Lothian NHS Board Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG

Telephone: 0131 536 9000 www.nhslothian.scot.nhs.uk www.nhslothian.scot.nhs.uk

Date: 15/10/2020 Your Ref: Our Ref: 4683

Enquiries to : Richard Mutch Extension: 35687 Direct Line: 0131 465 5687 [email protected] [email protected]

Dear

FREEDOM OF INFORMATION – FLU VACCINATIONS

I write in response to your request for information in relation to flu vaccinations within NHS Lothian.

Question: 1. Whether the flu vaccination programme in 2020/21 will be carried out by GPs or by the local health and social care partnerships.

Answer: Mixed Model - HSCPs heavily involved in delivery this year and some remaining GP involvement Primary school flu delivered by Health Board NHS Staff flu largely delivered by peer vaccinators Community Pharmacy pilots have been expanded this year Models vary across four HSCPs in Lothian.

Question: 2. The number of people who were eligible for a free flu vaccine in 2019/20 and the number who will be eligible in 2020/21.

Answer: Cohorts 2019/20 Numbers Eligible age 65 and over 152,000 all at risk 119,000 Preg no risk 6,000 Preg clin risk 1,000 Carers 6,000 NHS staff 26,000 2-5 years not at school 24,000 Primary School 67,000 Total 539,000 New cohorts 2020/21 - COHORT INFORMATION WILL BE

Flu Vaccinations - October 2020

AVAILABLE ON FLU PORTAL STARTING 12 OCTOBER. THIS WILL NOT INCLUDE 50-64 AGE GROUP.

Question: 3. The number of invite letters that have been sent out for the 2020/21 vaccination programme.

Answer: Letter National Flu Letter 136,198 2 to 5 Flu letter 6,284 Consent Packs Primary Pupils 67,000 National At risk Letter 84,625 SIRS Scheduled Letters( to date) 27,815 Total 254, 922 Please note that not all patients are invited by letter as models vary.

Question: 4. The dates on which the flu vaccination programme is to take place and the planned location for where vaccinations will be carried out.

Answer: Programme started 14 September and will mainly end early to mid December as things stand. Delivered in a variety of settings including walk through, drive through, GP, Council and NHS buildings and public spaces such as large gardens, pavilions and halls. Model varies across HSCPs.

Question: 5. The number of flu vaccines ordered for the vaccination programme in 2019/20 and the number that have been ordered (or for which there are plans to order) for the programme in 2020/21.

Answer: Season 19/20 Area Stores were issued in total 100,145 doses of Flu vaccine. These were made up of:

o Fluenz to schools, GPs o Staff Flu o Inpatient Flu In practices and Hubs and Community Pharmacy, 191, 940 doses were ordered

Flu Vaccinations - October 2020

For 20/21, Planned allocations for first phase of campaign is 259, 610 vaccines so far allocated to Lothian GP practices and hubs. This is determined by National Procurement based on uptake last year plus 10%. We await further allocations from National Procurement for the first phase of the campaign. Further stock will become available in November. Vaccine Holding Centre: Total doses = 11, 386 ordered so far and hoping to order another 10,000 doses.

Primary School Flu: Total allocation: 80, 130 (32130 deliveries pending, 48180 deliveries received)

For further information adult flu, please find our allocations https://nhsnss.org/services/practitioner/medical/adult-flu-vaccine-distribution- arrangements-202021/.

Question: 6. What the costs (or estimated costs) were for the flu vaccination programme in 2019/20 and will be in 2020/21.

Answer: In 2019/20 the costs of the flu vaccination programme was £4.5m (including £2.2m for Vaccines). In 2020/21 the estimates is £7.8m (including £3.3m for Vaccines)

Question: 7. A copy of all official correspondence sent to GPs regarding the flu vaccination programme.

Answer: Please see enclosed.

I hope the information provided helps with your request.

If you are unhappy with our response to your request, you do have the right to request us to review it. Your request should be made within 40 working days of receipt of this letter, and we will reply within 20 working days of receipt. If our decision is unchanged following a review and you remain dissatisfied with this, you then have the right to make a formal complaint to the Scottish Information Commissioner within 6 months of receipt of our review response. You can do this by using the Scottish Information Commissioner’s Office online appeals service at www.itspublicknowledge.info/Appeal. If you remain dissatisfied with the Commissioner’s response you then have the option to appeal to the Court of Session on a point of law.

