EVALUATION OF A PILOT PROGRAMME
TO PROVIDE SEASONAL INFLUENZA
VACCINATION TO STAFF IN CARE HOMES
Dr Selina Rajan
Public Health Registrar
Elaine Dunlop
Public Health Lead
Surrey County Council
1
Executive Summary
The Surrey County Council Public Health team was awarded a grant by NHS Surrey Downs
Clinical Commissioning Group (CCG) as part of the CCG’s Systems Resilience Grant to provide
seasonal influenza vaccines to staff in care homes in the Surrey Downs area. The team
commissioned a pharmacist to visit all interested homes and vaccinate staff on site. Local
pharmacies were also recruited to accept vouchers, which were distributed to participating care
homes to be cashed in for vaccinations.
We recorded uptake among staff members and carried out a theory of change process evaluation
to establish the challenges and barriers to a staff vaccination programme and also to identify the
existing assets within care homes and the community.
We vaccinated 33 of 76 (43%) care homes in Surrey Downs and we established that 21 (28%)
were already offering vaccinations to their staff. Overall, seasonal flu vaccine was made available
to 71% of care homes in Surrey Downs in 2015.
Of homes who participated, we supplied 205 vaccinations. On average, for each home we
vaccinated, we reached 54% of staff on duty that day. This ranged from home to home from 20%
to 100%. If we were to extrapolate this average uptake, we could estimate that this year, 38% of
staff in care homes in Surrey Downs may have been vaccinated and had we not rolled out this
project, this would have been approximately 15%.
We also carried out qualitative analysis in the form of key informant interviews and focus groups
with involved parties. This analysis was used to address each of the assumptions in the theory of
change model. In summary, we identified that care homes in the Surrey Downs area are keen to
vaccinate staff, but struggle with logistical difficulties in providing the vaccine and also enabling
staff to access it outside of their often antisocial hours. Staff were very keen on a model in which
their own nurses could give the vaccine to all staff in the care homes, thus saving on logistical
difficulties, time and cost. We also established that staff felt that their access to information and
education regarding flu was limited but were very keen to promote this.
This evaluation was made possible from a single pilot programme and we would recommend that
this programme was repeated and scaled up. The potential cost savings from hospital admissions
are substantial and staff were keen to help to find further cost saving initiatives to vaccinate
themselves and educate among themselves if provided with the resources.
2
Introduction
Influenza is an acute, highly infectious viral infection of the respiratory tract, which can manifest
clinically as fever, chills, headache, muscle aches and fatigue. It occurs every year – with most
cases reported during an eight to ten week period in the winter. For the otherwise healthy,
influenza is usually self-limiting within a week but can be easily transmitted to others. In older
people and people with longstanding underlying health conditions such as chronic obstructive
pulmonary disease, serious illness can result from influenza. These groups are at a greater risk of
developing more serious complications of flu, such as bronchitis, pneumonia or cardiac problems.
Influenza is a key factor in NHS winter pressures. It impacts on both those who become ill, the
NHS services that provide direct care, and on the wider health and social care system that
supports people in at-risk groups. In particular, influenza is a key cause of mortality, morbidity and
use of health services in elderly patients. It can spread particularly rapidly in care homes, with
attack rates ranging from 20-40%, reaching potentially 60% of residents (Hayward et al, 2006).
Hospital admissions can occur in more than 10% of cases (Coles et al. 1992) and between 5 and
55% of cases are fatal (Morens & Rash 1995)
Ambulatory Care Sensitive Conditions (ACSC) are those which cause emergency hospital
admissions, which are deemed to be preventable; these include those avoidable through
vaccination. Influenza and pneumonia were the leading causes of emergency hospital admissions
for ACSC in England in 2009/2010 and accounted for 13.4% of admissions and 20% of cost. (Tian
et al. n.d.). These admissions cost approximately £286 million annually to the NHS, which would
otherwise be preventable through vaccination. Admissions for influenza and pneumonia in
