A Population Health Approach to Flu 2020

"Seasonal influenza (flu) is an unpredictable but recurring pressure that the NHS faces every winter. Vaccination offers the best protection." PHE, 2020

Summary

·        Population Health / Integrated System delivery approach to make every contact count.

·        Test bed of communicable disease framework applicable for COVID-19 vaccine, when available.

·        Identify those eligible for the flu 2020 and related immunisation (possibility for COVID-19) surfacing the patient lists via a case finding tool, with PCN focused summary view analytics.

·        Show progression through the flu season of those eligible and received vaccine, against modelled system utilisation. 

·        Create opportunities for staff to make every contract for those with long term conditions by surfacing gaps in care and 1 key metric that can completed during an immunisation appointment (i.e. 30-90 seconds | Blood Pressure and brief advice).

·        Support strategic monitoring and commissioning across the Health Network.

·        Support Payment Reform modelling for integrated care system focus on outcomes. 

·        Allow people see their own immunisation status.

·        Promote immunisation across acute clinical pathways.

·        Opportunity to include data science as a service analysis for increased acuity / complexity / deterioration risk, applicable to pneumococcal immunisation and COVID (if/when available). 

·        Engage directly with people through outreach to ensure sustained reach and vaccination coverage across flu season.

·        Utilisation of the whole system to reach the expanded eligible population.

A Population Health Approach

Each year the NHS prepares for the unpredictability of flu. For most healthy people, flu is an unpleasant but usually self-limiting disease with recovery generally within a week. However, there is a particular risk of severe illness from catching flu for:

·        older people

·        the very young

·        pregnant women

·        those with underlying disease, such as chronic respiratory or cardiac disease

·        those who are immunosuppressed

For 2020 it is also recommended to have the flu vaccine if someone is:

·        the main carer of an older or disabled person

·        a household contact of someone on the Shielded Patients List for COVID-19

·        a child aged 2 to 11 years old on 31 August 2020

National Guidance on Flu is available here:

https://www.gov.uk/government/collections/annual-flu-programme#2020-to-2021-flu-season

Post COVID-19 the UK government has extended the at-risk cohorts to include more people who were identified to be at greater risk; including primary school children, those 50+, and those who are carers or household contacts of someone at risk. The 2020 flu season is comparable to what will be a test run for any COVID-19 vaccination programme, covering a similar at-risk population.

The expansion of the eligible population estimated to be an additional c.60-90% of the 2019 eligibility, is expected to now cover over 50% of an area’s total population.

The number of people receiving a seasonal flu vaccine has been declining over the past years and the expansion will be extra pressure on a system still recovering from the impact and effects of COVID-19.     

Beyond the system capacity and utilisation challenges, many of the risk factors identified for COVID-19 are linked to preventable lifestyle related diseases and risk factors; high BMI, smoking, CVD, COPD, Diabetes. 

Disease and risk factors which a Making Every Contract Count (MECC) approach across a health and care economy can have a positive impact upon. This flu vaccination programme offers the time with a person to discuss the impacts of risks and complications of flu, and wider health and lifestyle. Effective 90 second discussions at every contact support a population nudge them towards effective health improvement programmes that return on their investment for a health system:

·        ROI of Smoking cessation: ￡1.77

·        ROI of alcohol services: ￡1.51

·        ROI of hypertension / high blood pressure control: ￡5.10

·        Median ROI of public health interventions 14:1.

A MECC approach is greater supported by national campaigns which coincide with flu season raising awareness of common risk factors:

·        Know Your Numbers: High Blood Pressure / hypertension campaign; September

·        Stoptober: Stop Smoking campaign; October

·        Dry January: alcohol consumption reduction campaign; January

To be able to achieve MECC, and to be able to reach all of the eligible population, local flu programmes will have to be bigger than previous years, extending outside of GP primary care.

Every person who touches health and care services September – March should be asked if they are eligible for a flu vaccine and given the opportunity to receive a flu vaccination either there and then, or within a very short space of time to not lose the opportunity to make that contact count.

This approach requires a system to work within a population health approach, and integrated system working, across the health and care economy to; resourcing (including finance), staff and patient experience, improving outcomes from flu, and tackling inequalities.

