Vaccination of JCVI cohorts 5-6 and additional funding for vaccination in residential settings

Contents

 

Official

Publication approval reference: C1124

To:

  • PCN-led Local Vaccination Sites
  • Community Pharmacy-led Local Vaccination Sites

Cc:

  • Clinical Commissioning Groups
  • All GPs
  • Regional Heads of Primary Care and Public Health
  • Regional Directors of Commissioning Finance
  • Regional Medical Directors

13 February 2021

Dear LVS sites

Vaccination of JCVI cohorts 5-6 and additional funding for vaccination in residential settings

Thank you for your ongoing efforts to promote maximum uptake of the NHS’s offer to vaccinate everyone in JCVI cohorts 1-4 by 15 February. We have provided clarification on the position on vaccinating children and young people on the Clinically Extremely Vulnerable (CEV) list, and this is attached to this letter (Annex A).

Next week and the week after (i.e. the weeks commencing 15 and 22 February), PCN sites should focus their efforts on inviting JCVI cohort six, which includes a wider group of people at higher clinical risk, including carers and young adults in residential settings.

Building on the outstanding success General Practice has already shown in targetting vaccines for the clinically extremely vulnerable, it makes sense now to ask PCNs to focus on this JCVI group 6 given the relationship between general practice and those with long term conditions, and your important role in maintaining continuity of care. At the beginning of next week, we will also be sharing some further information about the prioritisation of people using an enhanced clinical stratification tool.

Further operational guidance on invitations to cohort six is attached to this letter (Annex B). Please help to make sure no one gets left behind. Continue to do all you can to minimise any inequalities in vaccine uptake between different patient groups wherever possible, working with CCG, LA and community partners, mindful of deprivation, ethnicity and all factors impacting COVID risk.

Template letters for contacting these groups are available on Future NHS.

As PCN-led sites focus on cohort 6, cohort 5 (those aged 65-69) will shortly start receiving an invitation from the national booking service (NBS) to attend a vaccination centre or community pharmacy setting. PCN sites may still vaccinate patients in this cohort and be paid for doing so should a patient request an appointment.

Vaccine should not be given to people outside of cohorts 1-6. It is absolutely permissible, and indeed encouraged, to have reserve lists of recipients, who can come in at short notice if vaccine is still available. However, these lists should only be drawn from eligible recipients in these cohorts.

Vaccination in residential settings

In the coming weeks, PCN groupings, and in some cases community pharmacies when requested by NHS England, will need to deliver vaccinations in residential settings, such as care homes for people with learning disabilities or mental health problems, or hostel/hotel accommodation for the homeless, where it would not be possible for these patients to attend vaccination sites. PCN groupings should work with CCG, ICS, local authority and other partners to establish the most effective ways to serve all of these residential settings and specific groups and determine the most appropriate vaccination delivery model for them.

In such cases from 15 February onwards, a PCN grouping or community pharmacy contractor will be able to claim an additional supplement of £10 for each vaccination administered to eligible residents and staff in these settings, on top of the £12.58 Item of Service fee. All payments made under this mechanism will be made to GP practices under Section 96 of the NHS Act 2006 (as amended) “Assistance and support: Primary Medical Services”, on the terms set out in this letter. This arrangement will be in place until further notification otherwise. A contract variation will be provided to any community pharmacy contractor requested to provide this service. The provision of this supplement is only for COVID-19 vaccination and does not apply to wider vaccination programmes.

We also confirm that there is nothing to prevent PCN groupings from subcontracting this service to another contractor under the existing arrangements and we support innovative models of professional collaboration to ensure patients are vaccinated as quickly as possible.

Recording the setting of the vaccination event

The Pinnacle/Outcomes4Health Point of Care System will be updated to include an additional field relating to the collection of data to support payment of the £10 residential settings supplement.

Any vaccinations recorded as ‘Long-stay care home or long-stay residential facility’ will automatically flow to the NHS Business Services Authority to support the payment of the £10 supplement alongside the Item of Service fee.

How to claim

Guidance on how PCN groupings and community pharmacy contractors should submit claims will be published shortly on the FutureNHS workspace. A Post Payment Verification (PPV) process and review of a sample of practice claims will be carried out. In accessing this funding, practices agree to this process.

Further details on the claims process will also be shared with CCGs and NHSE/I regions shortly.

Movement of the Oxford/Astra-Zeneca vaccine

We issued a position statement on the use of the COVID-19 Oxford/AstraZeneca vaccine to visit housebound patients last month, which provides guidance on safe transport and use of punctured vials. We have recently issued equivalent guidance for the use of the AstraZeneca vaccine in and between care homes. Please read and follow both sets of guidance to ensure safe transfer of vials between residential settings in line with aseptic technique.