particular were greatest in the elderly population. We know that nearly 80% of patients who stay
over two weeks in hospital are of the 65 and above age group (Poteliakhoff & Thompson 2010)
and this extended length of stay can also magnify costs of hospital admissions amongst the
elderly.
The flu vaccine is still the best protection we have against an unpredictable virus, which can cause
severe illness and deaths each year among at risk groups, including older people and people with
long term conditions. We know that vaccination of care home residents against influenza is
effective in preventing respiratory illness, admissions to hospital and death (Jefferson et al., 2005;
Monto, Hornbuckle, & Ohmit, 2001; Ohmit, Arden, & Monto, 1999). However, research
demonstrates that the immune response to the influenza vaccine in elderly patients (especially
those with multiple morbidities) is reduced to 50-70% (Remarque et al. 1996; Beyer et al. 1989),
3
rendering this population at greater risk of influenza than other vaccinated individuals.
Reassuringly, vaccination of healthcare workers with direct patient contact has been shown to
significantly lower rates of influenza-like illness, hospitalisation, and mortality in the elderly in long
term healthcare settings (Public Health England 2015; Department of Health et al. 2016). A cluster
randomised trial demonstrated significantly reduced hospital admission rates in care homes where
staff were vaccinated compared to homes where they were not. It was estimated that for every
20.4 vaccinations delivered, one hospital admission could be prevented (Hayward et al. 2006).
Following advice from the Chief Medical Officer in 2012, (Professor Liam Donaldson 2000)the
Department of Health, Public Health England and NHS England collectively advise that the
influenza vaccination should be offered to all frontline healthcare workers irrespective of their age
or risk factors and advise that at least 75% of staff should be vaccinated to provide effective
immunity. In the public sector, frontline healthcare staff receive these vaccines for free; however,
vaccinations are not made freely available to health and social care staff in the independent sector,
who must rely on their employers’ occupational health department to provide these. In Surrey,
which has a diverse independent care sector, most care homes do not have an occupational health
department and many staff are therefore unable to access the vaccination unless they take time
out of their working day to get it and often pay for it.
In Surrey, uptake of the vaccine among NHS healthcare workers in 2014/15 was significantly lower
than the 75% target and lower than comparative areas (figure 1). This demonstrates that even
where the vaccine is made freely available, uptake rates remain insufficient and it follows that in
working environments where it is not available, these uptake rates are likely to be even lower.
4
Figure 1.
Surrey Frontline Healthcare Workers influenza Vaccination Uptake
2014/15
Organisation
No. of
Seasonal
Vaccine
healthcare
influenza
uptake
workers in
Vaccines given %
direct patient
since 1/9/2014
care
Surrey and Sussex Area Team
45,361
20,254
44.7
Ashford and St Peters
2588
919
35.5
Epsom and St Helier
3904
2164
55.4
Frimley Park
4653
2514
54
Royal Surrey County Hospital
2816
1081
38.4
1712
575
33.6
3360
1492
44.4
4438
3008
67.8
Trust
Surrey and Borders
Partnership NHS Foundation
Trust
Surrey and Sussex Healthcare
NHS Trust
Comparative data.
Hampshire Hospitals NHS
Foundation Trust
Care home staff provide a valuable service and residents rely upon them to be fit and able to look
after them. Whilst influenza is less likely to have serious sequelae among fit and healthy staff
members, many do develop influenza and have to take sickness absence as a result (O’Reilly &
Stevens 2002). Sickness absence in any healthcare setting can impact on service provision during
periods of increased winter pressures, particularly in care homes where many residents have a
high dependence.
5
Aims:
The project sought to establish whether there is an association between offering
vaccinations to staff in nursing and residential homes and uptake of the influenza vaccine
among staff in nursing and residential homes
Objectives:
1) To establish and compare acceptability, feasibility and cost of on-site and pharmacy based
vaccination delivery models
2) To facilitate uptake of the influenza vaccine by 75% of all care and domestic staff working in
private residential and nursing homes in the NHS Surrey Downs CCG area during the 2015/16
influenza season
3) To establish if increased uptake of influenza vaccine amongst staff is associated with:
i)
Reduced staff sickness absence
ii) Reduced staff incidence of influenza
iii) Reduced resident incidence of influenza
iv) Reduced resident morbidity
v) Reduced resident mortality
This project aligns closely with the integrated care agenda and supporting delivery of the Better
Care Fund metrics in the NHS Surrey Downs CCG area given the prevention focus of this
work.
6
Description of the project
Structure
This was a pilot study funded through NHS Surrey Downs CCG’s Systems Resilience Grant and
managed by Surrey County Council’s Public Health team. Following an application for funding,
Public Health was awarded a grant at the end of October 2015 to provide influenza vaccinations for
healthcare staff working in independent nursing and residential homes in the Surrey Downs area.
The team consisted of Elaine Dunlop, Public Health Lead and Selina Rajan, Public Health
Registrar, who co-ordinated all communications, management and administration as well as
monitoring and evaluation. The team collaborated with local agencies including the Surrey Care
Association and the Local Pharmaceuticals Committee. There were 76 care homes identified in
Surrey Downs.
Process:
We initially made contact with board members from the Surrey Care Association (SCA) to hear
their views and to better understand the issues they had faced in the past. They agreed to
participate and through this forum we contacted all SCA member homes in Surrey Downs via
emails, posters and flyers. We followed this up by attending the providers’ network meeting in early
December 2015, where we delivered a presentation to care home owners about influenza, the
importance of vaccinating staff and what the pilot project entailed. In addition to this, we
telephoned every care home manager in the Surrey Downs area to discuss the project with them
and to offer for them to participate. Where managers were keen to take part, they discussed the
project with care staff and displayed posters and flyers, which we supplied, to gauge the level of
interest. Accordingly the managers signed up to the program where staff were interested.
On site clinics:
For the on-site clinics, we commissioned a London based pharmacist who had been involved in
previous pilot projects to supply vaccinations in care homes. He had the appropriate training and
resources, and also had a private Patient Group Directive (PGD) that allowed him to vaccinate staff
on site. These resources included two mobile fridges to store vaccines at the suitable temperature
and an emergency kit in the event of acute anaphylactic reactions. The pharmacist himself was
passionate about the importance of providing vaccinations and education to healthcare staff to
protect vulnerable care home residents.
7
The pharmacist was commissioned to visit each care home in prearranged drop-in clinics between
the 26th November and 11th December 2015 to offer the vaccines to all care and domestic staff on
site.
We divided participating care homes into eight geographical clusters as shown in the figure below
and arranged on site clinics on eight separate dates accordingly. Following discussions with
managers, we agreed on a time when the highest possible numbers of interested staff would be
available, taking into account different shifts and busy times for care (such as meal times). When
the pharmacist arrived, he identified all staff who wanted the vaccine and took the opportunity to try
to engage other staff members as well. In some cases this resulted in the care home booking a
second visit with the pharmacist for him to vaccinate staff on different shifts. The pharmacist noted
down the total number of staff on duty that day as well as the number of people who had the
vaccine and any adverse reactions. There were no limits to the numbers of staff who received
vaccinations and each vaccination was allocated five minutes.
8
Map of the 8 clusters into which care homes were divided for on site flu clinics
Vouchers:
In addition, vouchers were provided to homes, which staff could cash in for an influenza vaccine at
one of five local pharmacies in the Surrey Downs area. These were valid until 31st December to
enable staff more flexibility. During initial discussions with care home managers, each of these
options were discussed and managers selected one or both of these delivery methods.
9
The vouchers were organised through the Surrey Local Pharmaceutical Committee (LPC), who
agreed to provide vaccinations to staff members who were not able to attend the clinics in the
workplace. The participating pharmacies were:

Asda Pharmacy, Burgh Heath, KT20 5NZ

Buckley Pharmacy, Ashtead, KT21 1AW

Grove Pharmacy, Great Bookham, KT23 4LP

Sainsbury Pharmacy, Epsom, KT17 1EQ

Sainsbury Pharmacy, Cobham, KT11 1HW
Care homes were issued with numbered vouchers by post to give to staff members to cash
in for an influenza vaccination at any of the above pharmacies. The pharmacies were
requested to return used vouchers to NHS Surrey Downs CCG to redeem their payment.
An example voucher is displayed below:
Example of an influenza vaccine voucher:
Surrey Downs Care Home Staff
Flu Vaccine Voucher:
To be redeemed at selected pharmacies only
before December 31st 2015
To be completed by staff member:
Care Home Name:------------------------------------------------------------------------------Staff Name:------------------------------------Signed:-------------------------------------------
To be completed by Pharmacist:
Pharmacy name:-----------------------------------------------------------------------------------
Date:---------------------------------------------Signed:-------------------------------------------
10
Evaluating the pilot project using a Theory of
Change Model:
We used a theory driven approach to evaluation of a complex intervention called ‘Theory of
Change’. Theory of Change is ‘a theory of how and why an initiative works which can be
empirically tested by mapping out what we believe to be the causal pathway to an impact and
assessing every expected step on that pathway (De Silva et al. 2014).
A map of the process is displayed below as a Theory of Change model. It identifies each of the
logistical preconditions necessary for the project to work in white boxes, for example:
Pharmacists trained to deliver
vaccinations and manage adverse events
Precondition
Pharmacist has relevant patient group
directive
Precondition
The green boxes depict any interventions, which the pilot intended to trial, for example:
Care home manager identifies staff interested to take part
Intervention
Vaccination administered by
pharmacists in return for
vouchers in participating
pharmacies
Intervention
The aim of the project was to monitor the effect on any primary outcomes and these are depicted
in orange boxes, for example:
Intervention
Vaccination
administered ‘on site’
to staff in care homes
by pharmacist
Care and Domestic staff in care homes receive flu
vaccination
75% of eligible staff in
care homes receive flu
vaccination
Primary
Outcome
Precondition
11
Furthermore, any secondary outcomes, which we predicted for the longer term, are depicted in
yellow boxes, for example:
75% of eligible staff in care
homes receive flu
vaccination
Primary Outcome
Reduced incidence of
influenza in staff in care
homes
Secondary Outcome
Each precondition depended on certain assumptions, which the evaluation was designed to test.
These are shown as blue stars. Aspects of the model were also evidence based and these are
depicted in the key as red stars.
Our evaluation set out to test the assumptions in this model and to determine what factors might
predispose success at each level. The theory of change model is displayed below.
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Grant Awarded
1
Preconditions
Pharmacists trained to deliver vaccinations and
manage adverse events
Intervention
Funds Available
Pharmacist has relevant patient group directive
Primary Outcome
2
100% Care Homes in
Surrey Downs identified
3
Secondary Outcome
Contractual agreement to commission pharmacists
to deliver vaccinations on site or in pharmacies
Assumptions
-Meeting and presentation with Surrey Care Association members
-Surrey Care Association emails
-Direct telephone calls to managers
-Supporting Flyers
-Supporting Posters
Rationale
Reduced mortality in residents
in care homes
4
Reduced incidence of morbidity
in residents in care homes
100% Care Homes not already providing flu vaccinations to staff
are aware of the programme and invited to participate
3
4
5
6
Reduced incidence of influenza
in residents in care homes
Care home manager identifies staff interested to take part
15
11
12
7
Vaccination administered by
pharmacists in return for vouchers
in participating pharmacies
8
2
Vaccination administered
‘on site’ to staff in care
homes by pharmacist
Reduced incidence of influenza
in staff in care homes
10
1
75% of eligible staff in care
homes receive flu vaccination
9
Care and Domestic staff in care homes receive flu vaccination
14
13
Pharmacist promotes vaccine to non
participating staff whilst on site
Increased awareness of flu vaccination
and its benefits among care home staff
Reduced staff sickness absence
13
Key Assumptions in Theory of Change Model:
Assumption
There is a pharmacist who is available with little notice to travel to care
homes with the necessary equipment to safely deliver flu vaccinations.
 4
Care homes are not providing the vaccination to staff already.
 5
Care home managers: understand the importance of flu vaccinations
for staff; are engaged, supportive and willing to take part.
 6
Staff understand the importance of flu vaccination and are willing to
have it.
Care homes are able to gather staff at a suitable time for the
pharmacist to attend.
Staff attend the flu clinic and give verbal consent to have the
vaccination.
Sufficient vaccinations are available in Surrey Downs.
 7
 8
 9
 15 Reduced incidence of confirmed influenza in staff will reduce
confirmed influenza incidence in residents.
Care
home
staff
absence
records
 14 Reduced influenza incidence alone will reduce staff sickness absence.
Care home
manager KII
more staff to get vaccinated.
 11 Staff are willing to go in their own time to community pharmacies to
receive the flu vaccination.
 12 Staff are able to get to the pharmacy during opening hours to receive
the flu vaccination.
 13 Staff have not already had the vaccine for health reasons.
Pharmacist KII
Care home staff
focus groups
 10 Improved awareness of the benefits of the flu vaccine will motivate
Care home manager KII
 3
Personal reflections
There are pharmacists who are engaged and willing to take part in
both care home flu clinics and voucher based delivery systems.
Care home staff focus
groups
 2
Pharmacist KII
Agreement of the grant from NHS Surrey Downs CCG will necessarily
mean that funds will be available in good time to carry out the project.
Pharmacist uptake records
 1
Evaluation
method
14
Monitoring and Evaluation:

Assumptions 1 to 3 were addressed using the team’s personal reflections and were mostly
based on what resources were available in Surrey Downs. We also carried out a key informant
interview (KII) with the pharmacist who delivered the on-site vaccinations and this provided
further information to inform assumptions 1 to 3.

In August 2016, we carried out two KIIs with care home managers and two focus group
discussions with staff members in a home who did and a home who did not take part in the
project. We aimed to use this qualitative research to answer assumptions 4 to 8 and 10 to 13.

Participating care homes were asked to record the numbers of staff absences and any
incidence of acute illness or death amongst residents to address assumptions 14 and 15.

