Do community pharmacists add value to routine immunization programmes? A review of the evidence from the UK

Do community pharmacists add value to routine immunization programmes? A review of the evidence... Abstract Background Community pharmacies are an important setting for the provision of preventative health services in the UK. There has been debate over the value of delivering routine immunizations in a pharmacy setting, though government policy supports this initiative and in 2015 the first nationally commissioned community pharmacy vaccination service was launched for seasonal influenza vaccination. The impact of these vaccination services needs to be evaluated to inform future policy. Methods We conducted a comprehensive review of peer-reviewed studies and unpublished evaluations of community pharmacy-based vaccination services implemented in the UK between 2000 and 2015. We assessed evidence of their impact on acceptability, uptake, cost-effectiveness and addressing inequalities. Results We identified 28 evaluations of pharmacy immunization programmes in the UK, only three of which were published in peer-reviewed journals. These showed no evidence of increased vaccination uptake, and weak evidence of widening access to individuals who had not previously been vaccinated. There was good evidence that pharmacies were acceptable and convenient venues for vaccination. Cost-effectiveness was not assessed in any of the included studies. Conclusions Our review challenges an assumption that pharmacy provision of immunizations will simultaneously improve patient choice, increase uptake and widen access. These are important findings for policy makers. community pharmacy, immunization, vaccination Introduction Community pharmacies are retail outlets, usually located on high streets or in supermarkets, which dispense prescribed and over-the-counter medicines to the public under the supervision of a pharmacist.1 They are contracted by the National Health Service (NHS) in England and Wales to provide services which include dispensing medicines, providing pharmaceutical and medical advice, and, increasingly, offering preventative services such as promoting healthy lifestyles and immunizations.2 Political drivers for expanding the role of community pharmacists in delivering the national immunization programme include government policy which supports a patient’s choice to receive healthcare in a range of settings and from different providers. National policy also favours community pharmacy as a frontline public health service to support healthier lifestyles and improved health outcomes for patients.3,4 In addition, pharmacists are a skilled healthcare workforce, and there is interest in their potential role in easing pressure on general practitioners (GPs). Increasing immunization uptake is also a key driver. While England has an effective national immunization programme which reaches more than 90% of the target population for most childhood immunizations,5 and achieves high uptake for some of its adult programmes, there are programmes which persistently fall short of targets. For example, seasonal influenza vaccine uptake in clinical risk groups aged 6 months to 65 years and in pregnant women in 2016/17 was 48.6 and 44.9%, respectively, compared to an uptake ambition of 55% for each group.6,7 There is ongoing debate among policy makers about whether pharmacists can add value to the national immunization programme e.g. by increasing uptake. Opinion is also divided among providers: pharmacists naturally see the benefit of offering routine vaccinations ‘on the high street’, whereas GPs have concerns about the potential negative impacts on clinical management, data flow, funding for practices and efficiency due to vaccine wastage.8 When the first nationally commissioned pharmacy service for seasonal influenza vaccination in England was introduced in 2015 it received a mixed reception.9,10 We conducted a review of the literature to assess the evidence for delivering routine immunizations in community pharmacies in the UK. We aimed to assess the impact of pharmacy-based vaccination services in terms of acceptability, uptake, cost-effectiveness and addressing inequalities in order to inform future commissioning of routine immunization programmes. Methods We searched MEDLINE for peer-reviewed papers published in the English language from January 2000 to November 2015. We used the following search terms on MEDLINE: ‘immunization’ OR ‘vaccination*’ OR ‘exp MASS VACCINATION’ AND ‘exp COMMUNITY PHARMACY SERVICES’. In addition, we searched Cochrane and Trip by topic and review, and we hand searched public health and pharmaceutical journals. We also searched for unpublished reports that did not appear in peer-reviewed journals. We contacted heads of public health commissioning and the screening and immunization leads in each of the 27 former NHS England local area teams to request copies of written evaluations of local programmes. We supplemented this with a search on google and by contacting public health bodies and associations representing GPs and pharmacists. All immunizations offered by community pharmacy to adults and children as part of the national immunization schedule were within the scope of this literature search.11 This included vaccinations that targeted whole cohorts as well as ones for groups at higher risk of infection. Papers were included if they focused on services that: (i) offered immunizations free as part of the national immunization schedule (at the recommended age or as catch up or in response to an outbreak), and (ii) were provided by community pharmacists, and (iii) were locally or nationally commissioned by the NHS in the UK. We excluded reports of other pharmacy vaccination services, such as travel vaccines and private vaccination (Fig. 1). Fig. 1 View largeDownload slide Flow chart for study search and selection process. Fig. 1 View largeDownload slide Flow chart for study search and selection process. We classified the type of peer-reviewed publication using standard typology for the hierarchy of evidence12 (Table 1). We reviewed the quality of peer-reviewed papers using checklists adapted from the Critical Appraisal Skills Programme (CASP).13 We also reviewed the quality of unpublished evaluation reports and made note of weaknesses and the risk of bias where this was present. Our quality appraisal was to inform our synthesis of findings rather than to include or exclude studies. We extracted data from included papers on programme characteristics and looked for reported evidence of effect in four domains: acceptability of the service (patient surveys which measured user satisfaction on a Likert scale), vaccination uptake (number and proportion of vaccines delivered in pharmacies), cost-effectiveness and impact on inequalities (evidence of individuals accessing vaccinations for the first time). Outcome measures are listed in Table 2. One researcher (S.P.) performed the searches, data extraction, coding and analysis. Table 1 Typology of evidence used to grade studies included in this review A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] View Large Table 1 Typology of evidence used to grade studies included in this review A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] View Large Our approach was systematic and comprehensive. However, it did not meet the full requirements of a systematic review and we have not categorized it as such. The research was overseen by a project steering group made up of senior representatives from Public Health England, the UK Department of Health and NHS England. Results Description of included papers We identified 28 evaluations of pharmacy services for delivery of routine vaccinations; all papers meeting the inclusion criteria were evaluations of seasonal influenza vaccination programmes. Three were peer-reviewed studies published in pharmaceutical journals.14–16 Of these, two were reviews of the same service implemented in Scotland in different years14, 15 and the third covered a service on the Isle of Wight.16 The 25 remaining papers were all unpublished evaluations of pharmacy services. In total, 24 evaluated services operating in England and covered 21 of the 27 former NHS local areas. Of these, four areas provided two evaluations covering consecutive years of their service. The final paper evaluated a service implemented across Wales.17 The type and quality of evaluations