Commissioning Support for London

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• Commissioning Support for London
• Increasing MMR uptake
• Debrief on HCP Stakeholder Workshop
• and Project Recommendations
• 9th September 2010

A partnership between The Information Centre for
health and social care and Dr Foster Holdings
LLP FESC approved supplier
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Purpose
To share output from the HCP Stakeholder Workshop
held on 23rd August, 2010. To make, discuss and
agree recommendations for next steps.
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Context
Kensington Chelsea
Newham
Higher SEG Workshop
Higher SEG Workshop
Lower SEG Workshop
Lower SEG Workshop
Quantity of Ideas
Stakeholder Workshop
Refined Intervention Ideas
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An aside Asian paired depths
There were two differences compared to non Asian
responses 1. Their GP practice places
responsibility on them to make appointments It
is our responsibility to make the appointments
for the injections. They dont call you or send
you a letter to remind you. It is left entirely
to you.
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An aside Asian paired depths
2. They are culturally pre-disposed to
comply.. I got the MMR and other jabs
because it is the procedure. It is in the red
book and the midwife told me I must get all of
them on time. You dont question health
professionals. They know best. MMR-It was
just like any other jab. You got to do it because
it is in the book. There is no question about it.
It is also for the safety of my son. But they
want and seek out information in a way their
mothers never did We had concerns about all
the injections in general and wanted to find out
more about side effects for all of them. Our
mothers simply followed the procedures without
asking any questions.  
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An aside Asian paired depths
They perceive the potential barriers in their
community to be language and accessible
information These women would not know when
to make the appointments. There is no one to
remind women to get the jabs and the
responsibility is entirely on you to get it done.
We were proactive about it because we are
educated. But it is easy for many to forget it
because of the language barrier. If they
cant read the Red Book they wont know what to
do.
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HCP Workshop - Sample
From Newham 2 GPs School nurse Health
Visitor Practice Nurse   From KC Practice
Manager GP Practice Nurse Immunisation
Improvement Nurse Specialist Team Co-ordinator
Health Visiting 2 School Nurses
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HCP Workshop

• Objective
• To assess a range of ideas generated by primary
  care givers, to build on
• those ideas and generate additional ones which
  can then be taken into
• further research.

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HCP Workshop - Findings

• What issues do you have with the child
  immunisation journey?
• 1. Parents
• If I could get away without having the parents
  there it would be great! PN
• They make it harder
• Children tend to exhibit their worst behaviour in
  the presence of their parents.
• The 4-5 year olds are the worst because they
  fight and kick.
• They can adversely influence the child
• Quite often the parents have warned the child
  youre
• going to have an injection so theyre
  screaming before they arrive.

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HCP Workshop - Findings

• What issues do you have with the child
  immunisation journey?
• 1. Parents
• They have lots of questions or anxieties
• You find in KC that you have a lot of Google
  mothers and they challenge everything with lots
  of questions ... but they listen more to the GP
  than they do to nurses.
• The parents who resist usually know someone who
  has had a bad experience or theyve heard
  something on the grape vine but they dont tell
  you this when they come in so its really
  difficult to work with because you dont really
  know what the issue is
•  

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HCP Workshop - Findings

• What issues do you have with the child
  immunisation journey?
• Parents
• They often dont want to hold the child
• At our practice weve had to train the
  receptionist to hold the child
• Its why school nurses enjoy immunisation the
  parents arent present and the children are
  reluctant to make a fuss in front of a teacher or
  class mates
•  

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HCP Workshop - Findings

• What issues do you have with the child
  immunisation journey?
• 2. The effects of the MMR diseases are not well
  enough known by parents
• We cover a travellers site and they point blank
  refused to have the vaccine until one of the
  children got mumps and they saw how sick they
  were and they all came in for their vaccine. PN
  KC
• The acronym MMR
• Parents have an issue with MMR because it is 3
  in 1, yet have already had a 5 in 1
  (DTaP/IPV/Hib) without demur. Should the name
  change to make it less obviously 3 in 1?
•  
•  