Flu Vaccinations - October 2020

If you require a review of our decision to be carried out, please write to the FOI Reviewer at the email address at the head of this letter. The review will be undertaken by a Reviewer who was not involved in the original decision-making process.

FOI responses (subject to redaction of personal information) may appear on NHS Lothian’s Freedom of Information website at: http://www.nhslothian.scot.nhs.uk/YourRights/FOI/Pages/default.aspx

Yours sincerely

PROFESSOR ALEX MCMAHON Executive Director, Nursing, Midwifery and AHPs Executive Lead for REAS and Prison Healthcare Cc: Chief Executive

Foi

From: on behalf of GMSContract Sent: 04 September 2020 09:28 To: GMSContract Attachments: Ordering Open email - 27 August 2020 v1.0.docx; MarketPlace User Guide Aug2020.pptx; 2020 03 09 Letter to GPs Seasonal Flu Vaccine Arrangements.pdf

Importance: High

1 is made available on GP practice websites to help patients find out all the available options where they can get an NHS flu vaccine locally as part of the communication strategy for the flu campaign.

The community pharmacy provision of flu vaccine in the eligible cohorts is anticipated to be opportunistic and act as a top up/mop up for flu vaccination. Practices may choose to direct patients to the pharmacy flu vaccine pilot service where they are unable to offer a suitable appointment time and they cannot get to other clinics organised by HSCPs. Patients should be directed to the list of participating pharmacies so they can choose one which is most convenient for them or to check the service directory on NHSInform for their postcode.

Due to Covid 19 restrictions participating pharmacies will vary in how they offer the service compared to normal. Your local pharmacist may contact the practice to discuss how they will provide the service and how they can best help support the flu campaign this year.

Please ensure all practice staff who deal with flu vaccination appointments for your patients are made aware of the HSCP and community pharmacy options so they can sign post appropriately if a suitable appointment is not available in the practice.

The vaccine used by the pharmacies will be the aTIV for the over 65s and cQIV for the other eligible groups.

Pharmacies will record NHS flu vaccination using an NEO IT system flu module. This information can be downloaded by NHS Lothian. The information will be added to GP patient records for those who have received flu vaccine along with HSCP data for flu vaccination. How this happens will be dependent on the local HSCP arrangements for external clinics.

Key Points  Opportunistic top up/mop up flu vaccination to support the 2020/21 flu campaign  Eligible groups include: >65 years; 18‐64 years at ;pregnant women, unpaid carers and household members of those shielding.  Vaccination may only be obtained from pharmacies which are participating in the pilot (see attached lists)  Please ensure all reception and practice staff who deal with flu vaccinations are aware of all the local options for flu vaccination

Do please contact us if you have any further questions. Thank you for your support.

Best wishes Maureen

Maureen Reid Consultant in Pharmaceutical Public Health Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG Telephone number: Mobile Work days: Tuesday Wednesday Friday

2 From: on behalf of GMSContract Sent: 26 August 2020 14:25 To: GMSContract Subject: PCA(M)(2020)14 - Influenza and Pneumococcal DES Attachments: PCA(M)(2020)14 - Influenza and Pneumococcal DES.PDF

Message sent to senior GPs, clinical mailboxes and practice managers in Lothian

Please ensure that all relevant staff are aware of this message

Dear colleagues, please find attached PCA(M) 2020 (14) on Flu and Pneumococcal Immunisation DES.

Once you have had a chance to read this you will appreciate that it is a different approach to what we have agreed in Lothian.

HSCPs , NHS Lothian and GPs have been working together to implement plans since June.

We have discussed this PCA with HSCPs and GP Sub Committee/LMC and we believe that it is too late in the day to introduce a completely new approach to the flu vaccine campaign. We also believe that what has been agreed in Lothian and in each HSCP gives the best chance to maximise uptake for your patients, treats practices fairly, accommodates local variation and protects practice profitability.

NHS Lothian and GP Sub Committee/LMC will write to the Scottish Government saying that we will exercise para 43 in the PCA and that we will continue with the arrangements that we have agreed locally. These were set out in the recent flu update to practices.

The PCA notes that more detail will follow in a further letter e.g. on item of service fees.

We will review this when it is received and discuss any implications with GP Sub Committee/LMC.

