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Administering flu and pneumococcal vaccines

The flu vaccination season always comes at a time when workload is high. Stockport PCT has developed a pilot programme for healthcare assistants to provide influenza and pneumococcal vaccines, and free up skilled nursing time

Michelle Falconer
RGN MPH BN(Hons) Nursing DN Cert
Immunisation
Coordinator
Halton &
St Helens PCT
Cheshire

David Baxter
MB ChB MSc PhD
FFPH DTM & H
Consultant in Communicable Disease Control
University Lecturer
Greater Manchester Health Protection Unit
Control of Infection Unit
Stockport PCT

Donna Davenport
RGN BSc(Hons)
Professional Development Nurse
Practice Nursing
Stockport PCT

The flu vaccination season always comes at a time when workload is high. Stockport PCT has developed a pilot programme for healthcare assistants to provide influenza and pneumococcal vaccines, and free up skilled nursing time Primary care is increasingly looking at ways to create capacity and there are countrywide initiatives to employ healthcare assistants (HCAs) and assistant practitioners (APs) to cover an expanding diversity of roles. The role of the HCA is developing rapidly and includes nonclinical tasks such as new patient registration and health assessments, health promotion, ordering and stock control of supplies including vaccines, and clinical tasks such as blood pressure monitoring, phlebotomy and, in district nursing, insulin administration.
With the current reorganisation of primary care trusts and practice-based commissioning (PbC) alongside the government's modernisation agenda there is a much greater emphasis on skillmix, a flexible approach to meet increasing demands on services and appropriate use of scarce resources.(1) Combined with this nationally and locally there is an aging nursing workforce that is already starting to have a huge impact on services in primary care and the community. Liberating the Talents recognised the need for optimising clinicians' roles in order to combat staff shortages exacerbated by the aging workforce in primary care, and to discuss different methods of delivering healthcare, thus making the best use of the skills available to improve the health and healthcare of the population.(2)
Each September the flu vaccination season commences at a time when workload and demands for appointments in general practice and other community services are high. For 2007 the chief medical officer has set a target of 70% uptake of the influenza vaccine for those aged 65 years and over. Vaccine uptake in England during 2006 was 74% for those aged over 65 years and 42% for those in at-risk groups. In Stockport PCT it was slightly higher for those aged 65 years and over (77.4%), but considerably lower for those in at-risk groups (30.9%).

Influenza pilot programme
In January 2007 Stockport PCT District Immunisation Committee and Standards for Better Health Committee agreed that extending the role of HCAs and APs in immunisation could be pursued in Stockport on a pilot basis. However, it was considered to be essential that participating practices ensured that the following areas were addressed:

  • Policy and protocol that would comply with the legal requirements to prescribe vaccines, eg, HCAs should use patient-specific directions.
  • The HCA should undertake adequate education and training as recommended in the National Minimum Standards for Immunisation Training.(3)

Ten HCAs/APs (from both general practice and the PCT) who met the criteria for inclusion into the pilot programme (see below) and had agreement and support from their practice/manager for participation in the programme were identified. An experienced nurse mentor was also required to support the HCA to complete the programme and ascertain that appropriate competencies were acquired.

Criteria for inclusion into the pilot programme

  • HCAs who had completed two-day basic training provided by the PCT, including assessment of competence, evidence of continuing professional development and also trained to NVQ level 3 in health and social care.
  • APs (foundation degree in health and social care).
  • Access to an identified experienced nurse mentor.
  • High standards of infection control in their place of work.
  • Appropriate space/rooms in the practice.

Additionally, it was a requirement that practices ensured that medical insurance was obtained before commencing the pilot. The Medical Defence Union has issued advice to practices regarding administration of flu vaccines by HCAs, which states:

"We recognise that the role of the HCA is changing and many are taking on extended roles. We ask doctors and nurses to ensure they have assessed that the HCA is competent to take on the role, in line with GMC and NMC advice on delegation and have kept a record of training/competencies. In addition we expect practices to have a protocol in place, which complies with the law on administration of vaccines, and to have a system in place to monitor performance and regular update training. We also recommend that a doctor or nurse be on the premises to support the HCA in case of an emergency.