ranged widely. Some were brief descriptions of the service, others full service evaluations, and two were research studies of which one has since been published in the BMJ.8 Evaluation methods also differed across the papers, consisting of a mix of patient survey, staff survey and analysis of service delivery data (see Tables 2 and 3 for study characteristics). Table 2 Key features of and outcome measures reported in included studies (n = 28) n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 View Large Table 2 Key features of and outcome measures reported in included studies (n = 28) n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 View Large All the included studies were observational in design (C1). Only one evaluation was a well-designed non-experimental study (B3).8 Many evaluations had methodological flaws as follows: incomplete reporting of methods for data collection, presence of confounding in design and analysis, and under-use of statistical techniques (e.g. confidence intervals and tests of significance). Two of the three peer-reviewed studies had small sample sizes,14,15 and one had a high probability of confounding.16 Features of service delivery The majority of papers (n = 23) reviewed immunization services that were only offered to adults. These services were divided into two types: ones which included the over-65s (n = 10) or ones which were only targeted at clinical risk groups aged 18–64 years (n = 13). Two papers reviewed services for children as well as adults, and three services were for children only (Table 2). The services described were similar in design. Patients were informed of the service by poster, leaflet, local media or by opportunistic vaccination when the patient collected his or her medication. Vaccinations were administered by pharmacists who had received specific training. Patient Group Directions provided the legal framework for pharmacists to administer vaccines without the need for a signed prescription for each patient. Pharmacists recorded patient details on paper or via an IT platform. Pharmacists were usually required to inform GP practices of vaccinations given within 24–48 h. Patients’ eligibility for NHS vaccination was verbally confirmed except in four services where pharmacists required written evidence of entitlement.15 Seven of the unpublished evaluations reported issues with the quality and timeliness of data entry and transfer from pharmacies to general practices. The London evaluation found that there was considerable under-reporting of pharmacy delivered vaccines in GP systems and therefore the loss of data for surveillance.8 Four services reported concerns from GPs that patients were inappropriately vaccinated though reported instances were few in number. The scale of service delivery varied widely. The overall number of vaccines delivered in pharmacies ranged from 56 to 41 282 (interquartile range: 4528 – 1103 = 3425) (n = 27). The proportion of area vaccines delivered in pharmacies was between 0.6 and 20% (n = 11). Three of four papers evaluating the same service in successive years saw an increase in the number of vaccines delivered as programmes expanded in their second year (Table 3). Table 3 Characteristics and outcomes of included studies Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Table 3 Characteristics and outcomes of included studies Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Outcomes Acceptability Nine studies reported user satisfaction on a Likert scale; in seven of these more than 90% of patients rated the pharmacy service as ‘good’ or ‘excellent’. Nine other studies stated that convenience was the main reason for people choosing to be vaccinated at the pharmacy (Table 3). Uptake Eight evaluations attempted to measure changes in vaccine uptake by comparing year-on-year differences in area vaccination rates. Two studies reported increases in uptake of up to 6.2%;16 two reported decreases of up to 1.1%; two reported a mix of increased and decreased uptake depending on the risk group; and two reported no change in uptake. In only one of these studies was a significance test conducted for this outcome. This study found a modest reduction in vaccine uptake of 1.8–3.0% between 2013/14 and 2014/15 (P < 0.001). The largest risk groups vaccinated in pharmacy were people with chronic respiratory disease (n = 12) and diabetes (n = 4). When over 65s were included in the service, this group made up between 56.5 and 69.5% of the total vaccinated (n = 5). One study found a significantly higher proportion of at risk groups aged 18–64 years were vaccinated in pharmacy compared to practices, and that the reverse was true for the over 65 s (P < 0.01). Carers were found to have a significantly higher representation in the pharmacy vaccinated cohort than in the GP cohort in another study (P < 0.001)16 (Table 3). Cost effectiveness None of the studies reviewed compared the cost of vaccine delivery in pharmacy with that in GP practices. Inequalities Eight evaluations estimated the proportion of people vaccinated in pharmacy who had not had an influenza vaccination the previous year (median 22.5%), and nine reported the proportion of people who had never had an influenza vaccination previously (median 23%). These findings assumed that patients vaccinated in pharmacy had been in a risk group in previous seasons (Table 3). Discussion Main findings of this study This study is the first to bring together evidence from evaluations of community pharmacy vaccination services across the UK. Together these studies indicate that pharmacy-based services are highly acceptable to those who use them and that many service users find pharmacy a convenient setting to receive their vaccinations. We found no surveys exploring the views and attitudes of people who did not use pharmacy services, and no evidence for immunization programmes other than seasonal influenza. The largest groups vaccinated in community pharmacy were people with respiratory conditions and diabetes, and those aged over 65 years—this is to be expected as these individuals regularly use pharmacies. Carers also appeared to have a higher representation in the pharmacy cohort than in the GP cohort, which may be because carer status is not recorded on clinical records and therefore these individuals may not be called for influenza vaccination by their GPs. We found no evidence from existing studies that pharmacy services in the UK lead to overall increases in vaccination uptake. Some studies reported slight local variation in seasonal influenza vaccination rates following the introduction of the pharmacy vaccination programmes, with two areas reporting an increase and two a modest reduction. This reduction was also seen nationally in data comparing 2013/14 with 2014/15. This suggests that reasons other than the ‘pharmacy effect’ may have accounted for this change because many areas did not have a pharmacy programme. Year-on-year comparisons fail to take into account alternative explanations for changes in area uptake. These explanations would include any factors that might increase or decrease patients’ decision to seek vaccination, such as a change in public confidence in the effectiveness of the vaccine. There is weak evidence that pharmacy services address inequalities in vaccination uptake: across eight studies an estimated 22.5% of individuals attending pharmacies for vaccination reported having no vaccination the previous influenza season. However, it is not known what proportion of these individuals were eligible for the vaccine in previous years, and patients’ ability to recall accurately their vaccination history was not explored. It is worth noting that 17 studies reported that they were able to attract ‘new’ patients and nine reported that service users found pharmacies convenient vaccination venues, which suggests that community pharmacies are an agreeable alternative to GP practices for receiving the seasonal influenza vaccine. There is however insufficient evidence to show that this translates to increased uptake among the general public or among hard-to-reach groups. What is already known on this topic There is evidence from studies overseas that pharmacy-based vaccination service users report high satisfaction, and that these services may increase uptake, including among at-risk groups. Most of the research has been undertaken in the USA where pharmacy-based immunization, mostly involving seasonal