Public Health (1992), 106,277-281
O The Society of Public Health, 1992
Introducing the New Schedule--A Health Board's Experience D. M. Campbell MRCGP MFPHM Consultant in Public Health Medicine, Department of Public Health, Argyll and Clyde Health Board, Paisley
On 1st October 1990 a revised primary immunisation schedule was introduced throughout Scotland. Following a review of current practice, Argyll and Clyde Health Board adopted a distinct implementation strategy. A questionnaire study of the 461 likely providers of primary immunisations or advice was performed to review this process. Sixty-four percent responded within 21 days. Over 90% were satisfied with the information supplied on the change. Almost equal proportions of immunisers were using 2, 4, 6 and 2, 3, 4 month schedules. The commonest sources of immunisation advice were the Health Board Immunisation Manual and the JCVI 'Green Book'. Twenty percent of responders volunteered that primary immunisation should have some statutory basis. The outcome of this change in terms of reduced morbidity and increased vaccine uptake will require active monitoring though concomitant changes in general practice remuneration make this difficult. The role of the Standard Immunisation Recall System requires re-examination.
Background During November 1989 a revised primary immunisation schedule was recommended by the Joint Committee on Vaccination and Immunisation (JCV1) and announced by the Scottish Minister of Health on 26th April 1990 (Calman, K. C., personal communication). In Scotland the course was to commence at two months of age and be completed by six months. The reasons given for this change were to produce earlier protection, especially against pertussis, to reduce default rates and to limit the problems encountered with mobile families. In Argyll and Clyde Health Board, which serves a mixed urban and rural community on either side of the River Clyde, immunisation has been traditionally carried out by a combination of general medical practitioners (GPs) and clinical medical officers (CMOs) working in child health clinics. The proportions performed in the different types of treatment centres vary among the four local government districts comprising the Health Board. Health visitors (HVs) advise parents on immunisation as part of their child health duties. The Scottish computer-based Standard Immunisation Recall System (SIRS) has been used for both call/recall and appointment scheduling for over 10 years, with 93% of general practices and all Health Board clinics where childhood immunisation is offered participating in the system. Following the advance announcement of the revised schedule, an implementation group drawn from computing services, primary care and public health medicine with Correspondence to: Dr D. M. Campbell, Consultant in Public Health, Environmental Health (Scotland) Unit, Ruchill Hospital, Glasgow G20 9NB.
278
D. M. Campbell
ad hoc advice from clinical medical officers, community nursing and general practice was constituted. This team reviewed the current practice within the Board and examined the options for scheduling, based on current practice within immunisation treatment centres. An initial study revealed a median interval of 24 days between the date of a session and its schedule being received for processing within the Health Board's Primary Care Division's Community Screening Unit (Stirling, J., personal communication). This indicated that a 2, 3, 4 month schedule would be logistically inoperable. Examination of the implications of switching the children who had already begun their primary immunisation course on the existent 3, 5, 9 month programme demonstrated that, in addition to the initial increase in numbers due to the earlier commencement age and shorter intervals of the new regimen, it would create an unacceptable workload for many larger clinics. This at a time when GP workload was increasing in response to the new Contract and the emphasis on achieving targets. Also, because of the age-based hierarchical algorithm for scheduling clinic appointments inherent in SIRS, any child currently experiencing lapses in its course could be potentially further delayed. The group made the following recommendations: 1. That a 2, 4, 6 month primary immunisation schedule should initially be adopted. 2. That a transitional SIRS system should be created to permit users the option of maintaining the present schedule for children who had already commenced on this course. 3. That a review of immunisation practice within the Board should be held one year after the commencement of the GP Contract. These were formally accepted by the Board's Director of Public Health, Clinical Co-ordinators for Child Health, Directors of Nursing Services (Community) and the General Practice Sub-committee of the Area Medical Committee and implemented on 1st October 1990. In view of recommendation 3 and the fact that Argyll and Clyde had adopted a slightly different approach to implementing the new schedule to other Scottish Health Boards, it was decided to audit the process of its introduction. The opportunity was also taken to canvas health professionals' views on the suitability of available health education materials, the sources of immunisation advice used, and means of improving vaccine uptake. Method
