering clinics and appointments
More than 95% of practices held the main vaccination sessions at their usual surgery premises and 75% held the main sessions during normal surgery hours. Most practices reported using a variety of appointment types and timings to provide flu vaccination. Surprisingly, in our data, offering vaccinations at weekends, or before 8:00 or after 18:00, was not associated with a significant difference in the vaccination uptake rates achieved. Increasing numbers of reminders or repeat invitations were associated with significantly increased vaccine uptake in the under 65-year-olds (p=0.038), though not in those aged 65+ years. Significantly, higher rates of vaccination (for under 65s) occurred in practices that identified appointments for flu vaccination using a specific Read (computer identification) code (p=0.038).
Vaccinating pregnant women
The proportion of practices that reported that their community midwives recommended flu vaccination to pregnant women was disappointingly low (57.5%). Furthermore, there was a clear discrepancy between this figure and the proportion that reported that their community midwives actually administered vaccine (17.8%; see ). Our analysis demonstrated that practices where community midwives were active in administering flu vaccinations to pregnant patients achieved significantly higher rates of uptake in this particular at-risk group (p=0.023).
Showing (A) the reported activity of community midwifery teams in recommending and providing seasonal influenza vaccination to pregnant women and (B) the attitudes of participating healthcare workers to vaccination of colleagues and themselves.
Ending and reviewing the campaign
A total of 578 practices provided information on what influenced their decision to stop offering flu vaccination. Of major concern was the evidence that almost 50% of practices stopped offering flu vaccines partly, or solely, because they had exhausted their stock. Almost one-third (28.9%) cited a financial factor in making their decision and the data showed that ending flu vaccination only once QOF targets had been reached was associated with increased uptake rates for those aged 65+ years (p=0.048); in those aged under 65 years, this was only weakly significant (p=0.100), perhaps influenced by the smaller numbers of patients in this group. These results suggest that practices that focused on financial targets were motivated and/or organised to continue their efforts to vaccinate patients beyond the point at which other practices may stop. In support of this hypothesis, we found that patients whose vaccination would contribute to a QOF-related payment received an average of 42% (95% CI 33% to 51%) more reminders more than those who did not have a QOF-registered indication for vaccination (p<0.001).
Practices which produced a written report reviewing their flu vaccination rates achieved very significantly higher vaccination rates in both younger and older age groups compared with those practices which did not produce a written report (p=0.006 for patients aged 65+ years; p=0.002 for patients aged <65 years). Similarly, reviewing the practice's flu vaccination strategy in a written format was also significantly associated with achieving higher rates of vaccination (p=0.067 for patients aged 65+ years; p=0.028 for patients aged <65 years). This finding suggests that practices that produced written reports may have been able to organise more rigorous campaigns and/or have had more well-informed and motivated staff, resulting in more effective performance.
Personal motivations and attitudes of staff
shows a summary of GPs', nurses' and practice managers' views of the flu vaccination campaign. There was a significant association between encouraging vaccination among colleagues and other staff and achieving higher rates of vaccine uptake in patients aged 65 years or above (p=0.004) but not in those aged under 65 years (p=0.208). There was a trend for a similar association between positive attitudes of staff towards being vaccinated themselves and higher rates of patient vaccination in a practice, but this did not reach statistical significance in either the older or younger age group (p=0.440 and 0.185, respectively).
Predicted impact of strategies to increase rates of influenza vaccination
Seven factors were found to have significant independent positive associations with flu vaccine uptake levels following multivariable regression analysis ( and ). For patients aged <65 years, having a lead member of staff for planning the flu campaign and producing a written report of the practice's performance were associated with a combined OR of 1.37, which predicts an 8% higher flu vaccination rate for practices that employ these strategies compared with those that do not (54% vs 46%).
Statistically significant factors found on multivariate regression analysis of responses common to all three types of staff (general practitioners, nursing staff and practice managers)
Statistically significant factors found on multivariate regression analysis of responses from practice managers only
In patients aged 65 years or over, a further two factors were also found to remain independently correlated with increased rates of flu vaccination. These were sending a personal invitation to all eligible patients and only stopping vaccination when QOF targets are reached. The overall OR associated with the implementation of all four strategies in this age group was 1.45, which predicts a 7% higher vaccination rate in this age group when these strategies are used (78% vs 71%).
The strategies of using a lead member of staff for identifying eligible patients and either a modified manufacturer's search programme or an in-house search programme for interrogating the practice IT system were also independently correlated with increased rates of flu vaccination in patients aged 65 years or more. However, the effect seen was weaker as these data are derived from a subset of responses from practice managers only, suggesting a rise to 78% from a baseline of 74%.
The active involvement of midwives in providing flu vaccination was significantly associated with higher levels of vaccine uptake in pregnant women but, as the only significant variable within this group, the finding could not be included in a multivariable analysis. However, applying the OR of 1.20 predicted by the univariable analysis, our data indicate that the provision of vaccination by midwives rather than GPs is associated with an increase in uptake rate to 45% in pregnant women (from an observed average baseline vaccination rate of 41% in our cohort).