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Views And Reviews Primary Colour

Helen Salisbury: Bumps in the road to covid vaccine rollout

BMJ 2020; 371 doi: (Published 21 December 2020) Cite this as: BMJ 2020;371:m4925

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  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

General practices are mostly small businesses with a single (very complicated) NHS contract, and there’s much variation in how business-like they are. When doctors choose where to work, they need to know where a practice sits on the business-service spectrum if they’re going to feel comfortable with their colleagues.

A practice that’s entirely service oriented, responding to demand for appointments by increasing capacity with no limits, will soon find itself unable to pay the bills or with staff burning out from overwork—or both. If a practice focuses purely on the bottom line, attention may be paid to the most financially rewarding work (such as NHS health checks) rather than the most important clinically.1 Highly qualified staff may be replaced by those with a narrower range of skills who are cheaper to employ.

Most practices constantly walk this tightrope, trying to offer the best and safest service while staying afloat financially. Just as the pandemic has shone a bright light on health inequalities in the UK, so the covid-19 vaccination programme has brought this balancing act into the open. GPs are keen to deliver the vaccine, but it’s been tough to work out whether this can be done while continuing to offer patients a safe clinical service.

The original contract specified 15 minutes’ observation of patients after they received the vaccine, which led practices to conclude that they just didn’t have the space to vaccinate 975 people (the minimum allowed) in the five days that the vaccine stays viable at fridge temperatures. That rule was relaxed, and plans were developed accordingly—but it was then reinstated after two NHS staff had severe allergic reactions in the first week of vaccine delivery. Further uncertainty arose, with confusion over whether we had five or just 3.5 days from receipt of the vaccine to deliver it all, as well as a recent increase from five to six doses per vial.

As I write, changes to vaccine delivery dates have been announced, and some practices that have already booked appointments for patients have been told that they may not receive the vaccine in time.

The sooner we can vaccinate patients, the fewer we are likely to lose to covid-19. This is the priority, and there’s a huge amount of optimism and good will tied up in this programme. However, if the £12.58 (€13.70; $16.70) allowed per jab fails to cover the cost of extra admin staff to arrange or rearrange appointments at short notice—and the additional hours of clinical staff time needed to keep everyone observed for 15 minutes or backfill routine clinical work—practices may be forced to pull out.

The stated intention is that the vaccine programme should be cost neutral for practices,2 but in reality it will rely on the dedication of an already overstretched workforce. This stands in stark contrast to the profligate way money has been spent on the privatised test and trace system and PPE procurement.34