By Mike Rego
The rollout of the Government’s mass vaccination campaign across the country has by all accounts been a triumph of logistics, with some 17 million vaccinations having been given so far, approximately 25% of the UK population, and a very real chance that by the end of April, all over-50 year-olds will have received at least their first vaccination.
Implementing such a massive vaccination programme has required a tremendous effort from so many, not just regular healthcare professionals, but also the support from an army of volunteers to help co-ordinate so many aspects of the whole process. As an example, for a typical GP surgery operating in a typical urban environment organising a single vaccine clinic of just 120 patients over the course of just one day, The Moorlander has learnt that it can take many hours of administrative preparation by a team of up to five people, and to run the actual clinic on the day may require a car parking marshal, an additional receptionist to check-in vaccination patients, two clinicians to pre-screen the patients, an IT person available on standby throughout the process, two people to direct the flow of patients and three vaccinators as a minimum. And if being run from a local clinic or health centre, normal clinical duties must still be performed as well.
Across Devon, the vaccination programme is being co-ordinated at large-scale vaccination centres such at Westpoint Arena at Exeter and Home Park, Plymouth, as well as at selected community pharmacies and at various GP-led local sites. One such cluster of local GP-led vaccination sites is that of the North Dartmoor Primary Care Network, based around the Okehampton Medical Centre, also incorporating local GP-led vaccination clinics in Chagford, Black Torrington and Moretonhampstead.
One advantage of being in a smaller rural community as opposed to a more populous urban setting, is that the local health centres and GP surgeries tend to be more familiar with their patient lists – as Alex Austin, Practice Manager at Moretonhampstead Health Centre puts it, when they first looked at the over 80s, they knew pretty much who all the housebound patients were. However, despite many being normally housebound, so keen were some to have their first vaccination that over half decided that they didn’t want to wait and were able to make their way directly to the surgery, significantly speeding up the whole process.
Moretonhampstead Health Centre has its own additional support volunteers helping out with the local vaccination process. It has eight clinical volunteers who are retired nurses and GPs to help administer the actual vaccinations, and four administrative volunteers, who assist with data uploads, keeping track of patients and appointments. Despite their medical experience, all the clinical volunteers have had to undergo refresher training modules around each vaccine, including standard operating procedures such as handling and movement of the vaccines.
All the vaccines are initially delivered to a nominated site within the Primary Care Network (PCN), which in the case of the North Dartmoor PCN is Okehampton Medical Centre. The Pfizer vaccines usually stay on the main site due to their limited life cycle outside of the optimum -70⁰C storage temperature, whilst the AstraZeneca ‘Oxford’ vaccine can be delivered onwards and more easily stored for longer periods at the local vaccination sites over the rest of the PCN at Chagford, Black Torrington and Moretonhampstead. Twenty such PCNs have been set up across Devon, co-ordinating 123 of Devon’s GP practices to set up local vaccination centres. .
The role of the volunteers is crucial to the whole process. Not all patients are able to travel to vaccination sites or clinics, and so clinicians are also having to visit care homes to administer vaccinations, including those where there may be a known COVID-19 outbreak. This can add to the stress for the medical staff due to the added risk of transmitting an infection onwards. Meanwhile, routine healthcare still has to go on for all in parallel, resulting in many late nights and weekend working for both regular staff and volunteers at the health centre. According to Alex from the Moretonhampstead Health Centre, the workload has been heavy for all involved, requiring many weeks of double hours being worked since November to effectively plan the local vaccination programme on top of normal everyday healthcare: governance, logistics, organisation of the vaccine clinics, staff and volunteers, and of course inviting all the patients to their appointments by telephone.
The logistics of organising a vaccination clinic are a phenomenal task, made more complex still due partly to the limited shelf-life of the Pfizer vaccine, but most importantly to complete the vaccination programme nationwide as quickly as possible, particularly amongst the elderly and more vulnerable, which requires more advanced planning than usual. It is not like a normal flu vaccination clinic, where in pre-COVID-19 times at least it was a relatively relaxed affair, albeit a well co-ordinated streamlined process to vaccinate as many people as possible on scheduled clinic days. And of course in those care-free times there was usually little risk of flu virus transmission and cross-infection from patients attending the vaccination clinics.
The St Thomas Health Centre, Exeter, the hub of a larger PCN including the nearby Foxhhayes Practice in Exwick, is a designated site for receiving vaccines for onward distribution similar to the Okehampton Medical Centre. As Dr Alice Godwin, a GP Partner at St Thomas explains, they have some 43,000 patients on their books spread across four local health centres, with some 50% of their patients being students at the university. They have vaccinated as many as 5,400 patients over two weeks – with the annual flu vaccinations they would normally carry out that amount of vaccinations over four months.
