It is Sunday night, 10pm, and Claire has just put her toddler to bed before we settle in for a Zoom call. Dr Claire Thomas is the immediate Past President of the Vasco da Gama Movement (VdGM) and we have crossed paths many times before I joined VdGM as the Liaison Officer to WONCA Europe. She works, amongst other things, as a GP in London and works as a Clinical Lead with the local GP Federation & Primary Care Network. Claire describes the GP Federation as a network of several GP surgeries, covering approximately 150,000 patients, who work together to deliver care at scale and integrate primary, secondary, community and social care. In times of Covid, this has extended to how to provide healthcare in a safe way using ‘hot hubs’ to examine people likely to have Covid and ‘cold hubs’ for those who may not. Incidentally, I’m not sure why the term ‘hot hub’ was coined here in the UK because when said aloud, the word sounds very much like ‘hot tub’ which means that most of my non-GP friend thinks I work in a luxury bath. I don’t. Anyway, funny stories aside, the Federations & Primary Care Networks are also now tasked with the roll out of vaccines making Claire the ideal person to speak to in order to find out more about how this has been going.
On the practicalities
The UK commenced the vaccination programme on the 8th December 2020 with the aim to vaccinate 15 million before mid-February. The Joint Committee of Vaccinations and Immunisations (JCVI) have published the order of priority that the British public will be vaccinated (see below). This has mainly been rolled out by GPs in this country and we are lucky that all residents are supposed to be registered with a GP surgery. This means that we already have a database of patients to work with and a close relationship with the most vulnerable cohorts.
Trying to roll out a totally new service was always going to be a massive challenge. GPs in a Federation or Primary Care Network (PCN) may join together to hire a central venue where patients can come to be vaccinated which saves on moving the Pfizer vaccine (which is sensitive to temperature and shaking). Claire tells me that her team was essentially given only a few days notice to organise the logistics of vaccinating large swathes of her population. They would need a venue, staff and they would need to come up with a way to contact the right patients, consent them and inject them. Furthermore, Pfizer is a difficult vaccine to work with. Once defrosted, the whole box needs to be used within five days which, in real terms, is three and a half days once it has arrived at the vaccination site. Once opened and drawn up, the vials need to be used within a few hours. When they come in boxes of 195 vials, this is huge operation to vaccinate close to a 1000 patients in this time frame. Furthermore, the deliveries have a wide delivery slot window which means that they could arrive in the morning, lunchtime or sometimes as late as the afternoon on the delivery day. Claire says that her team had to be flexible. They booked a tentative amount of people for the first day and then as many as they could fit during day two and three using five-minute slots. Every patient was given an allocated appointment time and every patient needed to be consented before the vaccination. This can all be rather chaotic on the shop floor because the elderly patients would turn up at times convenient for them rather than at their allotted appointment time. On a few occasions, too many patients turned up at the end of the last day meaning that they have had to crack open an Astra Zeneca vial because all the Pfizer vials were finished. However, the Astra Zeneca vial provides ten vaccines so opening one up for a few patients seemed almost wasteful. At the end of the day, they would collect up all the unfinished vials and, rather than wasting them, they would frantically call local healthcare staff who might be able to come in straight away for a vaccination. I remember Claire once calling me at 8pm on a Friday evening asking me if I wanted a vaccine – even if I had jumped on my bike straight away, it would have taken me an hour to cycle to her clinic which would have meant the vaccine would have gone off by the time I arrived. Making sure that all the numbers add up can feel like a mind-boggling mathematics question.
We also had a sudden change in policy on New Year’s Eve when the government decided to change the interval between the first dose and second dose from three weeks to 12 weeks. GPs were given again just a few days notice to change their appointments when this was announced by the government publicly which created chaos and friction for GPs and patients. The task of cancelling and rebooking over a thousand appointments comes with considerable disruption, time wasted and financial cost. On top of this the cohort of patients was mostly over the age of eighty, thus vulnerable and not easily adaptable at short notice. This constitutes a real breach of trust with patients to whom their GP is often a vital source of support and care. Claire feels that a lot of these policies were designed without considering what it is like at the coal-face where you have a relationship with your patient as well as a duty of care.
On organising and delivering services
Recently, the UK government announced mass vaccination sites offering 24-hour services. Disappointingly, this has not been organised in co-ordination with the existing GP-led services that have been vaccinating patients since the beginning of December. There have been stories of the existing centres finding out about the mass vaccination sites through social media or through their patients which was very demoralising for our GPs. I’m surprised to hear that even Claire, who is well-connected in her local networks, often finds out about new policies through public government announcements and the media rather than through her NHS contacts. Covid policies have often been about political soundbites rather than holistic well-thought-through care in the UK. Do we really think that an elderly patient is going to come in at 3am to get a vaccine? If we are truly worried about anaphylactic side-effects, should we be vaccinating in the middle of the night? What will be the pecuniary cost of creating a 24-hour service and is it really worth it? However, they sound like great government promises and it does make it look like they are doing something.