Yours sincerely

Dr Nikita Kanani | Medical Director for Primary Care | NHS England and NHS Improvement

Ed Waller | Director of Primary Care | NHS England and NHS Improvement

Annex A: COVID-19 Vaccination of Children and Young People (CYP) in the Clinically Extremely Vulnerable (CEV) Group

In January, a letter was issued to all CEV patients from the Department of Health and Social Care, informing them that they would be invited to have a vaccine. As we are now offering vaccinations to those who are clinically extremely vulnerable, it is important that parents of children on the CEV list, as well as clinicians, are clear on the clinical policy for vaccinating children against COVID-19.

All CEV children have been included on the shielding list following a mandatory assessment by a paediatrician, based on the criteria published by the Royal College of Paediatrics and Child Health (RCPCH) which can be seen here.

Children included on the CEV list fall broadly into the following two categories:

  • Group A – mainly immunodeficiency or with types of cancer;
  • Group B – range of other conditions thought to put them at risk e.g. cardiology, neurology, respiratory etc.

The independent Joint Committee for Vaccination and Immunisation and Public Health England’s Green Book are clear that the majority of children should not be vaccinated at this time, on the basis of a low morbidity/mortality risk from COVID-19 infection; limited safety data; and overall uncertainty regarding efficacy.

For a small number of children, over the age of 12 years, the Green Book states:

Given the very high risk of exposure to infection and outbreaks in institutional settings, vaccination may be considered for children with severe neuro-disabilities who tend to get recurrent respiratory tract infections and who frequently spend time in specialised residential care settings for children with complex needs.

It is estimated that approximately 1,500 to 2,000 children and young people fall into this category. No other children aged less than 16 years old are recommended to be vaccinated.

CEV aged 16 to 18+ years

The Astra Zeneca vaccine is authorised for patients aged over 18 years and Pfizer BioNtech vaccine for those over 16 years. The AZ vaccine would need to be authorised for all CYP by a prescriber (doctor) as it is “off licence”. Pfizer can be administered under PGD or national protocol for CYP aged from 16 years, but to prescribe it for those below this age would be off licence. The Green Book states that either vaccine can be used.

It is recommended that the Pfizer vaccine be the vaccination of choice for CYP as it is authorised for those over the age of 16 years. Pfizer is not currently available at Vaccination Centres, therefore CYP would be vaccinated in Hospital Hubs or at PCN sites.

The following approach should now be actioned for those children and young people who have severe neuro-disabilities and who tend to get recurrent respiratory tract infections and who frequently spend time in specialised residential care settings:

  1. From age 16-18 years called to PCN for administration of Pfizer. This is on licence.
  2. From age 12-16 years called to PCN for administration of Pfizer. This will be off licence and discussions with RCGP indicates that GPs should seek advice from the patient’s paediatrician prior to administration.
  3. Aged less than 12 years, not called for vaccination.

It is important to emphasise that there is a low risk to CYP from COVID-19 infection. The scientific view on which cohorts should be offered vaccination is outlined by the JCVI, and Medical Royal Colleges, such as RCPCH and RCGP, support future work to further refine the understanding of at risk groups and the role of vaccine.

Annex B: Vaccination of cohort 6 in LVSs

From 15 February 2021, we would like you to focus on cohort 6. The majority of people in this cohort will be vaccinated in Local Vaccination Services, building on your existing relationships around the care of long-term conditions and supporting continuity of care. Adult carers who are flagged within GP systems will also be offered vaccination through this route. This note sets out how to approach this cohort.

Summary and eligibility

JCVI priority Cohort 6 includes ‘all individuals aged 16 years to 65 years with underlying health conditions which put them at higher risk of serious disease and mortality’. This also includes those who are in receipt of a carer’s allowance, or those who are the main carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill.

Cohort 6 is further defined in Green Book Chapter 14a as “Adults aged 16 to 65 years in an at-risk group”. The list of at-risk conditions can be further subdivided into three main sub-cohorts:

  • Adults aged 16 to 65 years in an at-risk group which includes:
    • Chronic respiratory disease
    • Chronic heart disease and vascular disease
    • Chronic kidney disease
    • Chronic liver disease
    • Chronic neurological disease, including severe or profound learning disability
    • Diabetes mellitus
    • Immunosuppression
    • Asplenia or dysfunction of the spleen
    • Morbid obesity
    • Severe mental illness
  • Younger adults in long-stay in-patient, nursing and residential care settings
  • Adult carers:
    • Those who are in receipt of a carer’s allowance, or those who are the main carer of an elderly or disabled person, someone who has a severe mental illness or whose welfare may be at risk if the carer falls ill.