An anonymous questionnaire was distributed by routine mailing methods to the professional addresses of all general medical practitioners and trainees currently attached to practices, to health visitors and tO clinical medical officers working in the child health field employed by or in contract to Argyll and Clyde Health Board in early May 1991. The questionnaire was piloted at a Health Centre in an adjoining Health Board. Data handling and analyses were performed using the Epi Info computer package. ' Results
Within 21 days 289 questionnaires were returned of the 461 dispatched. Four of these (all from GPs) indicated that they were responding on behalf of a total of 14 other
Introducing the New Schedule
279
colleagues, so were excluded from further study. The analysed overall response rate was 64% (285/443): 54% (165/304) for GPs, 84% (99/118) for HVs and 100% (21/21) for CMOs. Not all of the 14 questions were completed by each respondent. Within the GP group the response rate varied from 97% in predominantly rural Argyll and Bute to 44% in urban Renfrew. The SIRS system was used by 92% of GPs and HVs and by all CMOs. Over 90% of each professional group either personally performed or advised on childhood immunisations. Virtually all respondents recalled having been informed of the change in schedule and in sufficient time, though some would have wished for more detail (Tables I and II). The modal reported time for dispatching completed SIRS schedules by HVs and GPs was 1-2 days while that for CMOs was on completion of the clinic. The median times were 3-5 and 1-2 days respectively with 22% (32/149) of GPs reporting seven days or more. The transitional arrangement of maintaining the 3, 5, 9 month schedule until children had completed their courses was used by 88% (135/154) of GPs and 91% (82/90) of HVs. All CMOs and 87% (188/217) of those who used the facility believed their decision to be correct. Of all professionals involved in immunisation 87% (227/261) considered present Health Education material appropriate with no significant difference among the professional groups. The two commonest sources of immunisation advice used were Immunisation against Infectious Diseases (Green Book) (64%) and the Health Board Manual (55%). 2 (See Table III.) There were few comments on how the Board itself could improve immunisation apart from by further involving HVs in administering vaccine, possibly introducing a domiciliary service and by improving the accuracy of SIRS records--a function of both the Board and the immunisation centre. On immunisation generally 20% of responders proposed that primary immunisation should have some statutory basis, either as a condition for continued receipt of child benefit or that a child should be required to produce evidence of immunisation (or contra-indication) before entrance to education or possibly to a child care facility. These views were held equally by members of all professional groups. Table I
Satisfaction with information on change in schedule by professional groups (%)
Information Informed of change In sufficient time In sufficient detail
GP (162) 99 95 94
Professional group (n) HV (98) CMO (20) 100 100 93
95 100 78
Table II Schedulesin use by professional groups (%) Schedule 2, 4, 6 month 2, 3, 4 month Both Other
GP (165) 45 48 3 4
Professional group (n) HV (99) CMO (16) 61 34 3 2
75 19 6 0
D. M. Campbell
280
Table III Source of immunisation advice by professional groups (%) Source H. B. Manual National Formulary 3 Green Book Textbook Other
Professional group (n) HV (99) CMO (21)
GP (164) 52 16 60 6 2
65 5 65 4 13
29 14 86 5 0
Discussion
This study has a variety of implications for the provision of immunisation services within Argyll and Clyde Health Board and nationally. The disappointing response rate from GPs may be attributable to certain practitioners, with patients within Renfrew District but whose principal practice location lies within the adjoining Health Board, not responding. Due to the anonymity of the questionnaire it was impossible to send reminders or to study the characteristics of the non-responders. Users appeared satisfied that they had been informed of the changes in good time though some, especially CMOs, would have welcomed more information on the epidemiological and immunological evidence behind the decision of JCVI to recommend the change in schedule. T h e use of two differing schedules by general practice treatment centres may reflect the routine within some practices of giving monthly appointments at the time of first immunisation but using SIRS as a reminder. It was surprising that some CMOs reported one-monthly intervals when all Health Board clinics were using the two-month schedule. This is an unsatisfactory position. Ideally all treatment centres should be