I also want to know how much support GPs have had to set these Claire says that the help received has been insulting. They have been mandated to start these Covid services, such as vaccination centres and Covid assessment sites, but with very little guidance. However, they are subject to rules and regulations which can be quite furstrating when everyone is just trying their best. Claire points out that there has been many hours spent by lead GPs in her area trying to figure out how to deliver what has been asked of them and this is repeated up and down the country by different groups of GPs in different areas. Furthermore, GPs are being paid £12.50 per vaccine delivered but Claire says that a rough estimations at the moment suggests that they are spending far more than this – on staff (the majority being volunteers), venue and logistics, not to mention governance and planning. What they could have really done with was a template or a model on how to deliver these services which could be adapted depending on local needs. Either this or effective logistical support at a local level with appropriate costing. What we really needed was a system that was co-created between GPs who know their patients and service-providers who know how to put a service together. Instead, it’s a group of medics (all going above and beyond) cobbling together to the best of their abilities a service that works for their populations, probably at a loss.
We all know that I love general practice and certainly this conversation is making me love general practitioners even more. The fact that this is being done often without recognition, quietly and effectively I feel is very commendable. A lot of the focus of the UK media is on ITU understandably but I have loved the way that all healthcare professionals from all areas have pulled together to get this country out of this pandemic
On the moral arguments
We talked about the moral arguments that accompany the vaccine. Vaccines are a limited resource and decisions need to be made on who is most deserving of this precious commodity. This is probably the first time that many doctors in the UK have had to think about these moral debates in this country and it can be a very difficult conversation to have with ourselves, our patients and the public. Who do we vaccinate first? The older populations who have a higher mortality rate or the younger people who are able to contribute more to society? Do teachers count as front-line staff (at the moment, they don’t)? Do we vaccinate less people but ensure that they get both doses or do we vaccinate as many people as possible with only one dose but with less efficacy? Does calling around people you know at the end of the clinic in order not to waste vaccine doses count as nepotism or resourceful allocation? Both Claire and I have worked in low-resource settings before so these thoughts are not new to either of us but it doesn’t mean that we have any of the answers. Who we see as the most deserving in a society can speak volumes of the society itself.
On vaccine hesitancy
Claire is noticing the inequity in the uptake of the vaccine. She works in a very ethnically diverse area but she has noticed that there has been some vaccine hesitancy in her non-White communities. She knows that this comes down to trust and many of her ethnic minority groups have faced institutional abuse by medical systems worldwide. At every level and area of society, Covid has exposed inequities and the vaccine roll-out is replaying this. There has been some incredible work done by charities, religious organisations and minority groups in promoting the vaccine which makes me very proud of everyone working together to make the vaccine roll-out a success through community engagement.
We explored the concept of vaccine hesitancy further. I had to admit to Claire that I had an internal struggle in December about the Pfizer vaccine where my rational scientific brain would go through the reasons why I should have it and my less rational fanciful heart was very resistant. Admittedly, the situation in the UK became so bad that, in January, I decided that I would take the next vaccine that was offered to me but I couldn’t completely dismiss those who were declining getting vaccinated. Claire also admits that there were allied health professionals at the centres who were giving the injections who had said that they wouldn’t have it themselves – whether that was because they were blood type O or because they weren’t sure about the technology. There is so much cognitive bias and illogic which I know that even I succumbed to. I found it very hard to talk about my hesitancy to my colleagues before I had my vaccine (which ended up being Astra Zeneca anyway) and I can imagine that it will be harder for our patients with hesitancy to ask the relevant questions when the time comes. Claire also points out that these are difficult concepts to discuss even amongst healthcare professionals and perhaps it is even harder for the poor admin person who has to ring the patients up to book their appointments!
On working with colleagues
One of the things that I have been struck by during this pandemic is how doctors have variably responded. Some doctors have really put themselves forward to help and some haven’t. Admittedly, many of my own friends have stepped up but I wonder if that is due to the circles that I keep. Claire agrees – some people have risen to the challenge and have been inspiring but others have been apathetic or even unpleasant and opportunistic. At the beginning, it was easy to plough on but now that it is a sustained crisis situation, it is separating the wheat from the chaff. She sees the same tired faces who keep showing up repeatedly and has noticed some very absent faces too. She believes that the pandemic has forced people to show their cards and their inner motivations and is certain that this will impact professional relations once it is over.
She also points out that GPs are still expected to deliver on things that don’t seem particularly relevant at this moment. In the UK, we use Quality and Outcome Frameworks (QOF) to get paid – we hit targets, we receive the allocated money. GPs are still expected to deliver “extended hours” which are late clinics for people who are working. Given that we work remotely now and a lot of people are working from home, Claire feels that this time (and funding) could be used more effectively.
This has been a fascinating conversation with Claire and South London were lucky to have her, with her organisational skills and experience. But I do wonder about the toll it is taking on our senior GPs who are spending a lot of their own time planning these services with very little wider recognition. New Covid cases are falling as are hospital admissions and I sincerely hope that the government continues the lockdown long enough to allow staff to rest and recuperate.
Another thing that I am feeling really grateful for is the National Health Service. There is inequity highlighted by the vaccine roll-out but, at the end of the day, no one can buy the vaccine here. Whatever you say about the moral arguments, the people who are deemed to need it most by our society get it first and not the person with the biggest wallet or status. As heartbreaking as this second wave has been, everyone who needs healthcare has received it and I can only thank the powers that be that I live in a country with universal health coverage.