1. 2 commissioning support for london increasing mmr uptake – debrief on hcp stakeholder workshop...

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Commissioning Support for London

Increasing MMR uptake –

Debrief on HCP Stakeholder Workshop

and Project Recommendations

9th September 2010

A partnership between The Information Centre for health and social care and Dr Foster Holdings LLP

FESC approved supplier

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Purpose

To share output from the HCP Stakeholder

Workshop held on 23rd August, 2010.

To make, discuss and agree recommendations for

next steps.

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Context

Kensington & Chelsea

Higher SEG Workshop

Newham

Quantity of Ideas

Higher SEG Workshop

Lower SEG Workshop Lower SEG Workshop

Stakeholder Workshop

Refined Intervention Ideas

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An aside – Asian paired depths

There were two differences compared to non Asian responses:

1. Their GP practice places responsibility on them to make appointments

“It is our responsibility to make the appointments for the injections. They don’t call you or send you a letter to remind you. It is left entirely to you.”

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2. They are culturally pre-disposed to comply…..

“I got the MMR and other jabs because it is the procedure. It is in the red book and the midwife told me I must get all of them on time. You don’t question health professionals. They know best.”

“MMR-It was just like any other jab. You got to do it because it is in the book. There is no question about it. It is also for the safety of my son.”

But they want and seek out information in a way their mothers never did

“We had concerns about all the injections in general and wanted to find out more about side effects for all of them. Our mothers simply followed the procedures without asking any questions.”

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They perceive the potential barriers in their community to belanguage and accessible information

“These women would not know when to make the appointments. There is no one to remind women to get the jabs and the responsibility is entirely on you to get it done. We were proactive about it because we are educated. But it is easy for many to forget it because of the language barrier.”

“If they can’t read the Red Book they won’t know what to do.”

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HCP Workshop - Sample

From Newham:2 GPsSchool nurseHealth VisitorPractice Nurse From K&C:Practice ManagerGP Practice NurseImmunisation Improvement Nurse SpecialistTeam Co-ordinator Health Visiting2 School Nurses

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HCP Workshop

Objective

To assess a range of ideas generated by primary care givers, to build onthose ideas and generate additional ones which can then be taken into

further research.

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HCP Workshop - Findings

What issues do you have with the child immunisation journey?

1. Parents

“If I could get away without having the parents there it would be great!” PN• They make it harder:

• Children tend to exhibit their worst behaviour in the presence of their parents.“The 4-5 year olds are the worst because they fight and

kick.”• They can adversely influence the child

“Quite often the parents have warned the child ‘ you’re

going to have an injection’ so they’re screaming before they arrive.”

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1. Parents

• They have lots of questions or anxieties

“You find in K&C that you have a lot of Google mothers and they challenge everything with lots of questions ... but they listen more to the GP than they do to nurses.”

“The parents who resist usually know someone who has had a bad experience or they’ve heard something on the grape vine but they don’t tell you this when they come in so it’s really difficult to work with because you don’t really know what the issue is”

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1. Parents

• They often don’t want to hold the child

“At our practice we’ve had to train the receptionist to hold the child”

• It’s why school nurses enjoy immunisation – the parents aren’t present and the children are reluctant to make a fuss in front of a teacher or class mates

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2. The effects of the MMR diseases are not well enough known by parents

“We cover a travellers site and they point blank refused to have the vaccine until one of the children got mumps and they saw how sick they were and they all came in for their vaccine.” PN K&C

3. The acronym MMR

Parents have an issue with MMR because it is 3 in 1, yet have already had a 5 in 1 (DTaP/IPV/Hib) without demur. Should the name change to make it less obviously 3 in 1?

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4. Administrative hassle

• Unclean databases

“We’re chasing ghost patients that we know don’t exist because the records aren’t updated”

• Effort required to gain recalls

“We’ve started doing text message recalls and that works so much better than the letters.”

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5. Dislocated System

• Accessing and sharing patient records across different reporting systems can be very frustrating.

• Co-operation between GP’s, Practice Nurses, Health Visitors, School Nurses, PCT’s is not as good as it needs to be.

• It should be compulsory for private practices to share details of their patients who have/have not had their vaccinations.

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6. Inconsistency of information & messaging

• There is no ‘anchor’ information source for them

• Perceive currently available leaflets to be ‘vague’ or insufficiently detailed

• Perceive there to be nothing available in a wide range of languages.

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7. Migrants

Families coming from abroad have had MMR in their home country but not to the same level as in the UK – nurses have to titrate the vaccination to bring them up to the UK standard.

8. Distrust within the Somali community

Perception fanned by propaganda that vaccinations are insidious ‘invasions’ of Muslims. Suggestion to get Mosques on side to communicate the importance of vaccination for the health of the child.

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Training & Education

• All, bar GP’s, had and continue to receive training.

• Most believed it to be good and some thought it had improved recently

• Updates are sometimes irrelevant – e.g. health visitor going to training for HPV which they do not give

• All claimed they had received no training in dealing with anxious patients.

• All claimed to read CMO letters and Vaccination Update and appeared well informed.

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HCP Workshop – Idea Assessment

Patient Ideas assessed against 3 criteria:

Cost: 1 = Inexpensive 5 = Extremely Expensive

Practicality: 1 = Highly Practical 5 = Extremely Impractical

Time to Effect 1 = Short 5 = Extremely long

Treat results with caution!

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Idea Assessment

What would be the best way to find out about jabs?