David Small

David Small Director of Primary Care Transformation NHS Lothian 2‐4 Waverly Gate Edinburgh EH1 3EG

1

East GP HSCP HSCP (tbc by tbc HSCP with Mix HSCP HSCP HSCP HSCP end Aug) some GP between opportunistic GP, Acute Maternity etc and HSCP

Mid GP with GP with GP with tbc HSCP Mix HSCP HSCP HSCP with HSCP some HSCP some HSCP some HSCP between some GP support in support in support in GP, Acute opportunistic kind Maternity kind kind etc and HSCP

West GP with GP with GP with tbc GP with Mix HSCP HSCP HSCP HSCP some HSCP some HSCP some HSCP some HSCP between support in support in support in support in GP, Acute kind kind kind kind Maternity etc and HSCP

Pharmacy Yes Yes Yes tbc Yes Yes No No No

* note: some children will still come to general practice e.g. those than cannot have the nasal flu vaccine

Support For Practices

The CMT also agreed supports for general practice as set out in the table below.

HSCP Transfer Flexibility Flexibility Transfer Transfer Attainment Support Additional Additional of on on of of of £9.39 in kind Funding funding Residuals Enhanced postponing Residuals Residuals fee level from to to for 2‐5 Services planned for >65 for <65 for all >65 HSCP recognise recognise Nasal Flu Restart to care to adult flu adult flu flu reduced reduced ‐ 100% free free – 100% – 100% efficiency efficiency income capacity capacity income income in in protected – income protected protected practices ‐ practices ‐ protected >65 <65 existing at risk Edinburgh Y Y Y Y Y N (unless N N N already in transfer of residuals) East Y Y Y N Y Y Y Y N (tbc will depend on final model) Mid Y Y Y N N Y Y Y Y West Y Y Y N N Y Y Y Y

I can confirm that the additional funding referenced is £2 per vaccination and will apply to all vaccinations done by the practice.

It is also expected that more practices will reach the £9.39 fee level for >65’s (where a practice does reach the £9.39 fee it applies to all vaccinations)

Practices should also take account of the reduction in workload and protected income for the 2‐5 nasal flu programme.

Below is a worked example for a real anonymised practice that delivers all of the adult programme comparing last year’s income with a projection for this year. 2

From: on behalf of GMSContract Sent: 13 August 2020 13:18 To: GMSContract Subject: Flu Programme 2020/21 Update For Practices

Message sent to senior GPs, clinical mailboxes and practice managers in Lothian

Please ensure that all relevant staff are aware of this message

To all GP Practices.

Update on Seasonal Flu Programme 2020/21.

Dear colleagues, you will have received a copy of the CMO letter of 7th August on the adult flu programme. We are expecting a follow up letter shortly on contractual issues including fees and until we have this we cannot finalise the financial details for practices.

We will write again as soon as we have clarity on outstanding issues.

The principles we are working to for general practice are:

Flu 2020/21 – Underlying principles/assumptions

This year’s flu campaign will be one of the most important.

Uptake among existing cohorts will rise significantly and new age cohorts will be introduced.

This will require maximum capacity and co‐operation between all parts of the system.

At the time of writing we do not have clarity on all aspects of government policy.

In Lothian we will have a mixed economy for this winter as HSCPs are at different stages in transferring vaccinations away from practices under the MOU.

For winter 2021/22 it is expected that all vaccinations will have been transferred from practices, therefore arrangements for 2020/21 are transitional and will not set a precedent.

It is important that in those areas where practices will be asked to do the bulk of or the entire programme, practices are not disadvantaged financially by the reduction in efficiency imposed by Covid19.

It is also important that the transfer of residuals income guarantee is in place where practices will deliver less than previous years.

Activity should be maximised as early as possible in the season.

Below is a table setting out what parts of the Lothian programme will be delivered by who.

Flu 2020/21 “Who is doing what?