Noting infectious diseases disproportionately effect those already living with disparities in health, leading to unequal burdens in mortality and morbidity from flu those areas with significant health inequalities and deprivation will see their eligible population expand the most from 2019.

Hospital trusts have a key role to play in a vaccination programme across their inpatient and outpatient services. As a high-volume period for acute activity, trusts should seek every opportunity to deliver the vaccine to stop the spread within the trust and the wider community. Hospital trusts have close contact with those more vulnerable / at risk of poorer outcomes and should be active, and supported, to maximise coverage across all services. This includes support for the frontline staff admitting, discharging and reviewing people in outpatients. Understanding the workflows within the hospital will allow the MECC opportunity to added to the workflow without additional staff and patient distress. It is likely the vaccine can be administered to an inpatient during their time in hospital, the trust should allocate physical space to allow the MECC opportunistic testing of outpatients, staff, and household contacts of their patients. In an integrated system this extra service does not have to be delivered by the trust, there is opportunity for community trust / pharmacy to deliver outreach services.   

The ability to deliver the vaccine effectively across a health network, a single intelligence record per person, should be used to check if a person has already received the vaccine, and if not, the MECC approach used to ensure it is given as soon as practically possible; actionable MECC approach. The ability to see the vaccination status supports effective delivery; people are only asked the flu status once, allowing delivery of the vaccine across multiple organisations to achieve maximum coverage, reducing the risk of multiple vaccination.

It can support care delivery throughout the season, allowing clinicians with patients presenting with ‘flu like symptoms’ to see if they have received the vaccine, and if more support and testing may be needed.  

Having a single connected intelligence record allows the system to create a single eligible population list. A list which can be accessed across the network and is updated towards near real time (overnight), gives the providers of the flu programme access to a person’s flu status to deliver an effective programme. Surfacing key MECC metrics facilities the conversations about smoking, high blood pressure, alcohol which are risk factors in both flu and COVID-19.

The full range of services to deliver the vaccine across the expanded population should be used. Including, but not exhaustively, within; All healthcare interactions across GP, community, acute, and specialist services, as well as retail / community pharmacies, dentists, hospice, with outreach services close to at risk populations: care homes (nursing and residential, children, adults and older adults services), schools, health and care workplaces for staff, leisure centres, town centre ‘pop up’ services.

If an area is able to identify those considered ‘key workers’ from COVID considerations to vaccinate this population either publicly or privately. The local chamber of commerce can promote the vaccine across its members to be delivered at work either from a privately arranged pharmacy outreach, or through a voucher scheme which the local pharmacy committee supports.

A challenge in this area will be providing the vaccine to eligible care workers as their organisations can disconnected from public sector health and care organisations; encouraging care workers to register their occupations at their GP practices will be one way to surface the population need.  

Outreach will be key to reach the population. Those interacting with the health and care services will already be known and ‘reachable’ for the vaccine. Services for the expanded list will need to ‘go to the people’, and be where the people are, as traditional call and recall approaches will not reach those indirectly at risk such as those living in the same household as someone at risk, or those which have been historically underserved. 

Outreach services will require additional investment from commissioning groups or central NHS / government teams. The commissioner’s with the responsibility to support the programme will be committed to tackling inequalities and ensuring health protection, their additional investment is needed to address the issues that directly affect delivery; such as additional fridges to store the vaccine, as well as additional doses of vaccine, and practicalities of workforce deployment, as well as additional management and comms and engagement team resources to manage winter. 

As commissioners face financial pressure there are opportunities to create new risk / outcomes-based contracts for delivery and draw down additional funding based on business case justification, from regional and national teams. The additional eligibility may extend to 50-70% of a total population, and the ability to deliver based on current contract value / finances is unrealistic. The practicalities of the programme are not as applicable from 2019 to 2020. Example; GP practices will have already bought their supply of flu vaccine based on previous years delivery and targets. This supply may now only cover 40% of the eligible population. Commissioners could consider ‘buying back’ this vaccine supply from the GPs and creating a distributed storage and delivery approach system wide. This does not mean the GPs will be ‘double paid’ for the vaccine, but it ensures business continuity and removes the barriers of financial loss pressure from the programme delivery, it allows the vaccine to be stored correctly and delivered to those in most need as a priority. Realistically there will not be enough vaccine does to reach the larger population and there will need to be a re-prioritisation of those consider ‘priority 1’ already. Government advice is to start with the 2019 population and not to begin the 50-64 category until late November. Systems should make contingency plans if centralised stock releases are not realised.           