Before the birth

1. Face to Face

• At hospital appointments 2.5• Ante-natal class on subject 2.1• Pre-appointment with GP or at check-up 2.0• Meeting with other new parents in a facilitated group 2.1

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Idea Assessment

What would be the best way to find out about jabs?

Before the birth

2. Communications• DVD – given during pregnancy 2.9• TV screens in ante-natal departments 2.4• TV channel (not subscription) 2.3• Written

• In Pregnancy book, but easy to read with more visuals2.0• Emma’s Diary 2.0• NHS leaflet sent to home or in Bounty Pack 2.0

• Text 2.1• i-phone app 2.2

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Idea Assessment

What would be the best way to have your questions answered?

• Moderated Group discussion 3.4• On-line forum 2.2• Specialised jabs web-site 2.6• Pharmacist 2.8• Top supermarkets / Boots – stand 2.5• Imms helpline 2.7

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Idea Assessment

Where would be best? • At home 4.0• Mobile unit 3.4• Specialised centre for immunisation 3.3• Children’s environments 3.7

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Idea Assessment

Who could administer the jabs? • Midwives 2.7• Child-friendly nurses 2.2• Health visitor 1.9• Community immunisation specialist 2.3• Parents, specifically Dads 3.7• Phlebotomist 3.4• Health advisor 3.1• Pharmacist 2.8• Paramedics 3.6• Health care assistants 3.1

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Idea Assessment

When would be best? • Greater flexibility 2.6• Enable the making of appointments 2.7

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Idea Assessment

How could the experience be better?

• A less ‘clinical’ environment 3.4• Have a play worker 2.8• Have a more calming position for the child 2.3• Options of: 2.1

• A nurse to hold the baby• Take baby away

• Character transfer on plaster 2.3• Reward for the child e.g. lollipop 2.3• Telephone call to the parent 24 hours later 2.3• Enable anonymous feedback 1.8

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HCP Workshop – Their Ideas

What information should be made available and how?

• Timeline on an A4 sheet – showing what vaccine is due when

• Visual aids specifically for showing how bad the diseases are

• Given 34-36 weeks in pregnancy“Ideally the health visitor would meet with the mum at 34-36 weeks to give them the red book and the birth to 5 book and talk them through what to expect when the baby is born – including imms.”

•Have vaccination leaflets in different languages “I can print off information for all sorts of things in any language but I can only get information for vaccinations in a few languages”

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What information should be made available and how?

• Reminder letter to be sent out with a leaflet

• Have one good web-site that all HCPs use and to which to direct patients

• Parents evening at schools: invite parents who have had MMR to explain MMR to worried parents (similar to what is currently offered for breastfeeding)

• Provide answers to frequently asked questions on Mums Net

• Proactive media relations to counteract negative comment“Vanessa Feltz was going on about how bad MMR is on the radio

the other day.”

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Training

• HCPs should have a better understanding of the patient's journey• Workshop presentation was enlightening for many and copies

were requested

• Training in dealing with anxious parents and the best ways to addressspecific myths.

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Who, Where, When

•Imms centre – separate from GPs - offering flexible hours

•Immunisation days at nurseries and at schools

•Make it compulsory for children to have complete MMR vaccinations up to the British standard in order for them to gain entry into the UK

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The Experience

• Better preparation for parents – so they know what to expect

• Sweets before the jab

• Play specialist e.g. like they have at Great Ormond St

• Ensure the waiting time is short

• Reduce the turnover of practice nurses so that parents can see the same nurse each time they visit

• More time to give the jab“the actual time it takes to give the jab is not the problem – its the engagement that’s a problem”

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HCP Workshop – Findings

What degree of change is desirable?

Incremental5

or

Radical6

Voting in line with the degree to which they might ‘lose’ income/responsibility/satisfaction.

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Recommendations

1. The Project originally envisaged that the next stage be thedevelopment of stimulus for intervention concepts for further research.Based on the findings to date we no longer feel this to be appropriate.The ideas that have been generated are predominantly simple conceptually, and many would undoubtedly be validated in a further round of research.

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Recommendations

2. There is a strong strategic case to explore a radical option – placing responsibility for child immunisation within a new or existing (NHS Blood Transplant Immunisation) organisation, operating pan London at the outset:

• Focus• Economies of scale• Obviate many current issues:

• data collection and sharing across different systems• requirement for collaboration across differing organisations

and professionals• inadequate core information• GP’s and HCP’s seen as ‘partial’ or having vested interests

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Recommendations

3. We should initiate projects in two areas that will have specific influence on MMR uptake

3.1 HCP Training

A training course for HCP’s involved in immunisation should be scoped and developed.

Aims is to help HCP’s to better empathise with and confidently reassure anxious parents.

Should draw on the Patient Journey insights gleaned from the Workshops and make use of the ‘Conversations’ videos.

Suggested Next Step: Scope the course.

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Recommendations

3.2 Central Information Content Provision - a dedicated and actively managed Pan London resource providing:

• a website and online forum, consistently ‘optimised’ for search• search engine marketing to guide parents unerringly to the

site• a range of leaflets, letter and text templates, parent pre-

briefing materials in multiple languages• content to and influence with the publishers of Emma’s Diary,

Red Book• a ‘narrative line’ that works from pros (mumps is deeply

unpleasant) to cons (there has been a now discredited link to autism) rather than from cons to pros as in “MMR the facts”

Suggested Next Step: Draft scope and brief

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Recommendations

4. We should meet in a separate session or workshop to review the balance of ideas generated and determine whether and how they might be progressed.

1. 2 commissioning support for london increasing mmr uptake – debrief on hcp stakeholder workshop...

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