The decision about who should administer a vaccination must be based on what is in the patient's best interest and what is legally permitted. When deciding to involve a HCA the doctor or nurse would need to bear in mind the GMC and NMC advice and assess the competence and abilities of the HCA. However, the HCA should always work under the supervision of a qualified healthcare professional and the delegating person remains responsible for the overall management of the patient."(4)

WiPP toolkit
The Working in Partnership Programme (WiPP) toolkit was launched in November 2006 and was crucial to the development of this pilot programme. The project was funded by the Department of Health (DH), and the toolkit was developed to provide a range of stakeholders including practice nurses, HCAs, practice managers, GPs and PCTs with the tools to increase skills, increase skillmix, enhance the practice nursing image and improve recruitment and retention. Within this framework WiPP, in collaboration with the primary care training centre, Bradford and Cheshire and Merseyside Teaching PCT, developed resources for general practice to enable HCAs to safely administer the influenza and pneumococcal vaccine to adults. We found these invaluable in supporting the pilot and in particular the protocols and competency frameworks, which are easily adapted to meet local needs.
WiPP's objective is to liberate the talents and skills of the entire workforce so that every patient gets the right care in the right place at the right time. This is the clearly stated objective of the DH in the 2002 NHS Plan.(5)

Education, training and competence
National Minimum Standards for Immunisation Training have been set by the Health Protection Agency.(3) Immunisers should be able to demonstrate competence, understanding and current evidence-based knowledge of the suggested curriculum along with competency in the clinical delivery of immunisation. It is recommended that assessment of competency should be done in two ways:

  • Assessment of knowledge and understanding, which should be assessed immediately following training.
  • Assessment of competence by supervised practice with a trained immuniser.

The training was initially provided by a consultant in communicable disease control (CCDC) and supported by the PCT health protection team. It was also agreed that an experienced practice nurse who sits on the District Immunisation Committee would support the pilot and assist in the assessment/evaluation of it. Each HCA was allocated an identified mentor and offered support from the Professional Development Unit (PDU) to undertake this expanded role.

Legal issues
HCAs are not covered to work under Patient Group Directions (PGDs), which are specifically written instructions for the supply and administration of medicines or vaccines within an identified clinical situation.6 The Medicine's Act 1968 must be adhered to when supplying prescription-only medicines such as influenza and pneumococcal vaccines. A prescribing practitioner is required to individually prescribe the vaccine to be given before administration, as "nonregistered staff cannot administer medicines using a PGD and cannot train to prescribe medicines."(7) Therefore influenza or pneumococcal vaccines would need to be prescribed using a patient-specific direction for HCAs to be able to administer them.
Patient-specific directions are the usual method of supply and administration of medicines where there is a written instruction by an authorised prescriber for an individually named patient or list of named patients for whom a specific treatment is required. The routine annual influenza campaign of individuals over 65 and those in at-risk groups, and the routine pneumococcal vaccination of individuals in the same groups both come into this category. As the document Medicines Matters clearly states:

 "Any suitably trained member of staff in health or social care can administer medicines that have been prescribed, by an authorised prescriber, for an individual patient."(7)

Therefore there is no reason why HCAs and APs who have completed an immunisation course that meets national minimum standards and have also demonstrated competence cannot administer vaccinations in line with current UK policy as set out in the national policy document Immunisation Against Infectious Disease.8 However, both the RCN and the HPA believe that HCAs should not administer any part of the childhood vaccination programme.