using a single schedule, possibly 2, 3, 4 months, but delays in receipt of documentation make such a turnaround administratively difficult. The intervals in returning SIRS information reported by users are less than that found by the original audit within the Community Screening Office; a median interval of 24 days compared with the 3 - 5 days in this study. These cannot be explained by postal services. The probable reason is tardiness in dispatch from the treatment centre after completion. The facility to maintain the f o r m e r schedule for children who had embarked on it appears to have been successful despite requiring more clerical work from both treatment centre and Health Board staff due to failure of the National Centre of Responsibility for SIRS to produce a modified computer program. The changes in the timing of the schedule and the increase in immunisation activity within general practice require that the role of SIRS within a Health Board's overall immunisation programme be re-examined. It may now be m o r e appropriate to use it for initial call, for recording completed courses, and for identifying defaulters while individual treatment centres perform their own scheduling. T h e increasing use of computers in primary care makes this a viable alternative. 4 It would obviate many of the delays inherent in the present system. The satisfaction with the Health Education materials was surprising in view of verbal comments that had been previously received. It may be that responders were confused as to whether they were being asked to comment on material aimed at the public or on that for health professionals. The use made of the Health Board's Immunisation Manual was gratifying. This is a recent introduction aimed at both
Introducing the N e w Schedule
281
supplying practical information and at answering commonly posed questions by professionals and parents. It was alarming that certain HVs depended totally for their information on a health education leaflet designed for parents. The Peckham Report advocated that policy should change towards parents opting out of rather than in to immunisation. 5 This has already occurred to some extent within Argyll and Clyde Health Board, all children being called automatically by SIRS unless a specific contra-indication or parental refusal is recorded. Previous policy only invited those for whom a signed consent was held. Proof of immunisation for school, and possibly day care entry is desirable for both herd immunity and in forcing a parental decision. This would not restrict freedom of choice as a positive opting out scheme would allow the opportunity for withdrawal of a child from the programme because of medical contra-indications or active parental opposition. The case for discontinuation of statutory child benefit is less clear. The social deprivation consequent on this action might have a deleterious effect on the individual child's health. The role of nurses/health visitors has been examined by Begg et al. who reported that immunisations were routinely being given by nurses in a number of English Health Authorities although in less than a quarter by Health Visitors. 6 At that time 16% (30/193) of Authorities had an official domiciliary service, but in only 40% (12/30) of these was it targeted on non-attenders. It is difficult to measure the effect of this alteration in immunisation policy in isolation, as it so closely followed the introduction of financially rewarded immunisation targets into general practice. However, there have been demonstrable changes in achievement as shown by the percentage of practitioners meeting the specific targets. While on 1st April 1990 only 39% of GPs were meeting the 90% target and a further 58% the 70% target, this had changed by 1st January 1991 to 75% and 24% respectively (Oldroyd, M., personal communication).
Acknowledgements The assistance of Dr A. K. Fraser, Senior Registrar in Public Health Medicine, and the cooperation of Miss M. Oldroyd, Director, and the staff of the Primary Care Division, Argyll and Clyde Health Board are gratefully acknowledged. Mrs J. Morrison performed all the clerical work associated with the survey. References 1. Dean, A. G., Dean, J. A., Burton, A. H. et al. (1990). Epi Info, Version 5: a word processing, database and statistics system for epidemiology on microcomputers. Stone Mountain, Georgia: USD Inc. 2. Joint Committee on Vaccination and Immunisation (1990). Immunisation against Infectious Diseases. London: HMSO. 3. British National Formulary (1990). London: British Medical Association and Royal Pharmaceutical Society of Great Britain. 4. Ryan, M. P. (1989). A system for general practice computing in Scotland. Health Bulletin 47, 110-119. 3. Peckham, C., Bedford, H., Sentura, Y. et al. (1989). National Immunisation Study: Factors Influencing Immunisation Uptake in Childhood. London: Institute of Child Health. 6. Begg, N. & White, J. (1987). A Survey of Pre-school Immunisation Programmes in England and Wales. London: PHLS Communicable Diseases Surveillance Centre.