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HCP Workshop - Findings

• What issues do you have with the child
  immunisation journey?
• 4. Administrative hassle
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• Unclean databases
• Were chasing ghost patients that we know dont
  exist because the records arent updated
• Effort required to gain recalls
• Weve started doing text message recalls and
  that works so much better than the letters.
•  

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HCP Workshop - Findings

• What issues do you have with the child
  immunisation journey?
• Dislocated System
• Accessing and sharing patient records across
  different reporting systems can be very
  frustrating.
• Co-operation between GPs, Practice Nurses,
  Health Visitors, School Nurses, PCTs is not as
  good as it needs to be.
• It should be compulsory for private practices to
  share details of their patients who have/have not
  had their vaccinations.

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HCP Workshop - Findings

• What issues do you have with the child
  immunisation journey?
• Inconsistency of information messaging
• There is no anchor information source for them
• Perceive currently available leaflets to be
  vague or insufficiently detailed
• Perceive there to be nothing available in a wide
  range of languages.
•  

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HCP Workshop - Findings
What issues do you have with the child
immunisation journey? 7. Migrants   Families
coming from abroad have had MMR in their home
country but not to the same level as in the UK
nurses have to titrate the vaccination to bring
them up to the UK standard. 8. Distrust within
the Somali community Perception fanned by
propaganda that vaccinations are insidious
invasions of Muslims. Suggestion to get Mosques
on side to communicate the importance of
vaccination for the health of the child.    
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HCP Workshop - Findings

• Training Education
• All, bar GPs, had and continue to receive
  training.
• Most believed it to be good and some thought it
  had improved recently
• Updates are sometimes irrelevant e.g. health
  visitor going to training for HPV which they do
  not give
• All claimed they had received no training in
  dealing with anxious patients.
• All claimed to read CMO letters and Vaccination
  Update and appeared well informed.

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HCP Workshop Idea Assessment
Patient Ideas assessed against 3
criteria Cost 1 Inexpensive 5 Extremely
Expensive Practicality 1 Highly Practical 5
Extremely Impractical Time to Effect 1
Short 5 Extremely long Treat results with
caution!
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Idea Assessment

• What would be the best way to find out about
  jabs?
• Before the birth
• 1. Face to Face
• At hospital appointments 2.5
• Ante-natal class on subject 2.1
• Pre-appointment with GP or at check-up 2.0
• Meeting with other new parents in a facilitated
  group 2.1

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Idea Assessment

• What would be the best way to find out about
  jabs?
• Before the birth
• Communications
• DVD given during pregnancy 2.9
• TV screens in ante-natal departments 2.4
• TV channel (not subscription) 2.3
• Written
• In Pregnancy book, but easy to read with more
  visuals 2.0
• Emmas Diary 2.0
• NHS leaflet sent to home or in Bounty Pack 2.0
• Text 2.1
• i-phone app 2.2

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Idea Assessment

• What would be the best way to have your questions
  answered?
• Moderated Group discussion 3.4
• On-line forum 2.2
• Specialised jabs web-site 2.6
• Pharmacist 2.8
• Top supermarkets / Boots stand 2.5
• Imms helpline 2.7

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Idea Assessment

• Where would be best?
• At home 4.0
• Mobile unit 3.4
• Specialised centre for immunisation 3.3
• Childrens environments 3.7

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Idea Assessment

• Who could administer the jabs?
• Midwives 2.7
• Child-friendly nurses 2.2
• Health visitor 1.9
• Community immunisation specialist 2.3
• Parents, specifically Dads 3.7
• Phlebotomist 3.4
• Health advisor 3.1
• Pharmacist 2.8
• Paramedics 3.6
• Health care assistants 3.1

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Idea Assessment

• When would be best?
• Greater flexibility 2.6
• Enable the making of appointments 2.7

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Idea Assessment

• How could the experience be better?
• A less clinical environment 3.4
• Have a play worker 2.8
• Have a more calming position for the child 2.3
• Options of 2.1
• A nurse to hold the baby
• Take baby away
• Character transfer on plaster 2.3
• Reward for the child e.g. lollipop 2.3
• Telephone call to the parent 24 hours later 2.3
• Enable anonymous feedback 1.8