The participating pharmacists also kept a record of the numbers of vaccinations given for each
home for both on site clinics and vouchers to enable us to measure overall uptake in homes
from both delivery models.
Type of evaluation method
Quantitative / Qualitative
People involved
Team reflections
Qualitative
Elaine Dunlop, Selina Rajan
Key informant interviews
Qualitative
Care home managers x 2
Pharmacist
Focus Group Discussions
Qualitative
Care home staff from 2 care
homes
Care Home Staff Absence
Quantitative
Records
Pharmacist uptake records
Care home managers from 2
homes
Quantitative
On site and voucher based
pharmacists
15
Evidence Base Underpinning the Secondary Outcomes:
 1
There is some evidence from a randomised placebo controlled double blinded trial that
vaccination of healthcare staff in a paediatric setting reduced days of work lost due to
respiratory infections by 28%. This paper did not actually find a reduced incidence of
respiratory infections, but did find a reduced sickness absence (Saxén & Virtanen 1999).
 2
This evidence comes from a cluster randomised trial as described above, which
demonstrated that following vaccination of healthcare staff in care homes in the UK, there was
a reduced incidence of influenza like illness in residents (Hayward et al. 2006).
 3
The same paper above described that care home staff vaccination was associated with
reduced resident admissions to hospital (-2 (95% confidence interval -3, 0) and reduced GP
consultations (-7 (95% confidence interval -12, -2) for influenza like illness (Hayward et al.
2006). Furthermore, a systematic review assessing the efficacy and effectiveness of flu
vaccination demonstrated reduced hospital admissions for influenza and pneumonia amongst
the elderly living in long term institutions (Jefferson et al. 2005).
 4
The vaccination of care staff in care homes in the same study was also associated in a rate
difference in mortality in residents of -5 per 100 residents (95% confidence interval -7, -2).
Finally, mortality following flu vaccination was assessed in a cohort study that used electronic
health care records and demonstrated a significant reduction in confirmed influenza like illness
and mortality following flu vaccination (Mangtani et al. 2004).
LIMITATIONS:
This study was specifically in the Surrey Downs area and as such there were a limited number of
care homes we could invite to take part. This really meant that objective 3 was not possible to
address because there would not be sufficient statistical power and there were likely to be a
number of confounding variables for which we could not control. Furthermore, a limitation of the
design of this project was that it is not really possible to evaluate the actual cost benefits or cost
effectiveness because we are not ultimately able to address objective 3. Time constraints limited
our ability to inform and educate more care homes and ultimately there may have been some who
refused who might not have had there been some more time.
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EVALUATION FINDINGS:
Uptake of the influenza vaccine among staff in nursing and
residential homes
We identified 76 care homes in the Surrey Downs area. We telephoned every one of them and
discussed the project with the managers in October and November. As demonstrated in the figure
below, of all 76 homes, 28% (21) were already offering the vaccination to their staff. 43% (33)
volunteered to participate in the pilot project and 29% (22) declined. We estimated that including
the homes who already offered vaccinations to their staff, the flu vaccination was made available
this year to 71% of care homes in Surrey Downs. We also assessed the proportion of staff in each
home who consented to have the vaccine, and this is covered below under assumption 8.
No vouchers were cashed in at any of the participating pharmacies during the pilot. They were
distributed to all participating care homes.
Proportion of Care Homes in Surrey Downs Where Vaccinations
were Available in 2015
Declined
29%
Already Vaccinating
28%
Participated in the
Programme
43%
17
Acceptability, feasibility and cost of on-site and pharmacy based
vaccination delivery models
As described above, to answer these questions, we adopted a Theory of Change Model to test
whether the following assumptions were realistic and held true from our experience.
1. Agreement of the grant from Surrey Downs CCG will necessarily mean that funds will be available in
good time to carry out the project.
Personal reflections from the team highlight some challenges with this assumption. We received
notification that we had been successful in being awarded the grant in early October and set
straight to work in engaging stakeholders, establishing potential partners and starting to book flu
clinics. Unfortunately, due to a lack of clarity over the way funding would be managed there was a
delay in commissioning a pharmacist who could deliver the vaccinations. This was unfortunate in a
seasonal pilot such as this, where we endeavour to complete flu vaccination programmes as soon
as possible, but we received a letter of intent on December 4th which provided clarity on the
arrangements; These reflections provide useful learning for potential future projects. We would
expect now that the procedure would be the same and these delays could therefore be potentially
averted.
The onsite pharmacist reported that he did not necessarily mind working with a letter of intent but
felt that uptake could have been much improved if it were not for these delays. He reported that
there is no real need for too much detail in the contract, but swiftness would have been the most
important factor for success of the project.
2. There are pharmacists who are engaged and willing to take part in both care home flu clinics and
voucher based delivery systems.
From our personal reflections, we found that there were few pharmacists able to provide this
service who had the necessary skills and equipment to deliver this project and many local
pharmacists refused to take part.
For a pharmacist to be able to vaccinate on site, they must have:

A private patient group directive

License to carry clinical waste

An anaphylaxis kit

Appropriate fridges to store sufficient vaccinations
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
Training in vaccinations and delivery

Insurance
We used a London based pharmacist as he was ready and equipped with all the above and was
experienced at on site flu vaccination delivery as well as working in care homes with staff. From
our interview with the pharmacist himself, we established that the overheads involved in collecting
the above skills and equipment are substantial and many pharmacists would not want to take this
on without some guarantee that it will be worth their while. He estimated that it would cost
approximately £1000 for a pharmacist to purchase the above and all time out of their own shops is
also factored into their costs.
3. There is a pharmacist who is available with little notice to travel to care homes with the necessary
equipment to safely deliver flu vaccinations.
We were extremely lucky to identify the pharmacist as quickly as we did, which was predominantly
from previous working connections. However, discussions with other pharmacists who formed part
of the Local Pharmaceutical Committee identified that there were no other obvious contenders for
this role. Pharmacists locally were able to provide vaccinations to care staff in their own pharmacy
premises, but not, on site in care homes in general.
From our interview with the pharmacist himself, we established that he had been able to take on
the project with little notice because his company is big enough and has a big team. As such, he
could easily leave the premises without having to close his pharmacy and could have the flexibility
to do repeat visits where there was sufficient interest. He also commented that he has committed
to these types of programmes and in order to make it worth his while, he is willing to go the extra
mile and do visits as early as 6am but that other pharmacists may not be.
4. Care homes are not providing the vaccination to staff already
The analysis above demonstrates that in fact approximately 1 in 3 homes currently do have a
programme in Surrey Downs to vaccinate their staff. From our interviews, one home did also report
that from previous attempts to provide this, take up was so poor that they did not do it again.
5. Care home managers: understand the importance of flu vaccinations for staff; are engaged,
supportive and willing to take part.
The analysis above shows clearly that after accounting for the 21 homes who were already
providing the vaccination to staff, 60% of the remaining homes signed up. This could not have
happened had the managers not been engaged and supportive or willing to take part in the project,
19
which was a pivotal factor in this pilot. However, given that 40% of the remaining homes did
decline, we carried out the qualitative interviews to highlight some of the underlying views that
might underpin this.
We interviewed two managers; one from a care home that did not sign up (A), and one from a care
home that did (B).
Manager A reported that they were originally against the flu vaccine as they didn't see the need.
Now they realise that it is very important and are very much in favour of the project and taking part
but when they tried to engage the staff, there was no interest from any more than two staff
members. They felt that a lot of this was due to a lack of education as most staff were simply not
informed enough or willing to listen to the importance of the vaccination and managers cannot
enforce this. Manager A also commented that many staff come from abroad due to chronic
understaffing in the UK, and that in their home countries there are often not vaccination campaigns
in place.
Manager B reported that they were fully supportive of the project. They have been trying to get flu
vaccinations for staff for several years without success. They were the first care home to sign up to
our pilot and the manager was the first in the queue. They commented that the importance of flu
vaccinations for staff is underestimated and that people don't realise that flu kills the elderly. For
most of the elderly, by the time they reach a nursing home, they have lost the mental capacity to
make their own decisions, which are then made for them, often flippantly. When flu strikes in
winter, it spreads extremely fast. Year to year the impact of flu on the home varies but when
residents get flu, it morphs quickly into pneumonia, resulting in hospital admissions. They
commented anecdotally that 50% of residents die if admitted and so, ultimately, preventing flu will
represent clear cost savings to the NHS (from vaccinating all frontline staff and not just those in
hospitals). In manager B’s care home, they don't use agency staff - so if one person goes off sick it puts pressure on existing staff to fill the gaps. The remaining staff then get sick and it is a positive
feedback cycle of strain on the service. Ultimately the residents suffer if staff aren't vaccinated
against flu. The home have previously tried to access vaccines for their staff in the same way that
they do for their residents, through the GP. But GPs will no longer provide prescriptions for these
staff, in spite of the fact that they are frontline healthcare workers for NHS patients.
20
6. Staff understand the importance of flu vaccination and are willing to have it.
Unfortunately, many of the staff who attended the focus groups did not know about the project and
the majority had not taken part in the pilot itself. However, many staff reported that they had
previously had the flu vaccine, though most had not had it this year. The responses ranged from
people who had never had it and had never considered having it to those who had it every year,
either for their own health reasons or genuinely for the benefit of the residents. Individual
comments from those in favour included:

"I'd rather have the vaccine than go off sick for a week with proper flu";

"I get the vaccine because I know that I am looking after vulnerable residents and they are
frail and can't fight flu, so I must be vaccinated";

" I had tried to get it from my GP but he won't give it to me";
Most staff did agree that this was important for the health of the residents and was the staff's
responsibility to be vaccinated. Some did however, say that they had the vaccine and then got the
flu and had lost faith that it worked and felt it may have caused the flu. Other comments from those
not in favour of receiving the vaccination included:

"If my immune system is strong, I don't see why I should have the vaccine, because I never
get the flu and if I have the vaccine, I may become addicted to it".

" Nobody ever told me that I was meant to have the flu vaccine and I work part time so I
didn’t' think I needed it";

" I had heard about it, but didn't know much about it and didn’t know where to get it from";

There were some reports from staff about fears of introducing foreign 'medicine' into their
system when they did not see the need or feel that they needed it.
In care home A, staff all reported willingness and went as far as to suggest innovative ways to
increase uptake. One nurse commented that when nurses were vaccinating the residents, it could
be ideal to vaccinate all the staff. This would be good for increasing uptake and accessibility as
well as for team building and staff morale. Staff themselves suggested the nomination of a flu
champion who could monitor vaccination rates and use the opportunity to provide better education
to colleagues.
7. Care homes are able to gather staff at a suitable time for the pharmacist to attend.
From personal reflections, this was certainly a challenge. For each home, the staff work in shifts
and plan their lives very rigidly around those shifts, making it more difficult for managers to co21
ordinate a flu clinic in a single visit. Staff and managers reiterated this difficulty during the
interviews and groups. One nurse commented that some of her care staff wanted the vaccine but
could not be present at the time of the flu clinic - the interest was there, but the antisocial hours
that staff work made it impossible for them to get it. There weren’t any homes that did not sign up
for this reason, but it may well have contributed to the lower uptake in some homes.
However, all staff unanimously agreed that if their nurses were able to give the vaccination to staff,
it would be preferable. Both in terms of cutting costs, acceptability to staff and accessibility to staff.
8. Staff attend the flu clinic and give verbal consent to have the vaccination.
Overall, we supplied 205 vaccinations to care home staff in the Surrey Downs area. On average,
for each home we vaccinated, we reached 54% of staff on duty that day. This ranged from home to
home from 20% to 100%. If we were to extrapolate this average uptake, we could estimate that this
year, 38% of staff in care homes in Surrey Downs may have been vaccinated and had we not
rolled out this project, this would have been approximately 15%.
9. Sufficient vaccinations are available in Surrey Downs.
From the pharmacist interviews, this was not a concern this year, and particularly because it was a
mild flu season. The pharmacist commented that if he knew that there was a flu programme like
this taking place in advance, he could simply order the appropriate amount.
10. Improved awareness of the benefits of the flu vaccine will motivate more staff to get vaccinated.
This assumption was not so easy to test actively because this was not an experimental design.
However, on visiting the care homes, the pharmacist did use the opportunity to increase
awareness amongst unsubscribing employees. He commented that on his visits to the homes he
was able to increase uptake amongst those who had declined by approximately 50%. He explained
to staff the importance of them having the vaccine for the benefit of the residents rather than for
their own benefit. He did comment that many people reported myths to him, such as fears that the
vaccine might give them flu and that they had hear these myths from friends.
In the focus groups staff commented on the types of information they had come into contact with
until now. In general, staff highlighted that they knew of very few accessible mediums to increase
awareness of the flu vaccine. Staff felt that if people knew more about the importance of
vaccination, they might be more willing to get vaccinated. They suggested numerous mediums
through which care homes could try to communicate the value of vaccinating staff. These included:
22

an infection control policy that included flu vaccination

flu training

a flu protocol as part of the health and safety policy

a flu module as part of staff induction

a flu champion in every home who could be responsible for educating and monitoring
uptake of flu vaccination and staff sickness absences

