# Buying immunisation

### From Ganfyd

The aims of vaccination payment systems include:

- Ensuring maximum uptake of vaccines within target groups (by providing appropriate incentives to service providers)
- Equity for patients
- Fairness for service providers

Various approaches are possible. They include:

## Contents |

### Block payment

Practitioners are paid a capitation fee, and expected to do vaccinate their patients according to the policy.

Pros - simple to administer. Cons - provides no incentive to vaccinate "hard to reach" patients.

This system is not generally used in the UK; although children who are not vaccinated by the appropriate age may not count towards a target payment, and so in a sense this is the situation for such children.

### Item of service payments

Prior to the 1989 "New GP contract" this is how most vaccinations were paid for by the NHS.

This method is still used for certain vaccines, e.g. influenza and pneumococcal vaccination of patients in target groups (as a "Directed Enhanced Service" (DES)).

### Target payments

In 1989 childhood vaccination payments to GPs moved from being based on an item of service arrangement, to one based on the proportion of the eligible patients in the pratice who were vaccinated, so that practices get a capitation-based payment if they achieve a lower target, and a considerably higher payment if they achieve a higher target. When this system was adopted around 1990 vaccination uptake rose, partly due to this, and partly as computerisation of records made tracking easier. For some time afterwards many advertisement for GP posts (possibly most, certainly of the more adverts for desirable practices) would state "all vaccination targets reached". The problems with this approach include:

- That when there is a scare, and uptake falls, practices may feel under pressure - and put parents under pressure - to vaccinate the very small number of children that will make the difference to the target level achieved;
- That anti-vaccinationists are able to use this to claim that GPs are only trying to get children vaccinated for mercenary financial reasons; and
- That if the target is going to be disproportionately difficult to reach, the practice may not bother trying to do so.

### Other payment approaches

Ganfyd contributors might have other ideas as to how best to ensure maximal uptake, equity, and fair payment.

#### Graduated item of service payments

One suggestion is a graduated item of service payment, an attempt to combine the virtues of target payments and item of service payments. For example:

- For vaccinating the first 49% of the practice the practice might be paid 1/10 of the maximum fee for each jab given.
- For the number of jabs given that make up 50-67% of the practice the practice might be paid 2/10 of the maximum fee for each jab given.
- For the number of jabs given that make up 70-79% of the practice the practice might be paid 4/10 of the maximum fee for each jab given.
- For the number of jabs given that make up 80-89% of the practice the practice might be paid 6/10 of the maximum fee for each jab given.
- For the number of jabs given that make up 90-94% of the practice the practice might be paid 8/10 of the maximum fee for each jab given.
- For the number of jabs given that make up 95-100% of the practice the practice might be paid the full maximum fee for each jab given.

50-70% of the target group will probably come very happily for their jabs; but that each percentage point increase in uptake gets harder as the level you start from rises...

(It might also make sense to decrease the amount paid per vaccination once the proportion of the practice population needed to provide herd immunity has been vaccinated.)

## The rules about what is available on the NHS

The rules used to be described in the *Statement of Fees and Allowances*, widely referred to as the *Red Book* (as it came in a red ring binder, which allowed sections to be updated individually).

The current equivalent appears, in England at least to be the *Statement of Financial Entitlements (SFE)*. See Primary Medical Care (England): financial entitlements for more information.