Measles outbreaks: Investing in patient relationships through GP continuity will be key to boosting MMR confidence

Cultural memory

UKHSA has raised concerns about coverage in the “Wakefield generation”—those who were not vaccinated in the early 2000s and are now young adults. Samuel Finnikin, a GP in Sutton Coldfield, says, “We have people who are now in their early 20s and are having their own children who grew up at the height of the MMR autism scare and may have had parents who refused the vaccine for them. There’s also a huge amount of attention now on ADHD and autism and that reminds them, in the back of their minds, of the link. That cultural memory is still there.”

Paul Evans, a GP in Gateshead, says his practice has been doing opportunistic MMR jabs since before Christmas in people of any age. “The one asset is the trust we have hopefully managed to build with our patients over time.”

Covid mistrust is also a factor Finnikin has seen. One aspect he believes is underplayed, however, is a move away from continuity of care. “The underfunding of general practice and the burgeoning demand has meant there is less ability within the system to build trust. We’re being battered by high levels of demand which means we don’t have the capacity to respond proactively.” He adds, “GPs don’t really see young children with snotty noses anymore but that’s part of building the trusting relationship with the parent.”

Mina Gupta, GP and clinical chair at the Modality Group, which has practices across Birmingham and Walsall, agrees. She says there are “a huge number of reasons” behind declining vaccine uptake (across all vaccines but especially MMR) but a recent consultation explained some of it.

“Parents had come in with a newborn and said they didn’t want any vaccinations, so I spent half an hour talking with them. I explained the implications for their baby but they had done their own research and were absolutely convinced that these diseases don’t exist anymore.”

The relationship with parents is key, Gupta adds, but since covid there has been a lot of mistrust. “Sometimes it does take a few conversations and with those parents I do wonder if I had known them a bit more, seen them a bit more, if my words would have carried more weight.”

The acid test

This is all against a backdrop of rising demand for—and yet falling numbers of—GPs, points out Kamila Hawthorne, chair of the Royal College of General Practitioners. “This isn’t just about delivering vaccinations and ensuring those eligible know when they need to get them,” she says, “But having conversations with patients to make sure they understand the importance, effectiveness, and safety of vaccinations such as MMR, and allaying any concerns they may have.

“Many practices, particularly in areas with lower uptake, do a huge amount of outreach in order to tackle vaccine complacency and hesitancy.

“This all takes time, however, which is why it’s vital to the success of the childhood vaccination programme that general practice has sufficient resources and time to have these conversations.”

An NHS vaccination strategy published in December says all the right things, notes Greg Fell, president of the Association of Directors of Public Health. It talks about bespoke outreach services targeted to under-vaccinated communities and a more joined up approach—but the proof will be in how well it is implemented. “This will be the acid test.”

When you have an outbreak like the one in the west Midlands, it is “all hands to the pump,” he adds. It needs people on the ground and that must be resourced. There is also a “fundamental matter” of adequate resourcing for primary care in general, particularly in deprived areas. “GPs and health visitors are good at doing this, talking through worries and answering questions. It’s rarely just one conversation, it’s a long term relationship. It is the hard graft of skilled professionals—and it can’t be done with an app.”

In Slough, a multigenerational household project achieved a substantial increase in vaccine uptake (currently being evaluated) across 13 practices.1 As part of the project, teams offered more than 800 families home visits for a range of health checks, including immunisations where eligible. Some chose to book into the surgery instead after being contacted. “By just offering them a different option, this changed the interaction with the families and showed we cared beyond the normal levels of engagement,” says Priya Kumar, GP and transformational clinical digital lead for the Connected Care Programme, Frimley Integrated Care Board.

Lou Millington is a GP in a deprived part of Sheffield where measles cases started to rise at the end of last year. Also working as the inclusion champion for the city, her practice has never hit its vaccine targets and, post-pandemic, it is further away than ever. This means it misses out on Quality Outcomes Framework payments for hitting targets, further cutting into its available resources. “We’ve been doing a lot of work around building trust and community engagement and looking at the myths. Running extra clinics doesn’t increase uptake. It is a deeper problem than that for us.”

Lost link with families

Millington’s practice has heard worries that people will be getting an inferior vaccine or that covid jabs will be snuck in at the same time. Some concerns around autism persist, especially in the Somali community, she notes. Millington has been doing talks, collaborating with community leaders, and even initiating projects in schools to revise patient information material, but often this is not resourced or they have to bid for small one-off pots of funding. “There are a few of us doing this in our own time, at local schools and community centres, but it’s not resourced or recognised as additional work.” A question and answer session for parents she did at a primary school recently was attended entirely by Eritrean and Ethiopian parents who had questions about autism and why the rates are so disproportionately high in their communities, she explains. “We won’t increase immunisation numbers until we’re listening to, trusted by, and then heard by our communities.”

Millington also points to a decline in health visitor numbers as a lost link with a lot of families. Helen Bedford, professor of children’s health at UCL, says pinning the blame for low uptake on “anti-vaxxers” can be a lazy excuse that suggests there’s nothing that can be done. “One of the most important things is making sure that parents have access to somebody who can sit with them and talk about their concerns.”

Health visitors, who have seen huge cuts to funding and workforce, are a key part of that opportunistic conversation. They also used to be part of vaccination teams. “It’s about giving parents permission to ask questions,” says Bedford.

A January report from the Institute of Health Visiting (IHV) says there is a shortage of 5000 health visitors; England has lost more than 40% of its health visitors since 2015. Over the same period, the Public Health Grant that funds the service has been cut by £1bn in real terms.2 Alison Morton, chief executive of IHV, adds that people have forgotten how important connection with families can be when it comes to vaccination. “The reach of the health visitor is crucial. In places like London where you have transient populations, you need health visitors to see people even when they’re not registered with a practice,” she says. In some areas baby weighing clinics have been cut completely—that’s when they would have long queues of parents waiting for advice.

“When someone you know and trust advises you on immunisation, we know uptake is higher.”