The Pfizer vaccine is normally delivered to designated sites in vials in thermally insulated packaging, but once stored locally at normal temperatures of 2-8⁰C it can have a shelf-life of only three and a half days depending on when it is delivered. Each vial contains the equivalent of five doses, but as Pip Rubbra, Nurse Partner and Nursing Team Manager at Okehampton Medical Centre explained, when vaccinations started on a national basis it was quickly realised that each vial contained sufficient serum for six doses. Once the Pfizer vials are out of the refrigerator, they have to thaw and be made up with saline solution ready for vaccination within two hours, and then used within six hours – and that is when the pressure starts, to ensure that every single dose taken from the refrigerator is used, without any wastage, before it becomes time-expired. Although the AstraZeneca vaccine has a longer shelf life of six months, there is still the urgency to administer as many vaccinations as possible as quickly as possible, hence all vaccination centres. have compiled reserve lists of key workers and additional patients who are either classed as vulnerable or in qualifying cohorts, who can be available at short notice to come in for their vaccination – sometimes with as little as 20 minutes notice, in order to use up every available vaccination to avoid any wastage.
Naomi Gruitt, Operations Manager for the St Thomas Medical group, says that when vaccinations first started with elderly patients, they were allowing 15 minutes per vaccination, but as the centres have become more practiced the whole process has become much more efficient, helped also by the generally fitter and more agile younger age ranges of patients now being vaccinated.
For all vaccination centres, the real logistical challenge starts as soon as notice is received of the next vaccination delivery, which at first was sometimes as little as 48 hours, though generally it is now about one week’s notice. Kirsty Freeman, Senior Healthcare Assistant at Okehampton Medical Centre sums up the complexity by explaining that, for example, they may have 600 vaccines on site, with perhaps another 500 each at Moretonhampstead, Chagford or Black Torrington. If it is to be the Pfizer vaccine at Okehampton, they will have as little as three and a half days to use it before it expires, so the first task is to plan for sufficient patients to be booked in to precise time slots for their vaccination appointment… but of course not everyone is available to answer their telephone – elderly people may not hear it, they may have a poor signal, or they may not even be able to get to their phone quickly enough. Some people may require two or more attempts just to be contacted by telephone, which may lead to as many as 800 telephone calls or more in the space of two or three days (including weekends) to contact 600 people to arrange a convenient time slot. But then there are additional issues to be considered – is there sufficient parking available for all the patients who are expected to turn up at any one time? If they are parking elsewhere, can they still get to the vaccination site on time; not too early, so as to avoid congestion in the car park and waiting area, not late, so as not to create massive backlogs? And if there are road delays due to roadworks perhaps, or the weather is icy, or heavy snow as elsewhere in the UK recently, that can throw a major spanner into the works too. It is important that patients are in and out of the vaccination centres as quickly as possible, minimising contact with other patients and medical staff, and allowing as many patients to be vaccinated as possible. Hence the need for volunteers to assist with efficient car parking, to direct patients around the vaccination centre, and to monitor patients for 15 minutes after having received their Pfizer vaccine, and as soon as the last few vaccines are in sight prior to expiry time, the patients on the reserve lists have to be contacted, because there will always be the no-shows…
And if the logistics for the first vaccine sound complex, once the second dose rollout begins in earnest, it will become even more complex to administer, effectively dealing with mixed age-groups, some of whom require a second Pfizer vaccine and some a second AstraZeneca vaccine, plus new cohorts still having their first vaccine, all increasing the pressure on the vaccination centre staff to ensure a maximum patient turnover. And if a Pfizer vaccine is received on a Friday – it is all hands to the pumps to vaccinate over the weekend, not to mention confirming reserve appointments for the inevitable no-shows.
The St Thomas Medical Centre is the hub of the St Thomas Medical Group which has some 35 GPs with a correspondingly large support staff, so arranging appointments for 1,350 vaccinations over just three days whilst still conducting routine clinical work is perhaps less of a stress than at smaller vaccination centres and medical centres, but still a major challenge. For smaller practices though, with fewer staff and limited facilities such as internal waiting areas or car parking, contacting several hundred patients to attend a vaccination clinic by phone is no simple task. And then if for any reason a vaccination clinic has to be postponed perhaps due to a delay in receiving the vaccine delivery, the same patients have to again be notified by telephone, requiring a further round of phone calls for appointments to be rescheduled. Poor weather on the Moor may also increase the risk of no-shows, and in rural areas it is a harder task to call upon the reserve list at short notice.