influenza and travel vaccines, has been well established since the 1990s. One such review from Hogue et al.18 demonstrates that pharmacy vaccination can be safely delivered, and is highly acceptable to service users. Two further US studies found that pharmacists are able to encourage patients to be vaccinated either indirectly by providing education and information,19 or directly by providing services such as hepatitis B vaccination for intravenous drug users.20 Health systems and pharmacies in the USA are very different to those in the UK and results from the USA may not be directly generalizable to a UK setting. Our finding on acceptability reflects research by Anderson et al. which found that some people who are eligible for NHS vaccination choose to pay to have their flu jab at the pharmacy as they perceive this to be more convenient than going to their GP.21 A study by Evans et al.,22 published after we had conducted our review, found that community pharmacies in Wales may reach more younger at-risk individuals than other providers. What this study adds This is the first comprehensive review of the evidence for the impact of pharmacy vaccination programmes in the UK and highlights widespread experience of pharmacy services for seasonal influenza vaccination. It indicates that the pharmacy model is successful in offering patients convenience for receiving their influenza vaccine, as evidenced by 20% of influenza vaccinations being delivered in pharmacies in one area in London.8 Whether this experience is transferable to immunization programmes other than influenza is not known. This review has found no evidence that community pharmacies add value to routine immunization programmes by increasing uptake. It has been speculated that pharmacies could increase uptake for influenza vaccination among clinical risk groups aged below 65 years and pregnant women, for whom current vaccination rates are below national targets. However, our studies did not support this hypothesis. Our findings challenge the assumption that pharmacy vaccination programmes will simultaneously improve patient choice, increase uptake and widen access. A key explanation for our findings may lie in the fundamental difference between the pharmacy and general practice model for delivering vaccinations. Immunization programmes are public health programmes and the success of these depends on high coverage. GPs are well placed to deliver targeted vaccination programmes as they have a registered population, are able to identify eligible patients, and can offer them vaccination through an active call and recall system. The practice patient list acts as a denominator for measuring coverage. While community pharmacists may opportunistically identify people eligible for immunization, they do not have mechanisms for systematically identifying individuals within a target population, nor are they accountable for doing so, as GPs are. This review also exposes an evidence gap. We found only three peer-reviewed articles evaluating pharmacy immunization programmes in the UK and these were methodologically weak. There is a need for robust evaluations of pharmacy immunization programmes to assess their impact on vaccine uptake and health inequalities. Qualitative research is also needed to explore attitudes towards pharmacy vaccination services, particularly among groups that are under-represented in national immunization programmes, and for non-influenza programmes. Limitations We obtained evaluations from 84% of former NHS areas that had commissioned local influenza vaccination services from community pharmacy. We do not have information to assess whether the services we evaluated were similar to those we were not able to review in the remaining commissioning areas. Our review was limited to evaluations of influenza vaccination. We were not able to locate evaluations or peer-reviewed papers covering other community immunization services, such as maternal pertussis or hepatitis B vaccination for at-risk groups. Although we found no evidence of benefit in terms of increased uptake and improved access, the methods employed by researchers to demonstrate the so-called ‘pharmacy effect’ on vaccination uptake were not robust as they did not take potential confounding factors into account. Year-on-year differences in vaccine uptake may have been influenced by other factors affecting individuals’ health-seeking behaviours, such as public perception of vaccine efficacy (particularly in the wake of media messages regarding low influenza vaccine efficacy in the 2014–15 season) or unseasonably cold or warm weather. Studies evaluating access assumed that eligibility for vaccination was a constant, although individuals may have accessed pharmacy services for a first-time influenza vaccine on account of a new diagnosis or because they reached a significant age. In addition, there was a general lack of information regarding the administration of patient surveys. Studies in which the pharmacist entered survey responses on behalf of the patient are at risk of reporting bias. In spite of a comprehensive search of published and unpublished literature, we have found insufficient evidence to demonstrate that community pharmacies add value to routine immunization programmes. Our findings support the case for further research into other more targeted routine vaccination programmes, and into services offered to population groups whose use of primary care services and take up of vaccination is traditionally low. Local commissioning teams could be encouraged to pilot pharmacy delivery of immunization programmes which have historically suffered low uptake or inequalities in coverage. Robust evaluations of these new programmes would widen the research base and contribute to the ongoing debate about community pharmacy immunization programmes. Acknowledgements Thanks to Dr Louise Coole, Consultant Epidemiologist with PHE, for her comments on an earlier draft of this article. This review was part of a broader project, commissioned by the Immunisation Programme Board for England and Wales in 2015, to investigate the risks and benefits of extending pharmacy provision to support the national immunization programme. Funding None. Conflicts of interest None. References 1 World Health Organization . Essential Medicines and Health Products Information Portal: The Role of the Pharmacist in the Health Care System. http://apps.who.int/medicinedocs/en/d/Jh2995e/1.6.2.html (27 October 2017, date last accessed). 2 Pharmaceutical Services Negotiating Committee (PSNC) . About Community Pharmacy: PSNC Main Site. https://psnc.org.uk/psncs-work/about-community-pharmacy/ (27 October 2017, date last accessed). 3 Pharmaceutical Services Negotiating Committee (PSNC) . Community Pharmacy Call to Action. http://psnc.org.uk/the-healthcare-landscape/community-pharmacy-call-to-action/ (26 October 2017, date last accessed). 4 Public Health England. Consolidating and Developing the Evidence Base and Research for Community Pharmacy’s Contribution to Public Health: A Progress Report From Task Group 3 of the Pharmacy and Public Health Forum. ( 2014 ). 5 Public Health England . Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme ). Health Protection Rep 2017 ; 11 ( 23 ): 1 . 6 Department of Health, Public Health England & NHS England . The National Flu Immunisation Programme 2016/17: Supporting Letter. (2016). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529954/Annual_flu_letter_2016_2017.pdf (26 October 2017, date last accessed). 7 Public Health England . Seasonal Influenza Vaccine Uptake in GP Patients: Winter Season 2016 to 2017. ( 2017 ). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/613452/Seasonal_influenza_vaccine_uptake_in_GP_patients_winter_season_2016_to_2017.pdf (16 November 2017, date last accessed). 8 Atkins K et al. . Seasonal influenza vaccination delivery through community pharmacists in England: evaluation of the London pilot . BMJ Open 2016 ; 6 : e009739 . doi:10.1136/bmjopen-2015-009739. Google Scholar CrossRef Search ADS PubMed 9 Pharmaceutical Services Negotiating Committee (PSNC) . Flu Vaccination Service: PSNC Main Site. http://psnc.org.uk/services-commissioning/advanced-services/flu-vaccination-service/ (26 October 2017, date last accessed). 10 Madsen M . NHS recommissions controversial pharmacy flu vaccination scheme | News Article | Pulse Today. Pulse ( 2016 ). 11 Public Health England . The Routine Immunisation Schedule From Summer 2016. ( 2016 ). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/533829/9699_PHE_2016_Complete_Immunisation_Schedule_SUMMER16_A4_16.pdf (26 October 2017, date last accessed). 12 Department of Health . National Service Framework for Older People. ( 2001 ). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (19 January 2018, date last accessed). 13 CASP . CASP Critical Appraisal Skills Programme. http://www.casp-uk.net/ (26 October 2017, date last accessed). 14 Hind C , Peterkin G , Downie G et al. . Successful provision of influenza vaccine from a community pharmacy in Aberdeen . Pharm J 2004 ; 273 : 194 – 6 . 15 Hind C , Downie G . Vaccine administration in pharmacies—a Scottish success story . Pharm J 2006 ; 29 : 134 – 6 . 16 Warner JG , Portlock J , Smith J et al. . Increasing seasonal influenza vaccination uptake using community pharmacies: experience from the Isle of Wight, England . Int J Pharm Pract 2013 ; 21 : 362 – 7 . Google Scholar CrossRef Search ADS PubMed 17 Llywodraeth Cymru & Welsh Government . Community Pharmacy Influenza Vaccination 2012–13. A summary of the results of the national Community Pharmacy Seasonal Influenza Vaccination Service ( 2013 ). 18 Hogue MD , Grabenstein JD , Foster SL et al. . Pharmacist involvement with immunizations: a decade of professional advancement . J Am Pharm Assoc 2003 ; 46 : 168 – 79-82 . Google Scholar CrossRef Search ADS 19 Fuchs J . The provision of pharmaceutical advice improves patient vaccination status . Pharm Pract (Granada) 2006 ; 4 : 163 – 7 . Google Scholar CrossRef Search ADS PubMed 20 Noble K , Holden M , Warner GA . Solution to improving uptake of hepatitis B immunisation in at risk groups, through collaboration and adopting an integrated approach with pharmacists as service providers . Int J Pharm Pr 2010 ; 18 : 43 . 21 Anderson C , Thornley T . It’s easier in pharmacy: why some patients prefer to pay for flu jabs rather than use the National Health Service . BMC Health Serv Res 2014 ; 14 : 35 . Google Scholar CrossRef Search ADS PubMed 22 Evans AM , Wood FC , Carter B . National community pharmacy NHS influenza vaccination service in Wales: a primary care mixed methods study . Br J Gen Pract 2016 ; 66 : e248 – 57 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. 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Do community pharmacists add value to routine immunization programmes? A review of the evidence from the UK

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Abstract

Abstract Background Community pharmacies are an important setting for the provision of preventative health services in the UK. There has been debate over the value of delivering routine immunizations in a pharmacy setting, though government policy supports this initiative and in 2015 the first nationally commissioned community pharmacy vaccination service was launched for seasonal influenza vaccination. The impact of these vaccination services needs to be evaluated to inform future policy. Methods We conducted a comprehensive review of peer-reviewed studies and unpublished evaluations of community pharmacy-based vaccination services implemented in the UK between 2000 and 2015. We assessed evidence of their impact on acceptability, uptake, cost-effectiveness and addressing inequalities. Results We identified 28 evaluations of pharmacy immunization programmes in the UK, only three of which were published in peer-reviewed journals. These showed no evidence of increased vaccination uptake, and weak evidence of widening access to individuals who had not previously been vaccinated. There was good evidence that pharmacies were acceptable and convenient venues for vaccination. Cost-effectiveness was not assessed in any of the included studies. Conclusions Our review challenges an assumption that pharmacy provision of immunizations will simultaneously improve patient choice, increase uptake and widen access. These are important findings for policy makers. community pharmacy, immunization, vaccination Introduction Community pharmacies are retail outlets, usually located on high streets or in supermarkets, which dispense prescribed and over-the-counter medicines to the public under the supervision of a pharmacist.1 They are contracted by the National Health Service (NHS) in England and Wales to provide services which include dispensing medicines, providing pharmaceutical and medical advice, and, increasingly, offering preventative services such as promoting healthy lifestyles and immunizations.2 Political drivers for expanding the role of community pharmacists in delivering the national immunization programme include government policy which supports a patient’s choice to receive healthcare in a range of settings and from different providers. National policy also favours community pharmacy as a frontline public health service to support healthier lifestyles and improved health outcomes for patients.3,4 In addition, pharmacists are a skilled healthcare workforce, and there is interest in their potential role in easing pressure on general practitioners (GPs). Increasing immunization uptake is also a key driver. While England has an effective national immunization programme which reaches more than 90% of the target population for most childhood immunizations,5 and achieves high uptake for some of its adult programmes, there are programmes which persistently fall short of targets. For example, seasonal influenza vaccine uptake in clinical risk groups aged 6 months to 65 years and in pregnant women in 2016/17 was 48.6 and 44.9%, respectively, compared to an uptake ambition of 55% for each group.6,7 There is ongoing debate among policy makers about whether pharmacists can add value to the national immunization programme e.g. by increasing uptake. Opinion is also divided among providers: pharmacists naturally see the benefit of offering routine vaccinations ‘on the high street’, whereas GPs have concerns about the potential negative impacts on clinical management, data flow, funding for practices and efficiency due to vaccine wastage.8 When the first nationally commissioned pharmacy service for seasonal influenza vaccination in England was introduced in 2015 it received a mixed reception.9,10 We conducted a review of the literature to assess the evidence for delivering routine immunizations in community pharmacies in the UK. We aimed to assess the impact of pharmacy-based vaccination services in terms of acceptability, uptake, cost-effectiveness and addressing inequalities in order to inform future commissioning of routine immunization programmes. Methods We searched MEDLINE for peer-reviewed papers published in the English language from January 2000 to November 2015. We used the following search terms on MEDLINE: ‘immunization’ OR ‘vaccination*’ OR ‘exp MASS VACCINATION’ AND ‘exp COMMUNITY PHARMACY SERVICES’. In addition, we searched Cochrane and Trip by topic and review, and we hand searched public health and pharmaceutical journals. We also searched for unpublished reports that did not appear in peer-reviewed journals. We contacted heads of public health commissioning and the screening and immunization leads in each of the 27 former NHS England local area teams to request copies of written evaluations of local programmes. We supplemented this with a search on google and by contacting public health bodies and associations representing GPs and pharmacists. All immunizations offered by community pharmacy to adults and children as part of the national immunization schedule were within the scope of this literature search.11 This included vaccinations that targeted whole cohorts as well as ones for groups at higher risk of infection. Papers were included if they focused on services that: (i) offered immunizations free as part of the national immunization schedule (at the recommended age or as catch up or in response to an outbreak), and (ii) were provided by community pharmacists, and (iii) were locally or nationally commissioned by the NHS in the UK. We excluded reports of other pharmacy vaccination services, such as travel vaccines and private vaccination (Fig. 1). Fig. 1 View largeDownload slide Flow chart for study search and selection process. Fig. 1 View largeDownload slide Flow chart for study search and selection process. We classified the type of peer-reviewed publication using standard typology for the hierarchy of evidence12 (Table 1). We reviewed the quality of