O The Society of Public Health, 1992
Introducing the New Schedule--A Health Board's Experience D. M. Campbell MRCGP MFPHM Consultant in Public Health Medicine, Department of Public Health, Argyll and Clyde Health Board, Paisley
On 1st October 1990 a revised primary immunisation schedule was introduced throughout Scotland. Following a review of current practice, Argyll and Clyde Health Board adopted a distinct implementation strategy. A questionnaire study of the 461 likely providers of primary immunisations or advice was performed to review this process. Sixty-four percent responded within 21 days. Over 90% were satisfied with the information supplied on the change. Almost equal proportions of immunisers were using 2, 4, 6 and 2, 3, 4 month schedules. The commonest sources of immunisation advice were the Health Board Immunisation Manual and the JCVI 'Green Book'. Twenty percent of responders volunteered that primary immunisation should have some statutory basis. The outcome of this change in terms of reduced morbidity and increased vaccine uptake will require active monitoring though concomitant changes in general practice remuneration make this difficult. The role of the Standard Immunisation Recall System requires re-examination.
Background During November 1989 a revised primary immunisation schedule was recommended by the Joint Committee on Vaccination and Immunisation (JCV1) and announced by the Scottish Minister of Health on 26th April 1990 (Calman, K. C., personal communication). In Scotland the course was to commence at two months of age and be completed by six months. The reasons given for this change were to produce earlier protection, especially against pertussis, to reduce default rates and to limit the problems encountered with mobile families. In Argyll and Clyde Health Board, which serves a mixed urban and rural community on either side of the River Clyde, immunisation has been traditionally carried out by a combination of general medical practitioners (GPs) and clinical medical officers (CMOs) working in child health clinics. The proportions performed in the different types of treatment centres vary among the four local government districts comprising the Health Board. Health visitors (HVs) advise parents on immunisation as part of their child health duties. The Scottish computer-based Standard Immunisation Recall System (SIRS) has been used for both call/recall and appointment scheduling for over 10 years, with 93% of general practices and all Health Board clinics where childhood immunisation is offered participating in the system. Following the advance announcement of the revised schedule, an implementation group drawn from computing services, primary care and public health medicine with Correspondence to: Dr D. M. Campbell, Consultant in Public Health, Environmental Health (Scotland) Unit, Ruchill Hospital, Glasgow G20 9NB.
278
D. M. Campbell
ad hoc advice from clinical medical officers, community nursing and general practice was constituted. This team reviewed the current practice within the Board and examined the options for scheduling, based on current practice within immunisation treatment centres. An initial study revealed a median interval of 24 days between the date of a session and its schedule being received for processing within the Health Board's Primary Care Division's Community Screening Unit (Stirling, J., personal communication). This indicated that a 2, 3, 4 month schedule would be logistically inoperable. Examination of the implications of switching the children who had already begun their primary immunisation course on the existent 3, 5, 9 month programme demonstrated that, in addition to the initial increase in numbers due to the earlier commencement age and shorter intervals of the new regimen, it would create an unacceptable workload for many larger clinics. This at a time when GP workload was increasing in response to the new Contract and the emphasis on achieving targets. Also, because of the age-based hierarchical algorithm for scheduling clinic appointments inherent in SIRS, any child currently experiencing lapses in its course could be potentially further delayed. The group made the following recommendations: 1. That a 2, 4, 6 month primary immunisation schedule should initially be adopted. 2. That a transitional SIRS system should be created to permit users the option of maintaining the present schedule for children who had already commenced on this course. 3. That a review of immunisation practice within the Board should be held one year after the commencement of the GP Contract. These were formally accepted by the Board's Director of Public Health, Clinical Co-ordinators for Child Health, Directors of Nursing Services (Community) and the General Practice Sub-committee of the Area Medical Committee and implemented on 1st October 1990. In view of recommendation 3 and the fact that Argyll and Clyde had adopted a slightly different approach to implementing the new schedule to other Scottish Health Boards, it was decided to audit the process of its introduction. The opportunity was also taken to canvas health professionals' views on the suitability of available health education materials, the sources of immunisation advice used, and means of improving vaccine uptake. Method