Actions for PCN LVSs

PCN LVSs should commence the issue of invitations for individuals within cohort 6 from receipt of allocation information, with appointments for vaccination commencing from Monday 15/02/21.

PCN LVSs should invite individuals aged 16 to 65 with corresponding flags within their clinical record for vaccination. Each clinical condition within cohort 6 has been mapped to clinical codes (SNOMED) available within patient records. The mapping to these flags within SNOMED should be the primary determiner of eligibility for at risk conditions within cohort 6.

Those aged 65-69 are separately being invited to attend Vaccination Centres. If you have patients in that age group who fall into one of the categories above, you may also invite them to attend an appointment at the LVS.

As with previous cohorts, there will be no end date to cohort eligibility i.e., individuals can choose to accept the offer of vaccination at any time once their cohort has commenced.

Second doses of vaccine should be administered approximately 11 to 12 weeks after the first dose. Sites receiving supplies of Pfizer/BioNTech vaccine will be advised of corresponding second dose supplies in a coordinated manner to enable the appropriate scheduling of second dose clinics.

Asthma

An individual with a more severe case of asthma may have been included in the Clinically Extremely Vulnerable group, in which case they will be vaccinated in group 4.

People with asthma which requires continuous or repeated use of systemic steroids or with previous exacerbations requiring hospital admission, will be vaccinated in priority group 6.

This will include:

  • anyone who has ever had an emergency asthma admission or;
  • those who have an asthma diagnosis and have had 3 prescriptions for oral steroids over a 3-month period (each prescription must fall within separate individual month windows), as an indication of repeated or continuous oral steroids.

Learning disability

JCVI determined that those with severe and profound learning disability are in cohort 6. GPs can use GP Learning Disability Registers and SNOMED codes (which describe the impact of learning disability although there is variation in how these are applied) to help identify this group.

We recognise that there may still be people who are not on these registers and the NHS needs to make an extra effort to put this right. GPs should use clinical discretion to ensure the right people who meet the severe and profound learning disability definition are on the register.

Alongside this the NHS is asking our key stakeholders and our voluntary and third sector partners to encourage people who have a severe and profound learning disability to come forward to their local GP. GPs should then assess the individual and if appropriate, add them to the list to be vaccinated. When organising their COVID-19 vaccination, we also advise GPs to use this important opportunity to offer people with a learning disability their annual health check and to book them in for their flu vaccine, so the NHS makes every contact count for this important group of people.

Severe Mental Illness (SMI)

JCVI also determined that those with schizophrenia or bipolar disorder, or any mental illness that causes severe functional impairment are within cohort 6, and we would encourage GPs to take a similar approach for this group of people, to that being proposed for learning disability, working in partnership with secondary care mental health services and VCS partners to ensure appropriate outreach mechanisms are in place.

Settings of multiple occupancy

Green Book Chapter 14a states:

“Younger adults in long-stay nursing and residential care settings: Many younger adults in residential care settings will be eligible for vaccination because they fall into one of the clinical risk groups (for example learning disabilities). Given the likely high risk of exposure in these settings, where a high proportion of the population would be considered eligible vaccination of the whole resident population is recommended.”

The proposed definition for inclusion of such settings is “a closed community with substantial facilities shared between multiple people, and where most residents receive the kind of personal care that is CQC regulated (rather than help with cooking, cleaning and shopping)”.

This would include CQC registered care homes (excluding older people’s care homes who were included in Cohort 1) and those identified as part of the Mental Health Services Dataset (MHSDS) as well as Learning Disability settings sites which are not in the MHSDS and Special residential colleges and supported living.

Shared student accommodation, detained estates (including prisons and immigration removal centres) are excluded within this definition. The COVID-19 Vaccination Programme is addressing vaccination within detained estates separately in conjunction with Health and Justice teams. Vaccination within these settings for individuals within JCVI cohorts 1-4 has already commenced.

Local systems and regions are best placed to map and assure in-reach to the majority of settings of multiple occupancy through their delivery model mix of providers and should continue to advance their plans for delivery to these settings including the immediate mapping of such settings if this has not already commenced.

Further guidance in the form of a mobilisation support pack including; considerations in advance of a visit to such settings; the consenting process and support to prepare for vaccination for homes, residents and families, will be issued week commencing 15/02/21 on how to support vaccinations in settings of multiple occupancy.

Adult carers

Eligible adult carers will be contacted via the National Booking System (NBS) to receive an invitation to book vaccination through Vaccination Centres, Community Pharmacy LVSs or Hospital Hubs, once a list compiled by NHSE/I in conjunction with Local Authorities has been produced.