peer-reviewed papers using checklists adapted from the Critical Appraisal Skills Programme (CASP).13 We also reviewed the quality of unpublished evaluation reports and made note of weaknesses and the risk of bias where this was present. Our quality appraisal was to inform our synthesis of findings rather than to include or exclude studies. We extracted data from included papers on programme characteristics and looked for reported evidence of effect in four domains: acceptability of the service (patient surveys which measured user satisfaction on a Likert scale), vaccination uptake (number and proportion of vaccines delivered in pharmacies), cost-effectiveness and impact on inequalities (evidence of individuals accessing vaccinations for the first time). Outcome measures are listed in Table 2. One researcher (S.P.) performed the searches, data extraction, coding and analysis. Table 1 Typology of evidence used to grade studies included in this review A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] View Large Table 1 Typology of evidence used to grade studies included in this review A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] A1 Systematic reviews which include at least one Randomized Control Trial (RCT) (e.g. Systematic Reviews from Cochrane or Centre for Reviews and Dissemination) A2 Other systematic and high quality reviews which synthesize references B1 Individual RCTs B2 Individual non-randomized, experimental/intervention studies B3 Individual well-designed non-experimental studies, controlled statistically if appropriate; includes studies using case control, longitudinal, cohort, matched pairs, or cross-sectional random sample methodologies, and well-designed qualitative studies; well-designed analytical studies including secondary analysis C1 Descriptive and other research or evaluation not in B (e.g. convenience samples) C2 Case studies and examples of good practice D Summary review articles and discussions of relevant literature and conference proceedings not otherwise classified Reproduced from Department of Health. National Service Framework for Older People (2001). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (page 11) [19 January 2018, date last accessed] View Large Our approach was systematic and comprehensive. However, it did not meet the full requirements of a systematic review and we have not categorized it as such. The research was overseen by a project steering group made up of senior representatives from Public Health England, the UK Department of Health and NHS England. Results Description of included papers We identified 28 evaluations of pharmacy services for delivery of routine vaccinations; all papers meeting the inclusion criteria were evaluations of seasonal influenza vaccination programmes. Three were peer-reviewed studies published in pharmaceutical journals.14–16 Of these, two were reviews of the same service implemented in Scotland in different years14, 15 and the third covered a service on the Isle of Wight.16 The 25 remaining papers were all unpublished evaluations of pharmacy services. In total, 24 evaluated services operating in England and covered 21 of the 27 former NHS local areas. Of these, four areas provided two evaluations covering consecutive years of their service. The final paper evaluated a service implemented across Wales.17 The type and quality of evaluations ranged widely. Some were brief descriptions of the service, others full service evaluations, and two were research studies of which one has since been published in the BMJ.8 Evaluation methods also differed across the papers, consisting of a mix of patient survey, staff survey and analysis of service delivery data (see Tables 2 and 3 for study characteristics). Table 2 Key features of and outcome measures reported in included studies (n = 28) n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 View Large Table 2 Key features of and outcome measures reported in included studies (n = 28) n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 n % Well-designed non-experimental study (B3) 1 4 Descriptive research or evaluation (C1) 27 96 Vaccine type  Seasonal influenza 28 100  Other disease programmes 0 0 Target group  Clinical risk groups aged 18–64 years only 13 46  Clinical risk groups aged 18–64 years and ≥65 years 10 36  Clinical risk groups aged 18–64 years and ≥65 years with partial service offered to at risk children 2 7  <18 years only 3 11 Outcomes reported  Uptake   Number of vaccinations delivered 27 96   Proportion of area vaccines delivered in pharmacy 11 39   % of vaccines administered given to people with diabetes 4 14   % of vaccines administered given to people with chronic respiratory disease 12 43   % of vaccines administered given to individuals aged >65 years and older 5 18  Acceptability   Service user satisfaction on Likert scale 9 32   Reasons for choosing pharmacy 9 32  Cost-effectiveness   Cost of pharmacy delivery compared to GP 0 0  Impact on inequalities   % of individuals vaccinated who reported no previous flu vaccination 9 32   % of individuals vaccinated who reported no flu vaccination the previous year 8 29 View Large All the included studies were observational in design (C1). Only one evaluation was a well-designed non-experimental study (B3).8 Many evaluations had methodological flaws as follows: incomplete reporting of methods for data collection, presence of confounding in design and analysis, and under-use of statistical techniques (e.g. confidence intervals and tests of significance). Two of the three peer-reviewed studies had small sample sizes,14,15 and one had a high probability of confounding.16 Features of service delivery The majority of papers (n = 23) reviewed immunization services that were only offered to adults. These services were divided into two types: ones which included the over-65s (n = 10) or ones which were only targeted at clinical risk groups aged 18–64 years (n = 13). Two papers reviewed services for children as well as adults, and three services were for children only (Table 2). The services described were similar in design. Patients were informed of the service by poster, leaflet, local media or by opportunistic vaccination when the patient collected his or her medication. Vaccinations were administered by pharmacists who had received specific training. Patient Group Directions provided the legal framework for pharmacists to administer vaccines without the need for a signed prescription for each patient. Pharmacists recorded patient details on paper or via an IT platform. Pharmacists were usually required to inform GP practices of vaccinations given within 24–48 h. Patients’ eligibility for NHS vaccination was verbally confirmed except in four services where pharmacists required written evidence of entitlement.15 Seven of the unpublished evaluations reported issues with the quality and timeliness of data entry and transfer from pharmacies to general practices. The London evaluation found that there was considerable under-reporting of pharmacy delivered vaccines in GP systems and therefore the loss of data for surveillance.8 Four services reported concerns from GPs that patients were inappropriately vaccinated though reported instances were few in number. The scale of service delivery varied widely. The overall number of vaccines delivered in pharmacies ranged from 56 to 41 282 (interquartile range: 4528 – 1103 = 3425) (n = 27). The proportion of area vaccines delivered in pharmacies was between 0.6 and 20% (n = 11). Three of four papers evaluating the same service in successive years saw an increase in the number of vaccines delivered as programmes expanded in their second year (Table 3). Table 3 Characteristics and outcomes of included studies Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Table 3 Characteristics and outcomes of included studies Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports published in peer-reviewed journals (n = 3) Study Characteristics of included studies Outcomes Setting and study design Target group (s) Scale Vaccine uptake Acceptability Previous vaccination Hind et al.14 Scotland Questionnaire At risk groups aged 18–64 years vaccinated in one community pharmacy over a 4-week period 1 pharmacy 56 vaccines given 42.8% given to people with chronic respiratory conditions 73% chose pharmacy because it was a convenient venue Not reported Hind et al.15 Scotland Questionnaire At risk groups aged 18 to 64 years and those over 65 years. Plus fee-paying individuals not eligible for NHS vaccination A 3-year programme (Year 1 reported above). Year 3—seven pharmacies participated and 213 NHS vaccines given. 