An Evaluation of the Implementation of Routine Vaccination at GP Practice Level in England

Background: There have been multi-year reductions in childhood vaccination coverage in England, with persistent low coverage in adults and urban areas alongside long-standing inequalities. The programme has become significantly more complicated and the overarching health system underwent a substantial reform in 2013. However, there has never been an evaluation of how GP practices implement delivering vaccinations nor an assessment of what factors may affect coverage, including the associated costs. Therefore, the aim of this study is to undertake an evaluation of the implementation of routine vaccination at GP practices in England. Methods: Time-Driven Activity Based Costing was used to undertake a process evaluation and costing analysis, alongside semi-structured interviews to evaluate aspects of organisational sensemaking, in a geographically and demographically diverse set of GP practices. Results: Nine practices completed data collection and 52 staff participated in 26 interviews. Information relating to 372 vaccination appointments was captured using activity logs. Childhood vaccination mean appointment length was 15.9 minutes (range 9.0-22.0 mins) and 10.9 minutes for adults (range 6.8-14.1 mins). There is a high administrative component, comprising 59.7% total activity (48.4-67.0%). The mean cost of a childhood appointment was £18.20 (range £9.71-£25.97) and an adult appointment cost £14.05 (range £7.59-£20.88). Appointment length and total time was not related to coverage; whereas increasing capacity may improve coverage. Most practices exhibited either fragmented or minimal sensemaking, characterised by low levels of leadership sensegiving, which may limit the ability of larger practices to modify programme delivery to improve coverage. Conclusions: Reimbursement is likely to meet costs associated with the programme, however there is potential to improve the funding mechanism. Practices are isolated and lacking information on performance and support to make programme improvements. Greater strategic leadership at national and practice level and better coordination between professional groups could build on high levels of intrinsic motivation among staff to improve programme delivery.