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HCP Workshop Their Ideas

• What information should be made available and
  how?
• Timeline on an A4 sheet showing what vaccine is
  due when
• Visual aids specifically for showing how bad the
  diseases are
• Given 34-36 weeks in pregnancy
• Ideally the health visitor would meet with the
  mum at 34-36 weeks to give them the red book and
  the birth to 5 book and talk them through what to
  expect when the baby is born including imms.
• Have vaccination leaflets in different languages
• I can print off information for all sorts of
  things in any language but I can only get
  information for vaccinations in a few languages

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HCP Workshop Their Ideas

• What information should be made available and
  how?
• Reminder letter to be sent out with a leaflet
• Have one good web-site that all HCPs use and to
  which to direct patients
• Parents evening at schools invite parents who
  have had MMR to explain MMR to worried parents
  (similar to what is currently offered for
  breastfeeding)
• Provide answers to frequently asked questions on
  Mums Net
• Proactive media relations to counteract negative
  comment
• Vanessa Feltz was going on about how bad MMR is
  on the radio the other day.

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HCP Workshop Their Ideas

• Training
• HCPs should have a better understanding of the
  patient's journey
• Workshop presentation was enlightening for many
  and copies were requested
• Training in dealing with anxious parents and the
  best ways to address
• specific myths.

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HCP Workshop Their Ideas

• Who, Where, When
• Imms centre separate from GPs - offering
  flexible hours
• Immunisation days at nurseries and at schools
• Make it compulsory for children to have complete
  MMR vaccinations up to the British standard in
  order for them to gain entry into the UK
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HCP Workshop Their Ideas

• The Experience
• Better preparation for parents so they know
  what to expect
• Sweets before the jab
• Play specialist e.g. like they have at Great
  Ormond St
• Ensure the waiting time is short
• Reduce the turnover of practice nurses so that
  parents can see the
• same nurse each time they visit
• More time to give the jab
• the actual time it takes to give the jab is not
  the problem its the engagement thats a
  problem

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HCP Workshop Findings
What degree of change is desirable? Incremental
5 or Radical 6 Voting in line with the
degree to which they might lose
income/responsibility/satisfaction.
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Recommendations

• The Project originally envisaged that the next
  stage be the
• development of stimulus for intervention
  concepts for further research.
• Based on the findings to date we no longer feel
  this to be appropriate.
• The ideas that have been generated are
  predominantly simple conceptually, and many would
  undoubtedly be validated in a further round of
  research.

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Recommendations

• There is a strong strategic case to explore a
  radical option placing responsibility for child
  immunisation within a new or existing (NHS Blood
  Transplant Immunisation) organisation, operating
  pan London at the outset
• Focus
• Economies of scale
• Obviate many current issues
• data collection and sharing across different
  systems
• requirement for collaboration across differing
  organisations and professionals
• inadequate core information
• GPs and HCPs seen as partial or having vested
  interests

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Recommendations

• We should initiate projects in two areas that
  will have specific influence on MMR uptake
• 3.1 HCP Training
• A training course for HCPs involved in
  immunisation should be scoped and developed.
• Aims is to help HCPs to better empathise with
  and confidently reassure anxious parents.
• Should draw on the Patient Journey insights
  gleaned from the Workshops and make use of the
  Conversations videos.
• Suggested Next Step Scope the course.

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Recommendations

• 3.2 Central Information Content Provision - a
  dedicated and actively managed Pan London
  resource providing
• a website and online forum, consistently
  optimised for search
• search engine marketing to guide parents
  unerringly to the site
• a range of leaflets, letter and text templates,
  parent pre-briefing materials in multiple
  languages
• content to and influence with the publishers of
  Emmas Diary, Red Book
• a narrative line that works from pros (mumps is
  deeply unpleasant) to cons (there has been a now
  discredited link to autism) rather than from cons
  to pros as in MMR the facts
• Suggested Next Step Draft scope and brief

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Recommendations
4. We should meet in a separate session or
workshop to review the balance of ideas generated
and determine whether and how they might be
progressed.
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