HSCP >65 <65 at risk >55 new 50 – 54 Shielded Pregnant NHS Social Carers cohort new Households Women Staff Care cohort Staff (still to be agreed)

1 Edin HSCP with HSCP with HSCP with tbc HSCP with Mix HSCP HSCP HSCP some GP some GP some GP some GP between Acute opportunistic opportunistic opportunistic opportunistic GP, etc Maternity and HSCP East GP HSCP HSCP (tbc by tbc HSCP with Mix HSCP HSCP HSCP end Aug) some GP between Acute opportunistic GP, etc Maternity and HSCP Mid GP with GP with GP with tbc HSCP Mix HSCP HSCP HSCP wit some HSCP some HSCP some HSCP between Acute some GP support in support in support in GP, etc opportun kind kind kind Maternity and HSCP West GP with GP with GP with tbc GP with Mix HSCP HSCP HSCP some HSCP some HSCP some HSCP some HSCP between Acute support in support in support in support in GP, etc kind kind kind kind Maternity and HSCP Pharmacy Yes Yes Yes tbc Yes Yes No No

* Some children who cannot have nasal flu will still need to attend general practice Note: East Lothian is engaging with practices on some final details

The table below shows the range of support to practices that is being considered.

Support For Practices

HSCP Transfer Flexibility Flexibility Transfer Transfer Attainment Support “Premium” “Pre of on on of of of £9.39 in kind to to Residuals Enhanced managing Residuals Residuals fee level from recognise reco for 2-5 Services day to day for >65 for <65 for all >65 HSCP reduced redu Nasal Flu Restart to activity to adult flu adult flu flu (should efficiency effic - 100% free free – 100% – 100% be possible in in income capacity – capacity income income if uptake is practices - prac protected income protected protected over 85%) >65 <65 protected Edinburgh Y Y Y Y Y N N N N East Y Y Y N Y Y Y Y N (t Mid Y Y Y N N Y Y Y Y West Y Y Y N N Y Y Y Y

We aim to support practices across Lothian to enable them to maximise uptake.

All practices will receive Transfer of Residuals income guarantee for 2‐5 flu.

In Edinburgh where the HSCP will deliver c 90% of the adult programme, practices will have Transfer of Residuals income protected and will be able to be flexible in managing workload to maximise the vaccinations they are able to give.

In Mid and West Lothian where practices will be delivering almost all of the programme (and will certainly deliver activity above 2019/20) they will have these workload flexibilities, plus the ability to earn fees above previous

2 income levels, plus the opportunity to earn the higher fee for >65s, plus a "premium" to recognise inefficiency due to covid restrictions.

In East Lothian where practices will be delivering all of the >65 programme (and will certainly deliver activity above 2019/20) they will have these workload flexibilities, plus the ability to earn fees above previous income levels, plus the opportunity to earn the higher fee for >65s plus, plus a "premium" to recognise inefficiency due to covid restrictions.

In East Lothian, the <65 at risk group will be done by the HSCP through targeted clinics – any workload completed by GP practices from within this cohort will determine how much of these supports will apply.

The CMO letter indicates that the new age cohort from 55 ‐ 64 will be prioritised from December 2020. It is assumed that the delivery mechanisms will be the same as for existing groups (confirmation is still required for East Lothian) and that these supports and flexibilities will apply to this cohort too.

As indicated above, we are awaiting a letter on contractual issues and we cannot finalise fees and "premium" amounts at this point.

David Small Drummond Begg Director of Primary Care Transformation Chair NHS Lothian GP Sub Committee

David Small Director of Primary Care Transformation NHS Lothian 2‐4 Waverly Gate Edinburgh EH1 3EG