Delegation
As new roles evolve and skills develop there continues to be uncertainty about the accountability of unregistered staff for delegated tasks such as the administration of medicines, eg, immunisations. There is no specific guidance regarding which activities can or cannot be delegated. However, the WiPP HCA toolkit identifies common areas of practice for HCAs in primary care.
The Nursing and Midwifery Council (NMC) has provided the following guidance regarding the responsibilities of the employer and the professional in such circumstances:

"Employers have a responsibility to ensure that staff to whom registrant nurses/midwives are expected to delegate are suitably trained and competent to undertake tasks expected of them. If registrant nurses/midwives are expected to assess competency they must be suitably trained and competent to do so and meet the NMC requirements for mentorship.

In accordance with the NMC code of Professional Conduct, standards for conduct, performance and ethics registrant nurses/midwives remain accountable for the appropriateness of the delegation, for ensuring that the person who does the work is able to do it and that adequate supervision and support is provided. Such delegation must not compromise existing care, but must be directed to meeting the needs and serving the interests of patients and clients. Registrant nurses/midwives must maintain their professional knowledge and competence in all areas of their practice including mentorship and have a duty to facilitate all team members in their development of their competence."(6)

This point is emphasised in the guidance issued by The Royal College of Nursing, which concludes that those providing treatment must be trained and preferably qualified to a national standard, that registered practitioners should feel confident when delegating tasks to HCAs/APs and that patients/clients should not only know who is treating them but should also "expect that those who provide their care are knowledgeable and competent."(9)
 
Conclusion
Reorganisation in primary care and increasing demands on services and resources has led to the development of the role of the HCA in order to create extra capacity. It has been recognised by the Royal College of General Practitioners that HCAs can make a significant contribution to the delivery of general practice services to patients by freeing up skilled nursing time and contributing to the achievement of targets. The range of work undertaken by the HCA is likely to increase in the future and the recent addition of influenza and pneumococcal vaccine administration to their work remit is an example of this.
Although issues such as the legal position on HCAs administering vaccines has been highlighted, the MDU has informed GPs that HCAs can administer these vaccines providing that there is a protocol in place in the practice, that there is a record of training/competencies and that the HCA is competent when performing the task. l

In the next issue of Nursing in Practice: A pilot training programme recently delivered in Stockport PCT that enables HCAs to administer influenza and pneumococcal vaccine in their workplace will be described. It will cover the topics included in the training programme, evaluation of the training programme and recommendations for getting started with a similar training programme in other areas.

References

  1. Department of Health. Our health our care our say. London: DH; 2006.
  2. Department Of Health. Liberating the talents. London: DH; 2002.
  3. Health Protection Agency. National minimum standards for immunisation training. London: HPA; 2005.
  4. Medical Defence Union in Practice. MDU advice on healthcare assistants giving flu vaccinations. London: MDU; 2006.
  5. Department Of Health. The NHS plan. London: DH; 2002.
  6. Nursing and Midwifery Council. Code of professional conduct. London: NMC; 2004.
  7. Department Of Health. Medicines matters - a guide to the mechanisms for the prescribing, supply and administration of medicines. London: DH; 2006.
  8. Department of Health. Immunisation against Infectious diseases. London: DH; 2006.
  9. CSP, RCSLT, BDA, RCN. Intercollegiate information paper. Supervision, accountability and delegation of activities to support workers. 2006.

Resources
Medical Defence Union
W: www.the-mdu.com

Nursing and Midwifery Council
W: www.nmc-uk.org

RCN - Supervision, accountability and delegation of activities to support workers
W: www.rcn.org.uk/__data/assets/pdf_file/0006/78720/003093.pdf

Working in Partnership Programme
W: www.wipp.nhs.uk

Skills for Health
W: www.skillsforhealth.org.uk

RCGP - Healthcare assistants
W: www.rcgp.org.uk/services__contacts/information_services/is_publications/fact_sheets/healthcare_assistants.aspx
 
Health Protection Agency - Core curriculum for immunisation training
W: www.hpa.org.uk/infections/topics_az/vaccination/Core_Curr1.pdf