Kiran Bakhshi, Practice Manager at Okehampton Medical Centre explains that with 23,500 patients on the books, and approximately 3,000 at each practice in Moretonhampstead, Chagford, and Black Torrington, the North Dartmoor PCN is one of the smallest PCNs in the country, but being small does have one advantage in that it is great for effective teamwork. Okehampton Medical Centre has a total of 67 staff and eight partners: five GP partners, and one partner representing each of nursing, pharmacy and management. Volunteers have been vital to assist with the vaccination programme, to help with directing car parking, meeting and greeting patients, reception, and even directing patients efficiently to the correct rooms for their vaccinations to ensure a slick process. For the first round of vaccinations at Okehampton, up to 20 volunteer drivers were also available to make return trips ferrying those patients without their own means of transport from as far afield as Lustleigh. The nearby Police Station offered parking spaces as did a local school, and with free parking also at Okehampton Hospital, the Okehampton and District Community Transport Group offered free shuttlebus rides from Okehampton Hospital to the vaccination centre, the Okehampton Lions Club set up a complimentary tea and coffee bar for patients in the separate rest area for their 15 minutes observation after vaccination, all part of the process enabling 1,000 vaccines to be carried out over only three days.
Despite all the long hours and increased pressure on healthcare staff, all the Practice Managers, GPs, healthcare workers and volunteers spoken to by The Moorlander were unanimous in saying that everyone was proud to be taking part in such an important healthcare programme, and that the whole process has brought a lot of satisfaction and a sense of real achievement to those involved the process. As Alex at Moretonhampstead Health Centre says, one can see it on colleagues’ faces, the administrative staff on the phones, the clinicians, their delight at being able to successfully vaccinate so many, and the relief and gratitude of so many patients when they have come in and received their vaccination is quite visible.
The hours have been long for all, with all staff from senior GP partners to part-time ancillary staff to volunteers coming together as a team, each person recognising the important role that everyone performs in efficiently delivering an effective and vital service. Alex Austin says that the GPs are still conducting their normal clinics, but then may be on the telephones helping to organise appointments. One local GP for example did a home visit to vaccinate a patient in her 90’s, whilst on their way home just before ten o’clock at night, in order not to waste a single vaccine. The patients too have been supportive – coming in wearing suitable clothing to roll up their sleeves easily, quickly in and out to speed up the vaccination process, also being patient with the process and readily complying with all the new rules, all of which has been much appreciated by the staff. There is no denying it has been a stressful time for all of the staff. COVID-19 vaccination clinics were being planned from the start of November for a December rollout, but governance guidelines were changing almost daily, with seemingly continual modifications to the operating procedures on use of the vaccines. Fortunately as the programme has progressed and the whole process has become more practiced with lessons learnt, there has been a gradual but distinct improvement in the entire rollout process.
Kirsty Freeman, Senior Healthcare Assistant at Okehampton says that everyone has adapted well to the new systems and work practices, with training programmes in new methodologies and supply logistics on a hitherto unprecedented scale. She sums up the feelings of many by saying that it has been quite amazing for so many of the staff to be part of doing something so positive for their community, and getting real job satisfaction despite the long hours. Alex from Moretonhampstead says that many patients have become quite emotional too after receiving their vaccinations, after so much social distancing and isolation over the past year. She goes on to say that for many healthcare staff there has been so much uncertainty with so many unknowns and changing guidance, but that there is now a lot of satisfaction with starting to see a light at the end of the tunnel, overcoming so many of the difficulties encountered along the journey this far.
For all the medical staff involved in the vaccination process, it has undoubtedly been a stressful and emotional time, but on the whole a very positive emotion. Dr Alice Godwin at St Thomas, Exeter, tells how one patient’s relative told her how so many patients seem to appear nervous when coming in for their vaccinations, but seem leave visibly taller and more confident. She described how one elderly lady of 93, on receiving her appointment over the telephone, broke down with tears of joy as she hadn’t left her home for 12 months – ‘it made her year’. And of course there have been many expressions of support from patients and local businesses too: cards, gifts of chocolates or biscuits, even a local pub delivering a supply of cakes to the staff.
The NHS has also been looking after the staff too, with regular wellbeing meetings available, and TalkWorks, an NHS organisation of psychological wellbeing practitioners and psychological therapists, offering a priority service for NHS, Social Care and Police staff affected by the COVID-19 pandemic. Other benefits include free Yoga sessions once a week. Noticeably, albeit anecdotally, there have been fewer days of staff absence due to sickness at local vaccination centres and health centres. The next challenge will be in the coming few weeks with the start of the second vaccination rollout, simultaneous with the ongoing first vaccination of younger cohorts, which is where the mass vaccination centres are likely to really step in and play their part.
Despite all the worries and uncertainties caused by the COVID-19 pandemic, the staff of the NHS at all levels have risen admirably to the challenge on an unprecedented scale, confirming that in times of need the NHS and all the staff make up a truly world-class organisation that we should all be extremely proud of.
A useful website for further information about the COVID-19 vaccination programme may be found at:
Delivering an NHS COVID-19 vaccination programme (how the vaccine is being delivered in Devon)