3 Chief Medical Officer Directorate E: [email protected] 

Dear Colleagues From Chief Medical Officer ADULT FLU IMMUNISATION PROGRAMME 2020/21 Chief Nursing Officer Chief Pharmaceutical 1. We are writing to provide you with information about Officer the adult seasonal flu immunisation programme. 07 August 2020 2. We would like to begin by thanking you for all the SGHD/CMO(2020)19 hard work you are doing as part of the health and For action social care response to the global Covid-19 Chief Executives, NHS Boards pandemic. We know that this has been an extremely Medical Directors, NHS Boards Nurse Directors, NHS Boards challenging time for staff across the health and social Primary Care Leads, NHS Boards care sector. Directors of Nursing & Midwifery, NHS Boards Chief Officers of Integration 3. Given the impact of Covid-19 on the most vulnerable Authorities Chief Executives, Local Authorities in society, it is imperative that we do all that we can Directors of Pharmacy to reduce the impact of seasonal flu on those most at Directors of Public Health General Practitioners risk. It is therefore essential that we have effective Practice Nurses plans in place to deliver the flu immunisation Immunisation Co-ordinators CPHMs programme this winter to protect those at risk, Scottish Prison Service prevent ill health in the population and minimise Scottish Ambulance Service Occupational Health Leads further impact on the NHS and social care services. For information Chairs, NHS Boards Planning Infectious Disease Consultants Consultant Physicians Public Health Scotland 4. We recognise that delivering the programme this Chief Executive, Public Health year will be more challenging than ever before Scotland NHS 24 because of the impact of Covid-19 on our health and Further Enquiries social care sector. We are working through the Policy Issues Scottish Immunisation Programme Group to develop Vaccination Policy Team guidance on vaccination service delivery to ensure [email protected] that all who will benefit most from the flu vaccine will have the opportunity to receive it in a timely manner while maintaining good Infection Prevention & t Control practices and appropriate physical distancing. The provision of appropriate Personal Medical Issues Protective Equipment (PPE) to those involved in the St Andrew’s House delivery of the flu vaccination programme will also form an important part of the programme planning. Pharmaceutical and Vaccine Supply Please refer to the Covid-19 guidance available at: Issues Public Health https://www.hps.scot.nhs.uk/a-to-z-of-topics/covid- Scotland 19/infection-prevention-and-control-ipc-guidance-in- healthcare-settings/#title-container .

1 5. While General Practice will have an essential role to play in the flu immunisation programme, its capacity is likely to be substantially constrained by the need to maintain good Infection Prevention & Control practices and appropriate physical distancing measures. As set out in John Connaghan’s letter of 14 May, flu immunisation preparation is a key clinical priority for Boards and Partnerships. A whole system response, bringing in other parts of the health system, is required if a successful programme is to be delivered.

6. We would expect us all to draw on learning from our experience with Covid-19 and be mindful on how best to deliver a vaccination programme that is prioritised towards protecting the most vulnerable.

Key Objectives

7. The flu programme is a strategic and Ministerial priority. The key objectives of the 2020/21 adult flu programme are summarised below

 To protect those most at risk from flu in the coming season and to ensure that the impact of potential co-circulation of flu and Covid-19 is kept to an absolute minimum.  To plan to deliver the programme building on lessons learnt from previous years and our experience of Covid-19, recognising that arrangements may need to change and putting in place the resource needed to deliver the programme at scale.  To increase flu vaccine uptake across all eligible groups with particular focus on those who are aged 65 years and over; those aged 18-64 years in clinical risk groups, as well as pregnant women (at all stages of pregnancy). Full details of eligibility for flu immunisation this season is set out in Annex A.  To extend the national programme to offer vaccination to households of those who are shielding, social care staff who deliver direct personal care and all those aged 55-64 years old. Some of those aged 55-64 are otherwise eligible due to qualifying health conditions or employment.  To maximise uptake amongst frontline health and social care workers which may require creativity and innovation but is critical to safeguard staff, but also those in their care.

8. The Scottish Government has procured additional vaccine to cover increased uptake amongst existing cohorts, in light of Covid-19, as well as to provide vaccine supply to introduce additional eligible groups to the programme.

9. Scottish Ministers have indicated that the programme should be extended to those aged 50-54, if vaccine supply allows. We will review this in line with uptake rates and vaccine supply as the programme progresses.

10. A separate letter has been issued for the childhood flu immunisation programme, available at https://www.sehd.scot.nhs.uk/cmo/CMO(2020)17.pdf.

11. More information on the flu vaccines for this upcoming season as well as vaccine composition is provided below in Annex B.

2 Extension of the programme

12. Scottish Ministers have decided to extend the eligibility of the flu immunisation programme to social care workers providing direct personal care, households of those shielding and all 55-64 year olds this year. Some of those groups may already be eligible due to being part of one or more other cohorts e.g. those aged 55-64 may be otherwise eligible due to qualifying health conditions or employment.

13. The rationale for expanding to all 55-64 year olds, beyond those who are already eligible through qualifying health conditions or employment, is that it will help to protect an age group who are more vulnerable to both Covid-19 and seasonal flu than those in younger age groups; and will lower the risk for members of this group, of getting concurrent infection with both viruses. The vaccination of those aged 55-64 years who would not be otherwise eligible should commence in a second phase of the programme later in the season as detailed below.