Local systems may choose to flex these arrangements based on the needs of their populations and PCN LVSs should be prepared to administer vaccination to eligible adult carers who choose to receive vaccination in LVS settings, and are coded as such on the GP system.

Local systems including both the NHS and Local Authorities should continue to collaborate to ensure that individuals within cohort 6 who are resident in settings of multiple occupancy or are adult carers not flagged within GP systems can be appropriately offered vaccination. Further guidance relating to the vaccination of eligible adult carers will be published as a Standard Operating Procedure (SOP) week commencing 15/02/21. This SOP will detail the specific actions that will be required by Local Authorities, carers organisations, DWP, the NHS and adult carers themselves.

We recognise the difficulties in identifying people in this group. We are asking the third sector to help us identify people through public campaigns, with an ‘ask’ that eligible unpaid carers contact their local authority to make themselves known so they can be prioritised for vaccination through the National Booking Service.

PCN LVSs should also prioritise invitations to carers aged 16 and 17 flagged within their systems to align with their known allocations of Pfizer/BioNTech vaccine. The Pfizer/BioNTech vaccine is the only currently authorised vaccine under Regulation 174 which can be used for individuals aged 16 and 17.

PCN LVSs should coordinate the offer of vaccination to carers flagged in their systems so that the carer and the at-risk individual they care for can be vaccinated at the same time if both individuals are registered within a practice in that PCN.

When administering vaccinations to at risk individuals who are housebound, the PCN LVS should, where it is clinically appropriate to do so, vaccinate both the at-risk individual and their main carer (if present) at the same time.

PCN LVSs should ensure that minimum data set within Pinnacle/ NIMS is utilised to capture the status of eligible unpaid carers at the point of care which will ensure that the Validated Vaccination Event (VVE) can be appropriately counted as the vaccination of an adult carer.

Appendix 1
Green Book at risk category Green Book full definition
Chronic respiratory disease Individuals with a severe lung condition, including those with asthma that requires continuous or repeated use of systemic steroids or with previous exacerbations requiring hospital admission, and chronic obstructive pulmonary disease (COPD) including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD).
Chronic heart disease and vascular disease Congenital heart disease, hypertension with cardiac complications, chronic heart failure, individuals requiring regular medication and/or follow-up for ischaemic heart disease. This includes individuals with atrial fibrillation, peripheral vascular disease or a history of venous thromboembolism.
Chronic kidney disease Chronic kidney disease at stage 3, 4 or 5, chronic kidney failure, nephrotic syndrome, kidney transplantation.
Chronic liver disease Cirrhosis, biliary atresia, chronic hepatitis.
Chronic neurological disease Stroke, transient ischaemic attack (TIA). Conditions in which respiratory function may be compromised due to neurological disease (e.g. polio syndrome sufferers). This includes individuals with cerebral palsy, severe or profound learning disabilities, Down’s Syndrome, multiple sclerosis, epilepsy, dementia, Parkinson’s disease, motor neurone disease and related or similar conditions; or hereditary and degenerative disease of the nervous system or muscles; or severe neurological disability.
Diabetes mellitus Any diabetes, including diet-controlled diabetes.
Immunosuppression Immunosuppression due to disease or treatment, including patients undergoing chemotherapy leading to immunosuppression, patients undergoing radical radiotherapy, solid organ transplant recipients, bone marrow or stem cell transplant recipients, HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system (e.g. IRAK-4, NEMO, complement disorder, SCID). Individuals who are receiving immunosuppressive or immunomodulating biological therapy including, but not limited to, anti-TNF, alemtuzumab, ofatumumab, rituximab, patients receiving protein kinase inhibitors or PARP inhibitors, and individuals treated with steroid sparing agents such as cyclophosphamide and mycophenolate mofetil. Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day for adults. Anyone with a history of haematological malignancy, including leukaemia, lymphoma, and myeloma and those with systemic lupus erythematosus and rheumatoid arthritis, and psoriasis who may require long term immunosuppressive treatments. Most of the more severely immunosuppressed individuals in this group should already be flagged as CEV. Individuals who are not yet on the CEV list but who are about to receive highly immunosuppressive interventions or those whose level of immunosuppression is about to increase may be therefore be offered vaccine alongside the CEV group, if therapy can be safely delayed or there is sufficient time (ideally two weeks) before therapy commences. Some immunosuppressed patients may have a suboptimal immunological response to the vaccine (see Immunosuppression and HIV).
Asplenia or dysfunction of the spleen This also includes conditions that may lead to splenic dysfunction, such as homozygous sickle cell disease, thalassemia major and coeliac syndrome.
Morbid obesity Adults with a Body Mass Index ≥40 kg/m²
Severe mental illness Individuals with schizophrenia or bipolar disorder, or any mental illness that causes severe functional impairment.