An anonymous questionnaire was distributed by routine mailing methods to the professional addresses of all general medical practitioners and trainees currently attached to practices, to health visitors and tO clinical medical officers working in the child health field employed by or in contract to Argyll and Clyde Health Board in early May 1991. The questionnaire was piloted at a Health Centre in an adjoining Health Board. Data handling and analyses were performed using the Epi Info computer package. ' Results
Within 21 days 289 questionnaires were returned of the 461 dispatched. Four of these (all from GPs) indicated that they were responding on behalf of a total of 14 other
Introducing the New Schedule
279
colleagues, so were excluded from further study. The analysed overall response rate was 64% (285/443): 54% (165/304) for GPs, 84% (99/118) for HVs and 100% (21/21) for CMOs. Not all of the 14 questions were completed by each respondent. Within the GP group the response rate varied from 97% in predominantly rural Argyll and Bute to 44% in urban Renfrew. The SIRS system was used by 92% of GPs and HVs and by all CMOs. Over 90% of each professional group either personally performed or advised on childhood immunisations. Virtually all respondents recalled having been informed of the change in schedule and in sufficient time, though some would have wished for more detail (Tables I and II). The modal reported time for dispatching completed SIRS schedules by HVs and GPs was 1-2 days while that for CMOs was on completion of the clinic. The median times were 3-5 and 1-2 days respectively with 22% (32/149) of GPs reporting seven days or more. The transitional arrangement of maintaining the 3, 5, 9 month schedule until children had completed their courses was used by 88% (135/154) of GPs and 91% (82/90) of HVs. All CMOs and 87% (188/217) of those who used the facility believed their decision to be correct. Of all professionals involved in immunisation 87% (227/261) considered present Health Education material appropriate with no significant difference among the professional groups. The two commonest sources of immunisation advice used were Immunisation against Infectious Diseases (Green Book) (64%) and the Health Board Manual (55%). 2 (See Table III.) There were few comments on how the Board itself could improve immunisation apart from by further involving HVs in administering vaccine, possibly introducing a domiciliary service and by improving the accuracy of SIRS records--a function of both the Board and the immunisation centre. On immunisation generally 20% of responders proposed that primary immunisation should have some statutory basis, either as a condition for continued receipt of child benefit or that a child should be required to produce evidence of immunisation (or contra-indication) before entrance to education or possibly to a child care facility. These views were held equally by members of all professional groups. Table I
Satisfaction with information on change in schedule by professional groups (%)
Information Informed of change In sufficient time In sufficient detail
GP (162) 99 95 94
Professional group (n) HV (98) CMO (20) 100 100 93
95 100 78
Table II Schedulesin use by professional groups (%) Schedule 2, 4, 6 month 2, 3, 4 month Both Other
GP (165) 45 48 3 4
Professional group (n) HV (99) CMO (16) 61 34 3 2
75 19 6 0
D. M. Campbell
280
Table III Source of immunisation advice by professional groups (%) Source H. B. Manual National Formulary 3 Green Book Textbook Other
Professional group (n) HV (99) CMO (21)
GP (164) 52 16 60 6 2
65 5 65 4 13
29 14 86 5 0
Discussion
This study has a variety of implications for the provision of immunisation services within Argyll and Clyde Health Board and nationally. The disappointing response rate from GPs may be attributable to certain practitioners, with patients within Renfrew District but whose principal practice location lies within the adjoining Health Board, not responding. Due to the anonymity of the questionnaire it was impossible to send reminders or to study the characteristics of the non-responders. Users appeared satisfied that they had been informed of the changes in good time though some, especially CMOs, would have welcomed more information on the epidemiological and immunological evidence behind the decision of JCVI to recommend the change in schedule. T h e use of two differing schedules by general practice treatment centres may reflect the routine within some practices of giving monthly appointments at the time of first immunisation but using SIRS as a reminder. It was surprising that some CMOs reported one-monthly intervals when all Health Board clinics were using the two-month schedule. This is an unsatisfactory position. Ideally all treatment centres should be using a