64% of NHS vaccines given to people with chronic respiratory conditions (Year 2) Positive comments from individuals vaccinated in pharmacy Not reported Warner et al.16 Isle of Wight Mixed-methods At risk groups aged 18–64 years, carers and those over 65 years. Pregnant, paediatric and immunocompromised patients added later 18 pharmacies 2837 vaccines given 69.5% of individuals vaccinated were aged > 65 years. Greater proportion of carers vaccinated in pharmacies than in GP practices (P < 0.001). Proportion of area vaccinations given in pharmacy = 9.7% 91% rated the service as ‘excellent’ 8.2% said that they had not had a flu vaccine previously Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Reports not published in peer-reviewed journals (n = 25) Area Characteristics of included studies Outcomes Year Target group Scale Vaccine uptake Acceptability Previous vaccination London (NB now published: Atkins et al.8) 3-Year evaluation from 2012 to 2015. Mixed methods. All eligible groups aged 13 years and over in 2012–13 and 2013–14. In 2014–15, these groups added: children aged 2 years and older (inactivated flu) and pneumococcal to eligible children and adults. Pilots in four London boroughs in 2012–13. Pan-London from 2013–14. Number of participating pharmacies and vaccines given not reported. Pharmacy vaccination does not lead to any significant change in the uptake of seasonal vaccination in any of the risk groups. 99% of those vaccinated were registered with a GP. Relatively high use among carers. Proportion of area vaccinations given in pharmacy ranged from 3% (Enfield) to 20% (Tower Hamlets)—2014/15. Very high level of satisfaction reported by customers surveyed in 2014 Not reported Area 1 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 221 pharmacies (49% of pharmacies in the area). 15 603 vaccines given 61% given to the 65+ group. Proportion of area vaccinations given in pharmacy = 3.6% 99.2% ‘very satisfied’ 11.8% said they did not have flu vaccine in the previous year Area 1 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 421 pharmacies (56% of pharmacies in the area). 41 282 vaccines given 62.6% given to the 65+ group. Proportion of area vaccinations given in pharmacy =7.5% 99.9% ‘satisfied or very satisfied’ 11.2% said they did not have flu vaccine in the previous year Area 2 Service evaluation 2013–14 At risk groups aged 18–65 years, informal carers (pregnant women excluded) Nine pharmacies selected in areas with low uptake and high proportion of local population eligible. 96 vaccines given 50% given to people with chronic respiratory conditions 57.6% of patients said they chose pharmacy as it was ‘more convenient’ 66% (n = 63) reported not to have had flu vaccine in the previous year Area 2 Service evaluation 2014–15 At risk groups aged 18–65 years, pregnant women, informal carers 162 pharmacies. 3 643 vaccines given 46% given to people with chronic respiratory conditions 62% of patients said they chose pharmacy as it was ‘more convenient’ 41% reported not to have had flu vaccine in the previous year Area 3 Service evaluation 2014–15 At risk groups aged 18–64 years, informal carers and those over 65 years (pregnant women excluded) 315 pharmacies (84% of pharmacies in the area). 8 743 vaccines given 56.5% given to >65 years; 40.9% to <65 years (of which 44.3% given to people with respiratory conditions); 2.6% to informal carers. Proportion of area vaccinations given in pharmacy = 1.7% (65 years and over) and 2.6% (at risk groups aged 18–64 years) 80% of patients said they chose pharmacy as it was ‘convenient’ 7.9% said they had not had a flu vaccine for at least two years Area 4 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 207 pharmacies (31% of pharmacies in the area). 2611 vaccines given 44% given to people with respiratory conditions, and 19% to people with diabetes. Proportion of area vaccinations given in pharmacy =1% 79% of patients said they chose pharmacy as it was ‘convenient’ 23% said they had not had a flu vaccine previously Area 4 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 146 pharmacies. 1934 vaccines given 40.6% given to people with respiratory conditions, and 18.6% to people with diabetes 79% ‘very satisfied’ 26% said they had not had a flu vaccine previously Area 5 Service evaluation 2013–14 At risk groups aged 17–65 years, pregnant women, carers 1103 vaccines given Not reported 97% ‘very satisfied’ Not reported Area 6 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 2156 vaccines given Not reported Not reported Not reported Area 7 Service evaluation 2014–15 At risk groups aged 18–64 years, and pregnant women 92 pharmacies. 746 vaccines given Pharmacies selected if close to practices which had poor uptake the previous season 48% given to people with respiratory conditions, and 24% to people with diabetes Not reported Not reported Area 8 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers 6034 vaccines given 44.7% given to people with respiratory conditions 84% ‘extremely satisfied’ 25% said they had not had a flu vaccine the previous year Area 9 2014–15 At risk groups aged 18–64 years, pregnant women (carers excluded) 152 pharmacies Not reported 29.6% chose pharmacy as it was more ‘convenient’ 20% said that they had not a flu vaccine for at least three years Area 10 Service evaluation 2012–13 At risk groups aged 18–64 years, pregnant women, and catch up for over 65s if not vaccinated by GPs by 1 November. 24 pharmacies (19% of pharmacies in the area). 573 vaccines delivered Not reported 99% rated the service as ‘good’ or ‘excellent’ 20% said that they had not had a flu vaccine previously Area 11 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers, and those >65 years old 137 pharmacies. 1981 vaccines given 57.8% of individuals vaccinated were aged > 65 years. 2.9% were pregnant women. Proportion of area vaccinations given in pharmacy = 0.61% 99.6% ‘very satisfied’ 16.2% said that they had not had a flu vaccine previously Area 12 Service evaluation 2014–15 At risk groups aged 18–64 years, substance misuse clients, carers (pregnant women excluded) 37 pharmacies in areas with lowest rates of vaccination in previous season. 526 vaccines given 15.4% of individuals vaccinated had substance misuse problems. 45.5% said that pharmacy was ‘more convenient’ 31.3% said that they had not had a flu vaccine previously Area 13 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women, carers 100 pharmacies (40% of pharmacies in the area). 4 528 vaccines given Two-thirds of individuals vaccinated in pharmacy were aged > 65 years. A significantly higher proportion in under 65 at risk groups were vaccinated in pharmacy compared with practices, with the reverse applying for over 65 s (P < 0.01). Proportion of area vaccinations given in pharmacy = 2% 72% said that pharmacy was ‘more convenient’ 10% said that they had not had a flu vaccine previously Area 14 Service evaluation 2013–14 At risk groups aged 18–64 years, pregnant women 133 pharmacies 2 685 vaccines given 51% given to people with respiratory conditions. Proportion of area vaccinations given in pharmacy = 5.25% (area 1) and 1.66% (area 2) 78.6% said that pharmacy was ‘more convenient’ Not reported Area 15 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women (plus some NHS frontline staff and some carers) 177 pharmacies (33% of pharmacies in the area).4 225 vaccines given Proportion of area vaccinations given in pharmacy = 0.6 and 3.1% (depending on CCG area) Not reported Not reported Area 16 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women 95 pharmacies. 1 318 vaccines given 48.9% given to people with respiratory conditions Not reported 59.3% said they had not had a flu vaccination previously Area 17 Service evaluation 2014–15 At risk groups aged 18–64 years, pregnant women, carers in receipt of carer’s allowance 245 pharmacies (65% of pharmacies in the area). 4 532 vaccines given Largest groups vaccinated were individuals with chronic respiratory conditions and diabetes. Proportion of area vaccinations given in pharmacy = between 3.4 and 6.1% (depending on CCG) 65% said that pharmacy was ‘more convenient’ 24% said they had not had a flu vaccination previously Area 18 Service evaluation 2013–14 All primary school children in area 87 pharmacies. 