The Pharmaceutical Journal
Vol 269 No 7224 p710
16 November 2002

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Influenza vaccination is a logical progression from EHC provision

By Howard G. Lacey

Recently there has been an influenza vaccination campaign operated by Doctorcall's mobile 'flu vaccination clinic in the ASDA supermarket chain. The public have been encouraged to see a one-day-only clinic as a useful public service. I understand that it works on the basis of a private version of the patient group direction (PGD) rules using nurses at the supermarket. Also, a National Health Service PGD is allowing pharmacists to supply and administer 'flu jabs in Scotland. Both developments have been reported in The Pharmaceutical Journal (5 October, p470).

The NHS annual influenza vaccination campaign is quite effective but it does have weaknesses. Not all general practitioners achieve the immunisation targets for elderly patients and younger patients qualifying for NHS vaccination due to high risk status are often missed.

Probably most ASDA customers do not belong to the groups the NHS would wish to see vaccinated. These patients represent a demand for preventive medicine that the NHS is unwilling to supply. The ASDA service was available for only one day; this does not solve the problem of low vaccination uptake rates or ensure equality of health care provision. On the basis of improving access to vaccination services and increasing vaccination uptake in the NHS target groups, I believe community pharmacists should be offering this service.

The current legal position

Currently, influenza vaccine can only be supplied by pharmacies on a valid prescription from a qualified practitioner (this now includes independent nurse prescribers) or under a PGD. The use of a PGD would allow the free supply of vaccine to those patients the NHS wants to protect but would exclude private supply if the PGD was issued under the authority of an NHS doctor on behalf of a primary care trust.

To satisfy the legal requirements for private prescribing, it is necessary to employ either a doctor or an independent nurse prescriber, or to have a private only PGD.

So, having worked out how community pharmacists may supply the influenza vaccine, let us now consider how they will administer it.

Few health care professionals are allowed to administer injections. They include doctors, dentists, nurses and health visitors. The Medicines Act does not normally allow pharmacists to administer injections except in circumstances where the patient is in grave danger of immediate death (for example, adrenaline could be administered to a patient suffering an anaphylactic reaction). However, in the case of the Aberdeen PGD, a pharmacist who can administer 10 injections to the satisfaction of a supervising nurse will be allowed to work alone. This is subject to satisfactory training in vaccination risks and, presumably, resuscitation techniques, and patients being willing to complete the necessary consent form.

Extend Aberdeen programme

I believe that the Aberdeen programme should be extended throughout the United Kingdom. Furthermore, I can see similarities to the supply of emergency hormonal contraception that should be applied to influenza vaccine. In the case of EHC, patients whom the NHS wants to be protected can be treated free of charge while those outside the NHS at-risk categories could be asked to pay privately to obtain protective medication. How, then, might a community pharmacy service be seen?

Through the University of Derby I have been researching opinions relating to the supply of influenza vaccine from community pharmacies.

That ASDA is willing to offer the public a vaccination service must be based on market research findings. In order to avoid damaging its public image it must have found a degree of public acceptability for this service. Furthermore, research will also have identified a level of demand for the service which the company considered commerci-ally viable. This implies that a community pharmacy based service also could be a success in economic terms, particularly if a PGD to supply a free service to the NHS target groups was incorporated.

I sought opinions of interested parties, patients (represented by a local surgery's patient participation group), nurses and health visitors, doctors, pharmacists and preregistration pharmacy graduates. Members of the patient participation group were willing to accept pharmacy-based supply providing it improved access to vaccines and increased uptake rates. They saw advantages for medical centres in the form of a reduced work load for the doctors and surgery staff. They expected the pharmacies offering a walk-in service would increase patient access and would help them avoid queues at the surgery.

How do nurses and health visitors consider community pharmacy involvement? Nurses, when asked if they believed community pharmacists could administer the injection, said that, with the necessary training, including what to do in emergencies, pharmacists were easily capable of the task. During 'flu clinics, doctors and nurses vaccinate three or four patients every minute at the local health centre so the actual administration procedure cannot be too difficult to master.

Doctors' views were split on pharmacy supply. They conceded that pharmacists with training should be able to supply, as independent prescribers, and administer 'flu vaccine and that this would increase patient access and uptake. A contrary view was that such a move would have an adverse effect on doctors financially. At present, GPs receive an administration fee, profit on the discounted cost of the vaccine and a bonus for achieving their target level of uptake.

Pharmacists' and preregistration students' views were largely supportive of an extended role into influenza vaccination although some said they would be unwilling to administer the vaccine. Most were concerned about the time needed for this service but there were suggestions that qualified checking technicians could perform most of the dispensing role, freeing pharmacists' time. This is precisely the kind of health care service community pharmacists should be offering.

Practical considerations

All groups considered that pharmacists need improved consultation areas or treatment rooms, with inherent cost implications. To offer a vaccination service pharmacists would need a recording system (preferably with an ability to link to GP surgeries), resuscitation equipment, sharps disposal facilities, and training similar to that given to those involved in the Aberdeen project.

The management of a repeat prescription service also needs to include an improved consultation area; this proposed vaccination service could make such improvements more viable.

It requires a legal entitlement, and extra training and equipment to embrace this extended role but this could lead to a vastly enhanced potential for medicines management. For if pharmacists can administer injections, they should be able to take blood samples, and this will allow them to monitor many repeat medication plans.