14. Individuals who have been shielding have already been identified at being at a high risk from Covid-19. The health risks are heightened should they contract both Covid-19 and seasonal flu at the same time. Given that a high proportion of those shielding are either over 55, or else have an underlying health condition, it is likely that many of them are already eligible for the seasonal flu vaccine. However, there are some people shielding whose underlying condition may cause them to have a sub-optimal response to the flu vaccine. Vaccinating those who live in households with those in the shielding group for Covid-19 should provide additional indirect protection to individuals who are shielding.

15. The intention is that eligibility would be defined by the shielding list in place at the time of vaccination. Further detail on this will follow.

16. The Covid-19 pandemic has had an effect on every aspect of public health, including vaccine supply at a global level. This means that the Scottish Government has had to make difficult decisions about how we expand eligibility. The pandemic has also meant that situations can change hugely at very short notice. We will adapt our approach to any changes that occur throughout flu season, always prioritising those most at risk from seasonal flu, and always additionally seeking to protect the NHS as far as possible.

17. To allow us to be responsive to the changing context, we will review the availability of vaccine after uptake levels become clear within existing cohorts, household members of those shielding, and frontline social care workers. At that point we will decide whether there is sufficient vaccine supply to allow us to extend eligibility to 50-54 year olds.

18. Scottish Government will remain in regular dialogue with delivery partners through the Scottish Immunisation Programme Group and will update on any significant developments.

3 Phased approach

19. All those initially eligible should be given flu vaccination as soon as possible so that individuals are protected when flu begins to circulate. This is the case for all high-risk cohorts, excluding 55-64 year olds not otherwise eligible, and means starting to vaccinate in late September/October as in previous years.

20. For those aged 55-64, not otherwise eligible due to qualifying health conditions or employment, this will mean starting in December, at the latest. This phased approach is aligned to the availability of vaccines, and prioritisation of the cohorts who are most at risk from the seasonal flu. We will provide further advice, should the programme be extended later in the season to those aged 50-54.

21. NHS Boards and GP practices should aim to schedule their immunisation services to match vaccine supply, as outlined above, if possible: beginning in late September/October, and completing vaccination by the end of November for most high-risk cohorts; and beginning in December at the latest, and completing at the end of January for 55-64 year olds not otherwise eligible.

Health and Social Care Workers

22. Timely immunisation of all health and social care workers in direct contact with patients/clients will be a critical component in our efforts to protect the most vulnerable in our society.

23. High rates of staff vaccination will help to protect individual staff members but also reduce the risks of transmission of flu viruses within health and social care premises which will contribute to the protection of individuals who may have suboptimal response to their own immunisations. Furthermore, it will help to maintain the workforce and minimise disruption to services that provide patient/client care by aiming to reduce staff sickness absence.

24. Senior clinicians, NHS Managers, Directors of Public Health, Local Authorities and Integration Authorities should ensure this work aligns with the prioritisation already being given to our Covid-19 response to the care sector as a means to prevent transmission of the flu virus in an already vulnerable group.

Communication materials

25. The national media campaign (TV, radio, press, digital and social media) will seek to increase uptake rates amongst all groups and retain high uptake rates amongst groups who may now be more cautious about getting vaccinated. Research and insight work will underpin the campaign in light of Covid-19 and potentially changing attitudes to vaccination.

26. A national toolkit will be produced to support the promotion of the flu vaccine to health and social care workers and provide resources such as invitation emails, posters and suggested social media posts. We are also working in partnership with professional bodies and membership organisations to try to increase uptake rates.

4 27. The public should be signposted to http://www.nhsinform.scot/flu for up to date information on the programme.

28. Workforce education materials will soon be made available at https://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/public- health/health-protection/seasonal-flu.aspx.

Resources

29. NHS Boards are asked to ensure that immunisation teams are properly resourced to develop and deliver the extended programme.

30. Any additional costs related to adapting immunisation programmes to meet Covid-19 requirements (e,g. physical distancing, PPE) should be recorded in NHS Boards’ Local Mobilisation Plans, now called Covid-19 finance returns. This is in the form of a single row figure in the return.

31. Additional costs should also be submitted to the Scottish Government policy team directly with a breakdown of spend. The policy team will shortly issue a template to be submitted. Please ensure that costs are not double counted for services already delivered.

Action

32. NHS Boards and GP practices, are asked to note and implement the arrangements outlined in this letter for the 2020/21 adult seasonal flu immunisation programme. It is important that every effort is made this year to maximise uptake as this winter, more than ever, the flu vaccine is going to be a key intervention to reduce pressure on the NHS and protect the most vulnerable in our population.