Advanced analytics and data science services can model current and projected utilisation of the health and care system by those eligible / at risk of flu so decisions can be made on resourcing. Use machine learning, to advance this further, to predict the higher risk for those people who may develop complications and require intensive interventions and admission for flu / COVID-19 post test result / diagnosis. Risk modelling can be used to identify the need, and risk mitigation across the population. Senior leadership should be clear and aware of the risks to the programme in 2020. Deprivation and wider determinants have been shown to be risk factors to both flu and COVID and it is likely certain neighbourhoods / PCNs will have greater risks, and the vaccine will be distributed equally based on the populations and practice managers orders, less likely it is distributed equitably, and areas working as integrated systems should consider this disparity.   

Messages to promote flu vaccine to the public will be key to drive up take up and should be positive and relatable to achieve the coverage goals; maternity services should promote the vaccine for both mother and baby, acute and outpatient services deliver to patient and chaperone if they are both eligible, and positive messages to encourage parents to consent to school vaccination programmes.   

Campaigns which are not publicly funded, but can be publicly supported, should be considered. These can include promotional support to the local chamber of commerce, encouraging local businesses to provide the flu vaccine to their staff, and similarly to charities which may work with both eligible, and non-eligible people. The public sector can provide the connections between such groups and commercial providers of the vaccine, such as retail pharmacies and supermarkets to vaccinate school staff and teachers. If in place local authorities could allow other public services / key worker industries to use their already in place agreements with businesses like pharmacies to secure an agreeable price with pharmacies. 

Commissioners may also want to explore engaging with these suppliers in a partnership to cover the costs to deliver a MECC approach and reach the systems overall coverage goals. They may cheaper options if finances are tight to reach the extra people. GP’s will always deliver most of the programme and deliver to those most at risk, but as the season extends into January – March other options can be explored to reach more of the extra eligible people. Recent changes to the community pharmacy guidelines on delivery of the programme allow for greater flexibility in where and how they can deliver mass vaccination. 

NICE guidance on the cost effectiveness and resource usage of the influenza vaccine describes the increasing costs of reaching higher percentages of coverage, as the people to who you are trying to reach are from sections of the population which may have been more historically underserved, or ‘hard to reach’. Health systems should look towards different ways of communicating as well to this part of the population, with consistent and simple health messages to encourage participation in the outreach services available.

Customer relationship management (CRM) solutions can target those eligible automatically with messages they are likely to respond positivity towards to lead to the behaviour change to get the vaccine; this can be both sophisticated approaches including online social marketing, and direct text messages.

People who engage in their own health care achieve better health outcomes and benefit from lower health care costs. And having ready access to their own health information held by health care providers, and health plans, allows patients to be better managers of their health and care by making more informed treatment decisions, adopting healthy behaviours related to diet and exercise, and medications adherence.

Surfacing a person’s flu vaccine status in their patient portal will be an effective nudge to engaging more people to take up the flu vaccine. Linked to the effective promotion of the services available to them, the benefits of people accessing their own health data and becoming their own health managers outweighs those risk cited to increased system utilisation, and the emergence of the ‘worried well’. Effective health education and health promotion mitigate the risks.

Good management is key to risk and opportunities outlined. System-wide accountable clinical oversight is key to the delivery of any population health programme. Clinically led and locally delivered programmes, supported by the advanced analytics that leverage information across the whole system, are a success. Integrated systems that can breakdown silos and resolve barriers to improve patient / population health achieve better outcomes and lower costs.  

Strategic leaders can plan, resource and deliver effective services over winter to mitigate the risk of the unpredictable but recurring pressure that the NHS faces every winter. Vaccination offers the best protection and a population health approach can support the NHS to deliver better outcomes and prepare the system for COVID-19 resurgence and vaccination.