11 113 vaccines given 37.2% of the cohort were vaccinated through a mixed delivery model of pharmacy, general practice and one community clinic Users reported to be ‘overwhelmingly positive’ Not relevant Area 18 Service evaluation 2014–15 All primary school children in area 95 pharmacies (97% of pharmacies in the area). 11 356 vaccines given Not reported Not reported Not reported Area 19 Service evaluation 2014–15 Children in school Years 7 and 8 (~32 000) 151 pharmacies. 413 vaccines given Not reported Not reported Not reported Wales17 2012–13 At risk groups aged 18–64 years, pregnant women, carers and those over 65 years 81 pharmacies (11% of pharmacies in Wales). 1537 vaccines given 32% of vaccines given were to people with chronic respiratory conditions 94% ‘very satisfied’ with the service 31% said that they had not had a flu vaccine the previous year Outcomes Acceptability Nine studies reported user satisfaction on a Likert scale; in seven of these more than 90% of patients rated the pharmacy service as ‘good’ or ‘excellent’. Nine other studies stated that convenience was the main reason for people choosing to be vaccinated at the pharmacy (Table 3). Uptake Eight evaluations attempted to measure changes in vaccine uptake by comparing year-on-year differences in area vaccination rates. Two studies reported increases in uptake of up to 6.2%;16 two reported decreases of up to 1.1%; two reported a mix of increased and decreased uptake depending on the risk group; and two reported no change in uptake. In only one of these studies was a significance test conducted for this outcome. This study found a modest reduction in vaccine uptake of 1.8–3.0% between 2013/14 and 2014/15 (P < 0.001). The largest risk groups vaccinated in pharmacy were people with chronic respiratory disease (n = 12) and diabetes (n = 4). When over 65s were included in the service, this group made up between 56.5 and 69.5% of the total vaccinated (n = 5). One study found a significantly higher proportion of at risk groups aged 18–64 years were vaccinated in pharmacy compared to practices, and that the reverse was true for the over 65 s (P < 0.01). Carers were found to have a significantly higher representation in the pharmacy vaccinated cohort than in the GP cohort in another study (P < 0.001)16 (Table 3). Cost effectiveness None of the studies reviewed compared the cost of vaccine delivery in pharmacy with that in GP practices. Inequalities Eight evaluations estimated the proportion of people vaccinated in pharmacy who had not had an influenza vaccination the previous year (median 22.5%), and nine reported the proportion of people who had never had an influenza vaccination previously (median 23%). These findings assumed that patients vaccinated in pharmacy had been in a risk group in previous seasons (Table 3). Discussion Main findings of this study This study is the first to bring together evidence from evaluations of community pharmacy vaccination services across the UK. Together these studies indicate that pharmacy-based services are highly acceptable to those who use them and that many service users find pharmacy a convenient setting to receive their vaccinations. We found no surveys exploring the views and attitudes of people who did not use pharmacy services, and no evidence for immunization programmes other than seasonal influenza. The largest groups vaccinated in community pharmacy were people with respiratory conditions and diabetes, and those aged over 65 years—this is to be expected as these individuals regularly use pharmacies. Carers also appeared to have a higher representation in the pharmacy cohort than in the GP cohort, which may be because carer status is not recorded on clinical records and therefore these individuals may not be called for influenza vaccination by their GPs. We found no evidence from existing studies that pharmacy services in the UK lead to overall increases in vaccination uptake. Some studies reported slight local variation in seasonal influenza vaccination rates following the introduction of the pharmacy vaccination programmes, with two areas reporting an increase and two a modest reduction. This reduction was also seen nationally in data comparing 2013/14 with 2014/15. This suggests that reasons other than the ‘pharmacy effect’ may have accounted for this change because many areas did not have a pharmacy programme. Year-on-year comparisons fail to take into account alternative explanations for changes in area uptake. These explanations would include any factors that might increase or decrease patients’ decision to seek vaccination, such as a change in public confidence in the effectiveness of the vaccine. There is weak evidence that pharmacy services address inequalities in vaccination uptake: across eight studies an estimated 22.5% of individuals attending pharmacies for vaccination reported having no vaccination the previous influenza season. However, it is not known what proportion of these individuals were eligible for the vaccine in previous years, and patients’ ability to recall accurately their vaccination history was not explored. It is worth noting that 17 studies reported that they were able to attract ‘new’ patients and nine reported that service users found pharmacies convenient vaccination venues, which suggests that community pharmacies are an agreeable alternative to GP practices for receiving the seasonal influenza vaccine. There is however insufficient evidence to show that this translates to increased uptake among the general public or among hard-to-reach groups. What is already known on this topic There is evidence from studies overseas that pharmacy-based vaccination service users report high satisfaction, and that these services may increase uptake, including among at-risk groups. Most of the research has been undertaken in the USA where pharmacy-based immunization, mostly involving seasonal influenza and travel vaccines, has been well established since the 1990s. One such review from Hogue et al.18 demonstrates that pharmacy vaccination can be safely delivered, and is highly acceptable to service users. Two further US studies found that pharmacists are able to encourage patients to be vaccinated either indirectly by providing education and information,19 or directly by providing services such as hepatitis B vaccination for intravenous drug users.20 Health systems and pharmacies in the USA are very different to those in the UK and results from the USA may not be directly generalizable to a UK setting. Our finding on acceptability reflects research by Anderson et al. which found that some people who are eligible for NHS vaccination choose to pay to have their flu jab at the pharmacy as they perceive this to be more convenient than going to their GP.21 A study by Evans et al.,22 published after we had conducted our review, found that community pharmacies in Wales may reach more younger at-risk individuals than other providers. What this study adds This is the first comprehensive review of the evidence for the impact of pharmacy vaccination programmes in the UK and highlights widespread experience of pharmacy services for seasonal influenza vaccination. It indicates that the pharmacy model is successful in offering patients convenience for receiving their influenza vaccine, as evidenced by 20% of influenza vaccinations being delivered in pharmacies in one area in London.8 Whether this experience is transferable to immunization programmes other than influenza is not known. This review has found no evidence that community pharmacies add value to routine immunization programmes by increasing uptake. It has been speculated that pharmacies could increase uptake for influenza vaccination among clinical risk groups aged below 65 years and pregnant women, for whom current vaccination rates are below national targets. However, our studies did not support this hypothesis. Our findings challenge the assumption that pharmacy vaccination programmes will simultaneously improve patient choice, increase uptake and widen access. A key explanation for our findings may lie in the fundamental difference between the pharmacy and general practice model for delivering vaccinations. Immunization programmes are public health programmes and the success of these depends on high coverage. GPs are well placed to deliver targeted vaccination programmes as they have a registered population, are able to identify