notice boards

communications books

care home newsletters

information leaflets to be sent with payslips

word of mouth and staff meetings
11. Staff are willing to go in their own time to community pharmacies to receive the flu vaccination.
12. Staff are able to get to the pharmacy during opening hours to receive the flu vaccination.
From the focus groups, staff have done this in the past - either at Boots or even at Tesco's where
they are more likely to open late. Manager B commented that in the past staff had done this and
come back to the care home seeking reimbursement but there is an inconsistent system as many
care homes are small businesses that don't have formal HR departments who take this
responsibility. From the focus groups, the general view was that accessing any kind of service
such as a GP in working hours was extremely difficult. Care staff generally report that getting to a
GP in working hours is extremely tough as they work long hours and often work weekends. Some
staff felt frustrated and unhappy that their GPs had refused to give them the vaccine in the past
when they had explained their role as frontline healthcare workers but expressed a real
inconvenience of having to go to a GP outside of work.
13. Staff have not already had the vaccine for health reasons.
Only a handful of staff from the focus groups were eligible for the flu vaccine for health reasons.
However, not all of them always took these up. Examples of responses were:
"I have a poor immune system and asthma, so I have to have it every year for my own benefit" and
“I had it when I was pregnant but never did after that - now I will because I got flu this year!"
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14. Reduced influenza incidence alone will reduce staff sickness absence.
15. Reduced incidence of confirmed influenza in staff will reduce confirmed influenza incidence in
residents.
After following up on the project we tried to gather data on staff and resident sickness rates in
homes who engaged and homes who did not. However, data collection was a real barrier here and
many homes were simply not able to collect this data accurately. When there were able to, they
could not tell us the reason for sickness. With a small number of homes, it is not really possible to
imply with any statistical reliability the effect of vaccinating staff on resident and staff sickness and
there are key confounders, which could not in this case be accounted for. This certainly is an area
to consider for future work and if any similar projects were ever to be rolled out in collaboration with
other CCGs, this could make the case for trying to establish this in more detail.
Cost of the Project
The cost of the project in total was £3000, after accounting for time and travel for the team. For 205
vaccines, this is approximately £14 per vaccine.
Evidence from the Hayward et al study estimates the cost benefit of the influenza vaccine on
resident benefits. This is shown in the table below:
In order to prevent one episode of:
No. of Staff Vaccines Required
Cost of Vaccines (£)
Death
8
117
Case of influenza-like illness
5
73
GP consultation for influenza-like illness
6
88
Admission to hospital with influenza-like illness
20
293
This suggests that to prevent one hospital admission and one GP consultation would cost an
estimated £293 and £88 respectively. This represents a substantial potential in reducing health
service use costs. Estimates from the Department of Health indicate that the cost of a non-elective
inpatient stay in hospital was on average £1565 in 2014-2015 (Anon 2015). This includes direct
costs relating to the delivery of care; indirect costs such as catering and linen and overhead costs
including infrastructure and support services. Based on these estimations, vaccinating healthcare
workers in care homes would appear to be a cost effective intervention in reducing health service
spend.
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CONCLUSIONS
-
Providing the influenza vaccine to staff in care homes in the Surrey Downs area did increase
uptake substantially
-
Onsite vaccination model was acceptable and feasible and was popular among staff
-
The onsite vaccination model was a challenge to set up logistically as very few pharmacists
have the capacity to do this due to the overhead costs to them and the lack of any guarantee of
a return
-
The voucher system was not popular and was not utilised at all
-
Staff did have a fairly good understanding of the importance of the vaccine and most were
willing to have it, but were unable to access it
-
Staff were extremely positive on the whole about the vaccination but many had not known
about the pilot because time was insufficient means to raise awareness effectively
-
Evidence suggests that cost savings that could be redeemed from providing this vaccination to
staff in independent care homes could be of enormous benefit to Surrey Downs CCG, with an
estimated £293 to provide 20 vaccinations and prevent one hospital admission
Recommendations:
1) This report suggests that there is a missed opportunity for increasing immunity among the
elderly living in care homes in Surrey Downs by ensuring that healthcare staff are vaccinated,
as they would be in other clinical settings.
2) A system whereby a single pharmacist was able to visit each home sequentially might provide
an effective solution to the low vaccination rates among staff.
3) An alternative would be to consider the options for nurses in care homes vaccinating their own
staff as well as their own residents. The difficulty here might be supplying the vaccinations to
the care homes themselves. This might be best addressed utilising local pharmacists as long
as there was provision to store the vaccines appropriately.
4) If a project of this nature were to be repeated, we would suggest that it should start early and
allow enough time to provide educational materials and even potentially to visit care homes to
increase awareness and buy-in to the project. Staff themselves suggested a multitude of ways
to raise awareness of both the vaccine and the programme, which included but were not
excluded to: including it in their mandatory infection control and health and safety training,
having appropriate protocols for flu for each care home and having a flu champion who could
promote the vaccine and keep records of who has and has not been vaccinated as well as staff
sickness absence.
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