single schedule, possibly 2, 3, 4 months, but delays in receipt of documentation make such a turnaround administratively difficult. The intervals in returning SIRS information reported by users are less than that found by the original audit within the Community Screening Office; a median interval of 24 days compared with the 3 - 5 days in this study. These cannot be explained by postal services. The probable reason is tardiness in dispatch from the treatment centre after completion. The facility to maintain the f o r m e r schedule for children who had embarked on it appears to have been successful despite requiring more clerical work from both treatment centre and Health Board staff due to failure of the National Centre of Responsibility for SIRS to produce a modified computer program. The changes in the timing of the schedule and the increase in immunisation activity within general practice require that the role of SIRS within a Health Board's overall immunisation programme be re-examined. It may now be m o r e appropriate to use it for initial call, for recording completed courses, and for identifying defaulters while individual treatment centres perform their own scheduling. T h e increasing use of computers in primary care makes this a viable alternative. 4 It would obviate many of the delays inherent in the present system. The satisfaction with the Health Education materials was surprising in view of verbal comments that had been previously received. It may be that responders were confused as to whether they were being asked to comment on material aimed at the public or on that for health professionals. The use made of the Health Board's Immunisation Manual was gratifying. This is a recent introduction aimed at both
Introducing the N e w Schedule
281
supplying practical information and at answering commonly posed questions by professionals and parents. It was alarming that certain HVs depended totally for their information on a health education leaflet designed for parents. The Peckham Report advocated that policy should change towards parents opting out of rather than in to immunisation. 5 This has already occurred to some extent within Argyll and Clyde Health Board, all children being called automatically by SIRS unless a specific contra-indication or parental refusal is recorded. Previous policy only invited those for whom a signed consent was held. Proof of immunisation for school, and possibly day care entry is desirable for both herd immunity and in forcing a parental decision. This would not restrict freedom of choice as a positive opting out scheme would allow the opportunity for withdrawal of a child from the programme because of medical contra-indications or active parental opposition. The case for discontinuation of statutory child benefit is less clear. The social deprivation consequent on this action might have a deleterious effect on the individual child's health. The role of nurses/health visitors has been examined by Begg et al. who reported that immunisations were routinely being given by nurses in a number of English Health Authorities although in less than a quarter by Health Visitors. 6 At that time 16% (30/193) of Authorities had an official domiciliary service, but in only 40% (12/30) of these was it targeted on non-attenders. It is difficult to measure the effect of this alteration in immunisation policy in isolation, as it so closely followed the introduction of financially rewarded immunisation targets into general practice. However, there have been demonstrable changes in achievement as shown by the percentage of practitioners meeting the specific targets. While on 1st April 1990 only 39% of GPs were meeting the 90% target and a further 58% the 70% target, this had changed by 1st January 1991 to 75% and 24% respectively (Oldroyd, M., personal communication).
Acknowledgements The assistance of Dr A. K. Fraser, Senior Registrar in Public Health Medicine, and the cooperation of Miss M. Oldroyd, Director, and the staff of the Primary Care Division, Argyll and Clyde Health Board are gratefully acknowledged. Mrs J. Morrison performed all the clerical work associated with the survey. References 1. Dean, A. G., Dean, J. A., Burton, A. H. et al. (1990). Epi Info, Version 5: a word processing, database and statistics system for epidemiology on microcomputers. Stone Mountain, Georgia: USD Inc. 2. Joint Committee on Vaccination and Immunisation (1990). Immunisation against Infectious Diseases. London: HMSO. 3. British National Formulary (1990). London: British Medical Association and Royal Pharmaceutical Society of Great Britain. 4. Ryan, M. P. (1989). A system for general practice computing in Scotland. Health Bulletin 47, 110-119. 3. Peckham, C., Bedford, H., Sentura, Y. et al. (1989). National Immunisation Study: Factors Influencing Immunisation Uptake in Childhood. London: Institute of Child Health. 6. Begg, N. & White, J. (1987). A Survey of Pre-school Immunisation Programmes in England and Wales. London: PHLS Communicable Diseases Surveillance Centre.
