HC 1048-III Health CommitteeWritten evidence from Novartis Vaccines and Diagnostics (PH 123)

Summary

Novartis Vaccines and Diagnostics Limited believes that the UK’s current immunisation programme and its surveillance and monitoring is widely recognised as amongst the best in the world. Any reforms should therefore aim to build on this excellent heritage to deliver even better public health outcomes. In particular:

Successful immunisation programmes are built on the basis of solid epidemiological monitoring and surveillance which assesses disease burden. This surveillance can therefore not only measure the impact of introducing new immunisation programmes, but provide real time effectiveness data on the quality and impact of existing programmes.

Successful immunisation programmes require high and uniform uptake of vaccines by the population. As such, immunisation and vaccination should continue to be UK-wide and be centrally commissioned, by the NHS Commissioning Board, not by health and wellbeing boards, GP consortia, local institutions or public health authorities to deliver the optimal population benefit.

Local public health authorities do, however, have an important role to play in increasing vaccine local uptake rates. In particular, our experience of working with community pharmacists suggests that inclusion of wider healthcare professionals in public health delivery can improve healthcare outcomes.

As the HPA is subsumed into Public Health England, surveillance must remain a top priority and the HPA should be able to continue its research affiliations with non-NHS bodies (whether in the academic or commercial sector). This transition cannot compromise the effectiveness of the monitoring for infectious diseases.

The Government has already committed that the Joint Committee on Vaccination and Immunisation will remain as an independent advisory board to provide expert impartial scientific advice on vaccination and immunisation.

The Public Health Outcomes Framework should have uniform vaccination rates as a key Domain 1 indicator.

Background

1. Novartis Vaccines and Diagnostics Limited is a leader in researching and developing vaccines. We have the only large scale influenza vaccine manufacturing facility in the UK and are also able to draw upon extensive international experience of public health systems.

2. Immunisation is a crucial part of public health provision. The UK’s immunisation programmes have saved more lives in the UK in the last 50 years than any other health intervention, and we believe the UK immunisation programme already delivers effective public health outcomes; reducing morbidity and mortality as a direct result of intervening against infectious disease. For example:

(a)Since the introduction of the Meningococcal C conjugate vaccine in 1999 cases of Men C in children have reduced by 95%; over 500 deaths have been prevented.

(b)Seasonal flu accounts for approximately 8,000 deaths in England and Wales each year; 70–80% of those receiving the seasonal flu vaccine will be protected, while others are more likely to get milder symptoms.

(c)The UK currently vaccinates against ten diseases of childhood, which have been estimated as saving the NHS 150,000 quality adjusted life years per annum at a cost to society of £6.6 billion. Over the life of the NHS, that would come to almost £400 billion at today’s prices.

(d)The Marmot review recently noted that paediatric immunisations in particular are among the most cost-effective ill health preventions.

Arrangements for Commissioning Public Health Services

3. Novartis believes that the integrity of a UK-wide vaccination programme must be maintained. At present, DH’s Immunisation Branch, with the Commercial Directorate and the NHS Commercial Medicines Unit (CMU), centrally procure vaccine on behalf of the UK and further maintain responsibility for warehousing, distribution and the supply chain for the tens of millions of childhood vaccines that the UK immunisation schedule requires.

4. A common immunisation schedule for children and the unified approach to adult vaccination across the four devolved nations provides optimal public health protection. Centrally-organised immunisation is the best way to avoid healthcare inequalities, and ensure uniform coverage for essential vaccinations to deliver the optimal public health benefit.

5. The central tenders also provide the UK exchequer with good value for money (bulk purchase versus smaller purchases at a devolved or primary care organisation level) and we would support the continuation of a centralised tender programme in the case of paediatric vaccines.

6. There is no additional value or benefit gained for the UK population through the fracture or fragmentation of this system down to the devolved nations, or local authorities. Local implementation could result in variations in the provision of an essential public health service - leading to poor control of infectious disease. Under existing arrangements, primary care organisations are obliged to implement National Institute for health and Clinical Excellence (NICE) guidance within three months of its publication, but it is well known that implementation can be patchy and can vary hugely from area to area. Local commissioning may exacerbate this tendency and introduce public health risks.

7. As such, we firmly support the continued central commissioning of immunisation, now a designated responsibility of the NHS Commissioning Board, and we strongly and urgently advise against giving local public health authorities responsibility for school immunisations—regardless of the eventual format and composition of Health and Wellbeing Boards, or equivalent proposed institutions. The added public health benefit or value this would provide is unclear.

The Future Role of Local Government in Public Health

8. While we do not believe that central commissioning of vaccination should be exchanged for local commissioning, local public authorities do have an important role to play in improving public health—and in particular, increasing vaccine uptake. Again, this is irrespective of the eventual format these organisations will take.

9. At present, responses to public health incidents are coordinated between different levels of government, with the Health Protection Agency’s Local Health Protection Units leading at a local level. We seek clarity on how new local public health authorities will interact with central structures for health incidents. Regardless of the eventual shape of local authorities’ involvement in public health, it is crucial that leadership on this is clearly defined at each level of government.

10. There is currently significant variation in uptake of vaccines and vulnerability to disease, particularly in areas of socio-economic deprivation. For example, evidence suggests that the rates of meningococcal disease have been twice as high in deprived areas, and uptake rates for seasonal influenza vaccination can also vary widely. Local agencies can more effectively target such areas than any national campaign.

11. Novartis further sees opportunities for other healthcare workers, notably pharmacists, to play an increased role in the delivery of some vaccination services, such as travel vaccines and for seasonal flu vaccination in particular. GPs have demonstrated successful delivery of seasonal flu programmes in the over 65 years group (almost 75%) but rates in the at-risk population have remained largely static over the last few years.