eligible patients, and can offer them vaccination through an active call and recall system. The practice patient list acts as a denominator for measuring coverage. While community pharmacists may opportunistically identify people eligible for immunization, they do not have mechanisms for systematically identifying individuals within a target population, nor are they accountable for doing so, as GPs are. This review also exposes an evidence gap. We found only three peer-reviewed articles evaluating pharmacy immunization programmes in the UK and these were methodologically weak. There is a need for robust evaluations of pharmacy immunization programmes to assess their impact on vaccine uptake and health inequalities. Qualitative research is also needed to explore attitudes towards pharmacy vaccination services, particularly among groups that are under-represented in national immunization programmes, and for non-influenza programmes. Limitations We obtained evaluations from 84% of former NHS areas that had commissioned local influenza vaccination services from community pharmacy. We do not have information to assess whether the services we evaluated were similar to those we were not able to review in the remaining commissioning areas. Our review was limited to evaluations of influenza vaccination. We were not able to locate evaluations or peer-reviewed papers covering other community immunization services, such as maternal pertussis or hepatitis B vaccination for at-risk groups. Although we found no evidence of benefit in terms of increased uptake and improved access, the methods employed by researchers to demonstrate the so-called ‘pharmacy effect’ on vaccination uptake were not robust as they did not take potential confounding factors into account. Year-on-year differences in vaccine uptake may have been influenced by other factors affecting individuals’ health-seeking behaviours, such as public perception of vaccine efficacy (particularly in the wake of media messages regarding low influenza vaccine efficacy in the 2014–15 season) or unseasonably cold or warm weather. Studies evaluating access assumed that eligibility for vaccination was a constant, although individuals may have accessed pharmacy services for a first-time influenza vaccine on account of a new diagnosis or because they reached a significant age. In addition, there was a general lack of information regarding the administration of patient surveys. Studies in which the pharmacist entered survey responses on behalf of the patient are at risk of reporting bias. In spite of a comprehensive search of published and unpublished literature, we have found insufficient evidence to demonstrate that community pharmacies add value to routine immunization programmes. Our findings support the case for further research into other more targeted routine vaccination programmes, and into services offered to population groups whose use of primary care services and take up of vaccination is traditionally low. Local commissioning teams could be encouraged to pilot pharmacy delivery of immunization programmes which have historically suffered low uptake or inequalities in coverage. Robust evaluations of these new programmes would widen the research base and contribute to the ongoing debate about community pharmacy immunization programmes. Acknowledgements Thanks to Dr Louise Coole, Consultant Epidemiologist with PHE, for her comments on an earlier draft of this article. This review was part of a broader project, commissioned by the Immunisation Programme Board for England and Wales in 2015, to investigate the risks and benefits of extending pharmacy provision to support the national immunization programme. Funding None. Conflicts of interest None. References 1 World Health Organization . Essential Medicines and Health Products Information Portal: The Role of the Pharmacist in the Health Care System. http://apps.who.int/medicinedocs/en/d/Jh2995e/1.6.2.html (27 October 2017, date last accessed). 2 Pharmaceutical Services Negotiating Committee (PSNC) . About Community Pharmacy: PSNC Main Site. https://psnc.org.uk/psncs-work/about-community-pharmacy/ (27 October 2017, date last accessed). 3 Pharmaceutical Services Negotiating Committee (PSNC) . Community Pharmacy Call to Action. http://psnc.org.uk/the-healthcare-landscape/community-pharmacy-call-to-action/ (26 October 2017, date last accessed). 4 Public Health England. Consolidating and Developing the Evidence Base and Research for Community Pharmacy’s Contribution to Public Health: A Progress Report From Task Group 3 of the Pharmacy and Public Health Forum. ( 2014 ). 5 Public Health England . Quarterly vaccination coverage statistics for children aged up to five years in the UK (COVER programme ). Health Protection Rep 2017 ; 11 ( 23 ): 1 . 6 Department of Health, Public Health England & NHS England . The National Flu Immunisation Programme 2016/17: Supporting Letter. (2016). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529954/Annual_flu_letter_2016_2017.pdf (26 October 2017, date last accessed). 7 Public Health England . Seasonal Influenza Vaccine Uptake in GP Patients: Winter Season 2016 to 2017. ( 2017 ). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/613452/Seasonal_influenza_vaccine_uptake_in_GP_patients_winter_season_2016_to_2017.pdf (16 November 2017, date last accessed). 8 Atkins K et al. . Seasonal influenza vaccination delivery through community pharmacists in England: evaluation of the London pilot . BMJ Open 2016 ; 6 : e009739 . doi:10.1136/bmjopen-2015-009739. Google Scholar CrossRef Search ADS PubMed 9 Pharmaceutical Services Negotiating Committee (PSNC) . Flu Vaccination Service: PSNC Main Site. http://psnc.org.uk/services-commissioning/advanced-services/flu-vaccination-service/ (26 October 2017, date last accessed). 10 Madsen M . NHS recommissions controversial pharmacy flu vaccination scheme | News Article | Pulse Today. Pulse ( 2016 ). 11 Public Health England . The Routine Immunisation Schedule From Summer 2016. ( 2016 ). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/533829/9699_PHE_2016_Complete_Immunisation_Schedule_SUMMER16_A4_16.pdf (26 October 2017, date last accessed). 12 Department of Health . National Service Framework for Older People. ( 2001 ). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf (19 January 2018, date last accessed). 13 CASP . CASP Critical Appraisal Skills Programme. http://www.casp-uk.net/ (26 October 2017, date last accessed). 14 Hind C , Peterkin G , Downie G et al. . Successful provision of influenza vaccine from a community pharmacy in Aberdeen . Pharm J 2004 ; 273 : 194 – 6 . 15 Hind C , Downie G . Vaccine administration in pharmacies—a Scottish success story . Pharm J 2006 ; 29 : 134 – 6 . 16 Warner JG , Portlock J , Smith J et al. . Increasing seasonal influenza vaccination uptake using community pharmacies: experience from the Isle of Wight, England . Int J Pharm Pract 2013 ; 21 : 362 – 7 . Google Scholar CrossRef Search ADS PubMed 17 Llywodraeth Cymru & Welsh Government . Community Pharmacy Influenza Vaccination 2012–13. A summary of the results of the national Community Pharmacy Seasonal Influenza Vaccination Service ( 2013 ). 18 Hogue MD , Grabenstein JD , Foster SL et al. . Pharmacist involvement with immunizations: a decade of professional advancement . J Am Pharm Assoc 2003 ; 46 : 168 – 79-82 . Google Scholar CrossRef Search ADS 19 Fuchs J . The provision of pharmaceutical advice improves patient vaccination status . Pharm Pract (Granada) 2006 ; 4 : 163 – 7 . Google Scholar CrossRef Search ADS PubMed 20 Noble K , Holden M , Warner GA . Solution to improving uptake of hepatitis B immunisation in at risk groups, through collaboration and adopting an integrated approach with pharmacists as service providers . Int J Pharm Pr 2010 ; 18 : 43 . 21 Anderson C , Thornley T . It’s easier in pharmacy: why some patients prefer to pay for flu jabs rather than use the National Health Service . BMC Health Serv Res 2014 ; 14 : 35 . Google Scholar CrossRef Search ADS PubMed 22 Evans AM , Wood FC , Carter B . National community pharmacy NHS influenza vaccination service in Wales: a primary care mixed methods study . Br J Gen Pract 2016 ; 66 : e248 – 57 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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Journal of Public HealthOxford University Press

Published: Feb 15, 2018

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