Background: The expansion of available vaccines in recent years has increased the overall costs of the vaccine program and put pressure on providers responsible for vaccination. In England in 2016–17, GP practices responsible for vaccinating their local population were paid £227 million. However, the costs to general practice of delivering the program and the factors influencing these costs are unknown. Therefore, the aim of this study was to evaluate the costs of delivering the routine vaccination program at GP practices in England, to identify organizational factors impacting costs, and to compare these to the funding received. Methods: Time Driven Activity Based Costing was undertaken at a convenience sample of nine geographically and socio-economically diverse GP practices in 2017–2018. Cost data were gathered for the preceding year using a survey and clinical and administrative staff kept activity logs for a 2-week period. Results: The mean cost of delivering a childhood vaccination appointment was £18.20 (range £9.71-£25.97) and an adult appointment cost £14.05 (range £7.59-£20.88), of which 75% was for staff, 24% for facility costs and 1% for consumables. Organizational factors contributing to lower costs include: shorter length of allocated appointment; greater use of administrative and reception staff; lower working time for practice manager and practice nurse; and use of health-care assistants for adult vaccinations. The costs identified are lower than payments at all practices. Conclusions: Funding received for vaccination activities was higher than costs at included practices. Several organizational factors have been identified that impact on program delivery costs that could be modified.
Bibliographical noteFunding Information:
The research was funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Immunisation at The London School of Hygiene and Tropical Medicine in partnership with Public Health England (PHE). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England. The funders had no role in design, analysis or write-up of this study. In England, GP practices are independent private organizations that are contracted to provide health services to a defined population through a nationally negotiated contract (the General or Personal Medical Services contract) by NHS England (NHSE), the body responsible for commissioning primary health-care services.13,14 Currently payments made to practices providing vaccinations are not based on the costs of delivering vaccination services, but instead on achieving outcomes defined within this contract. Firstly, practices receive a ‘global sum’ capitation payment that is not related to activity, designed to fund ‘structural costs’ for all services provided by the practice based on size.15 If practices opt out of providing childhood vaccinations they receive a deduction of 1–2% of this payment. Secondly, delivery of some vaccines incurs an item-of-service payment, while others are considered in groups and payment is received on completion of a course, or when specified levels of coverage are achieved as shown in Supplementary material 1–Table 1.16 There is also an additional payment for timely vaccination when children receive vaccines during the first 3 months of eligibility. Finally, a small number are incentivized through the Quality Outcomes Framework (QOF), a pay-for-performance scheme (primarily influenza vaccine in clinical risk groups).17 These contracting arrangements are subject to annual negotiations between the Department of Health and Social Care (DHSC), NHSE and the General Practitioners Committee of the British Medical Association.18 The threshold targets have remained the same since the contract was introduced in 2004; however, the fee-for-service payment has been incrementally increasing over time, from £7.64 in 2013 to £10.06 in 2018, a 32% increase in 5 years, which has increased the costs to the government of delivering the program. In 2016–2017 NHSE paid GP practices £227 million for activity related to vaccination (excluding QOF payments and global sum payment).19 However, the system lacks transparency due to its complexity, and payments to practices are not aligned with costs. There are very few studies evaluating the costs to practices associated with delivering vaccinations to determine the appropriateness of payment levels. Together, these factors make it extremely challenging to recommend changes to the funding system that may improve coverage. Therefore, the aim of this study is to describe and evaluate the costs of delivering the routine vaccination program at GP practices in England and to compare them with funding payments and identify factors associated with differential costs between practices. Thanks to Dr Mary Ramsay and colleagues at Public Health England for their support with this study. Thanks also to all the staff at the participating GP practices for their time and effort.
© 2019, © 2019 The Author(s). Published with license by Taylor & Francis Group, LLC.
- organisational management
- primary care