12. One potential solution may be to commission community pharmacy to provide this service rather than GPs, the subject of a paper submitted by various pharmacy organisations to the Welsh Assembly Government recently, which argues that making flu immunisation available from community pharmacies is not only welcomed by patients, but has the potential to significantly increase vaccination uptake rates.

13. We believe that there is a willingness amongst the public to take responsibility for its own health, and our experience of working with community pharmacy supports this. Since the launch of our In-Pharmacy Flu Initiative (IPFI) in October 2008, our community pharmacy partners (Tesco, AAH, Lloydspharmacy, Superdrug) have vaccinated over 100,000 patients and we have trained over 2,000 pharmacists in providing flu vaccinations. 1.5 million customers enter UK pharmacies daily, but pharmacists remain an under-utilised health service resource—the extended opening hours, convenience and ability to “drop in” were drivers for customers using our IPFI. If GP consortia are able to commission pharmacies to deliver seasonal flu vaccinations to at-risk groups, we believe that the NHS would be able to increase uptake rates for seasonal flu vaccination.

14. Indeed, of the 2,700 patients who received a flu vaccination from a community pharmacy, 37% suggested they would not have had a vaccination had it not been offered by the pharmacy. It is clear from the evidence base that increasing the availability of flu vaccination and ensuing that vaccination is available at a time and place that meets patient’s needs is a key factor in uptake of the vaccination.

The Creation of Public Health England within the Department of Health

15. The UK already has an enviable surveillance and monitoring programme for infectious diseases. Currently, the Health Protection Agency (HPA) in England, Health Protection Scotland and Public Health Wales all routinely monitor and track infectious diseases. This is an essential task:

(a)These systems also identify local outbreaks of infection. This can extend to vaccinating the family and close contacts of an individual who has recently contracted a potentially life-threatening infection.

(b)Following the introduction of a vaccine, there is continuous monitoring of infection rates and levels to measure the impact of the immunisation programme - focussing on health outcomes such as number of cases of infection

(c)Any intervention (such as local emergency vaccination) can therefore be targeted to the areas that most need it, and if the incidence of disease rises, the immunisation programme may be re-evaluated and the vaccination schedule changed.

16. As such, it is imperative that the HPA’s independent scientific advice is retained when it undergoes its transition into Public Health England. There is a risk that the public loses faith in a body that is seen as close to central Government - the HPA is credible thanks to its independence, and so its evidence must continue to be based on the standards of impartiality, quality and transparency in the new structure.

17. As noted in point (9) above, leadership on local health incidents must be clearly delegated. While the transfer to the new structure is ongoing, it is also essential that any compromise of the surveillance and monitoring programme for infectious diseases is avoided at all costs. HPA staff need certainty, and clarity is essential to support these key personnel who are in the frontline of health protection.

18. The JCVI monitors the effectiveness of the vaccine programme as a whole, looking at vaccine coverage and uptake, and reviews vaccines according to the same health economic criteria that the NICE uses in its health technology assessments. However, it is important to understand that vaccines have particular specificities:

(a)For the childhood immunisation programme, this means looking at potential interactions with other vaccines, in which month(s) of life to provide the vaccination, whether a catch-up campaign (a temporary extension of the vaccination programme to other age groups in the case of a novel or new vaccine introduction) should be conducted.

(b)Vaccines are given to entire birth years (as for the childhood vaccination programme—healthy young babies do not have a fully developed immune system)—or according to risk-based strategies. In effect, this means hundreds of thousands of children/adults receive a vaccine so a coordinated approach to the delivery of a programme is essential.

19. Novartis welcome the Health and Social Care Bill’s provision for the retention of the JCVI within Public Health England. The makes a valuable contribution to impartial public health evidence and analysis, and should be retained as the body that evaluates novel vaccines and any changes to vaccination programmes for the UK.

20. Public Health England needs to take responsibility for ensuring that GP Consortia are provided with the information, resources and training required to implement immunisation programmes and encourage effective uptake, as well as acting as a centralised resource to support national and local immunisation awareness campaigns.

Public Health Evidence

21. Novartis welcomes the Government’s commitment to establishing a National Institute for Health Research School for Public Health Research. In order to for the institute to make the fullest possible contribution to public health evidence, the NIHR should make its research available to industry and other interested parties. It is essential to collect evidence about attitudes to vaccines and what influences individuals’ decisions to get vaccinated, particularly as new vaccines are developed.

22. In light of the commitment to an evidence-based approach to public health we also encourage the Government to publish and update its infectious diseases strategy. Given the pace of development and innovation, an update to Getting ahead of the curve (2002) is long overdue, and would make a substantial contribution to information and intelligence on public health and preventative healthcare.

The Structure and Purpose of the Public Health Outcomes Framework

23. Vaccination coverage should be a key part of the Public Health Outcomes Framework. We fully support vaccination coverage as an indicator for Domain 1 (health protection and resilience), as indicated in the Department of Health’s January 2011 consultation on the framework.

24. Vaccination is one area that requires absolute equality in access in order for it to be fully effective—thanks to the herd immunity effect, where if a population has vaccination above a certain threshold then non-vaccinated individuals are also protected. This will only be sustained if coverage is uniform. Therefore the outcomes framework needs to establish minimum vaccination coverage levels that are uniform across all local areas, as well as ensuring total equal access to vaccination for all. We see this as a crucial supporting policy for continued national commissioning of flu, as outlined above.

25. The indicators for vaccines should also include vaccination for healthcare professionals which has been relatively poor; only ~20% of all healthcare workers are vaccinated against seasonal influenza in a typical flu season, which puts themselves and their patients at risk of contracting influenza.

June 2011

Prepared 28th November 2011