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A decision made 3 August 2017:

Decision Reference: MD-S-2017-0052
Decision Summary Title :	DS_Removal of flu vaccination from Prescribed list		Date of Decision Summary:	01 August 2017
Decision Summary Author:	Policy Principal		Decision Summary: Public or Exempt?	Public
Type of Report: Oral or Written?	Written		Person Giving Oral Report:	N/A
Written Report Title :	WR_Removal of flu vaccination from prescribed list		Date of Written Report:	01 August 2017
Written Report Author:	Policy Principal		Written Report : Public or Exempt?	Public
Subject: Changes to be made to the Prescribed List (Jersey) as at 8 August 2017
Decision(s): Further to Article 15, paragraphs (11) and (12), of the Health Insurance (Jersey) Law 1967, and having consulted with the Pharmaceutical Benefit Advisory Committee, the Minister decided to make amendments to the Prescribed List with effect from 8 August 2017 to remove inactivated influenza vaccination from the list of medicines available as pharmaceutical benefit
Reason(s) for Decision: Over the past couple of years Jersey has achieved a poor uptake of flu vaccination amongst those most vulnerable to flu infection and experienced a spike in hospital admissions due to flu like illnesses. The current process for delivering seasonal flu vaccination has been reviewed, concluding that subsidy offered via medical benefit and pharmaceutical benefit restricts access and does not encourage practitioners to focus effort where the vaccination is most effective. A ‘flu group’ has been convened and proposed a new process to deliver a subsidised seasonal flu vaccination to target and indicated groups under contract. This new process necessitates the removal of the flu vaccination from the prescribed list. The new process aims to Improve coverage among clinically indicated groups, people and children vulnerable to the effects of flu Protect communities from an outbreak of seasonal flu by vaccinating targeted groups, these include nursery age and primary school children (who are more likely to catch flu, to experience more severe symptoms and spread flu within the population) and staff working in care homes Reduce the risk of winter pressures on the General Hospital Increase patient choice and improve access to flu vaccination services Additional benefits of the flu plan include Improving the value for money achieved with States funding Widening role diversity for primary care providers in line with the objectives of P.82 and the sustainable primary care strategy.
Resource Implications: The overall impact of the changes is expected to reduce total expenditure to the Health Insurance Fund by approximately £100,000
Action required: Business Manager to issue public notice listing amendments and notify all approved medical practitioners and approved contractors.
Signature:		Position: Minister
Date Signed:		Date of Decision (If different from Date Signed):

Prescribed List: Changes from 8 August 2017

Removal of intramuscular inactivated influenza vaccination available as pharmaceutical benefit on the ‘Prescribed List’

The Social Security Department have been working in partnership with HSSD and primary care providers to improve the coverage of the seasonal flu vaccination in Jersey. Analysis of the current process suggests that distribution of States subsidy via medical and pharmaceutical benefit play a significant role in the poor coverage of flu vaccinations.

A new approach seeks to restrict the distribution of public subsidy for flu vaccination to services delivered under contract. The contract will specify the groups which can be vaccinated, thus focussing the effort of practitioners on the groups where the vaccination has most impact and public health benefit. This new approach necessitates the removal of the flu vaccination from the prescribed list.

Further to Article 15, paragraphs (11) and (12), of the Health Insurance (Jersey) Law 1967, the Minister has consulted with the Pharmaceutical Benefit Advisory Committee. The committee offered support for the proposed system including

Agreement that the current coverage is poor
SoJ spends more than is necessary on flu vaccinations
A community pharmacy based model is successful in the UK
The pharmacy service can be delivered under a Patient Group Direction and practitioners are insured to provide this service
The proposed process is well developed and issues such as training have been considered
There is support for improving accessibility
GPs should be incentivized to improve data collection

The committee also noted concerns, however these can be addressed, as described below.

The programme design should consider if there might be a detrimental impact on patients if the flu vaccination is removed from the prescribed list

In previous years 18,000 flu vaccinations were given of which 30% were given to Islanders who were not clinically indicated or members of a target group. The public health benefit in vaccinating these people is not proven. Under the new flu plan the States subsidy will be available to 23,000 people, many of whom will access a fully funded service with no GP fees. Additionally practitioners are being commissioned to offer flu vaccination in work and community settings for target groups (residential care homes and nurseries). In this respect access will be improved and all patients who need the vaccination will have enhanced access.

Flu vaccinations can be given to non target groups as a private service and access for these private patients will also be improved in that the service will be available in high street pharmacy and via practice nurses.

The possibility that current GP processes suppress the number of vaccinations recorded, and coverage may not be as low as reported

In consultation with practice managers and GPs there are varying opinions as to the accuracy of data recorded under the old system. It is possible that the flu vaccination of adults in their place of work is not reported back to the patient’s GP clinical record and therefore is not captured in the public health stats available to policy makers. But it is unlikely that this under reporting is significant enough to lift the low coverage observed in Jersey to NHS England standards. Coverage among people aged 65 and over, who do not access workplace vaccinations sits around 50% in Jersey versus 70% in England. The pattern of low uptake is persistent across all groups and arguably corroborated by the spike in hospital admissions.

Under the old system improvement in data recording cannot be incentivized, the contract mechanism enables improvement in this area.

The possibility that in years when a pandemic emerges, or when the vaccination is matched to the circulating strain, there is some benefit in vaccinating non indicated people.

This contention isn’t supported by the experts in communicable disease who point out that the flu programme proposed here is to tackle seasonal flu. In a pandemic, seasonal flu vaccine (whether on the formulary or not) is unlikely to be of use because a pandemic only occurs when a new flu virus emerges and spreads worldwide because none (or few) of the world’s population have immunity. In a pandemic, the Island would need a pandemic specific flu vaccine and HSSD would source this directly from a pandemic flu vaccine manufacturer, wholly separate from seasonal flu vaccine supply.

HSSD manage a separate strategy for preparedness in the event of a pandemic and for the provision of pandemic specific vaccine. The interval between pandemics is variable but have ranged from 11 to 39 years in the last century – seasonal flu happens every year and the new flu plan work is aiming to improve and sustain access to and coverage of seasonal flu vaccine via an evidence based policy.

The risk that if there is a flu outbreak, removal from the prescribed list will be heavily criticized.

Flu outbreaks have occurred in recent years and are the driver for making these improvements since improving vaccinations rates among, for example nursery and primary school children, can have significant impact in reducing the likelihood of an outbreak.

Regardless of local arrangements, there is always a risk that the strain of flu virus may ‘drift’. This can happen in the period between the World Health Organization advising manufacturers on which flu strains are likely to be circulating the following winter which tells manufacturers which strains to include in the annual flu vaccine and the time when the flu vaccine is ready for use (this is the period between February and October). On average, about once every ten years, the match of the vaccine to the strains of virus circulating may not be a perfect fit because of ‘drift’ and the injectable vaccine available may be less or not effective. Retaining flu vaccination on the formulary would not improve this.

The new flu plan for Jersey aims to increase coverage, target subsidy, improve access and is evidence based. Therefore while criticism may be levelled, the new flu plan can be robustly defended.