33. We have procured additional vaccine to support higher uptake, however, ongoing and effective management at a local level is also required. NHS Boards should fully consider the needs of their eligible cohorts and plan appropriately and timeously in order to successfully deliver the programme.

34. We would ask that action is taken to ensure as many people as possible are vaccinated early in the season, and before flu viruses begin to circulate. The benefits of flu vaccination should be communicated and vaccination made as easily accessible as possible. This excludes those 55-64 year olds who are not otherwise eligible, as the commencement of vaccination of this group should be in December at the latest.

35. Integration Authority Chief Officers and Local Authorities are asked to work closely to communicate and promote the flu vaccination programme to social care workers providing direct personal care, and to ensure that they are supported to access the service. A separate letter will be issued to social care membership organisations to communicate the expansion directly to social care providers.

5 36. We would like to take this opportunity to express our gratitude for your continuing support in planning and delivering the flu immunisation programme and a heartfelt thank you for all your hard work in these most challenging of circumstances.

Yours sincerely,

Gregor Smith Chief Nursing Interim Chief Medical Officer Officer Chief Pharmaceutical Officer

6 Annex A

FLU VACCINE: PRIORITISING UPTAKE AND ELIGIBILITY

Prioritising flu vaccine uptake

37. Flu vaccination is one of the key interventions we have to reduce pressure on the health and social care system this winter. Since March 2020 we have seen the impact of Covid-19 on the NHS and social care, and this coming winter we may be faced with co-circulation of viruses causing Covid-19 and flu. We understand that planning this year is more challenging with the uncertainties of staff absences, and how long policies around physical distancing and alternative models of schooling will remain in place. However, it is more important than ever to make every effort to deliver flu vaccination.

38. Those most at risk from flu are also most vulnerable to concurrent infection with Covid-19. The people most at risk from flu are already eligible to receive the flu vaccine, and in order to protect them as effectively as we can, their vaccination should be prioritised.

39. We should also prioritise the vaccination of eligible health and social care workers, to protect them and minimise the likelihood of them spreading Covid-19 and flu to those they care for. We anticipate that concerns about Covid-19 may increase demand for flu vaccination in all groups this year, whilst others may have additional safety concerns around getting vaccinated.

40. All those eligible should be given flu vaccination as soon as possible so that individuals are protected when flu begins to circulate. This is the case for all high-risk cohorts excluding 55-64’s not otherwise eligible, and means starting to vaccinate in late September/October.

41. For those aged 55-64, not otherwise eligible through qualifying health conditions or employment, this will mean starting in December, at the latest. This phased approach is aligned to the availability of vaccines, and prioritisation of the cohorts who are most at risk from the seasonal flu. We will provide further advice, should the programme be extended later in the season to those aged 50-54.

42. NHS Boards and GP Practices should aim to schedule their immunisation services to match vaccine supply, as outlined above, if possible: beginning in late September/October and completing vaccination by the end of November for high- risk cohorts; and beginning in December at the latest, and completing at the end of January for 55-64 year olds not otherwise eligible.

Pregnant women

43. Most NHS Boards and Health and Social Care Partnerships (HSCPs) will be delivering flu vaccine to pregnant women through their local maternity services this year and should keep local practices informed about their plans including how to refer women to the services as appropriate.

7 GP practices however retain responsibility for vaccinating this cohort until alternative arrangements are made by local NHS Boards and HSCPs.

Existing Eligible Groups (those eligible in previous flu seasons)

44. In 2020/21 the seasonal flu vaccine should be offered, from the commencement of the programme, to the existing cohorts set out in the table below:

Eligible groups Further detail Pre-school children The childhood flu CMO letter for the 20/21 programme has further aged 2-5 years; and details. All primary school children in P1-7 All patients aged 65 “Sixty-five and over” is defined as those aged 65 years and over by 31 years and over March 2021. Chronic respiratory Asthma that requires continuous or repeated use of inhaled or systemic disease aged six steroids or with previous exacerbations requiring hospital admission. months or older Chronic obstructive pulmonary disease (COPD) including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD). Children who have previously been admitted to hospital for lower respiratory tract disease. Chronic heart Congenital heart disease, hypertension with cardiac complications, disease aged six chronic heart failure, individuals requiring regular medication and/or months or older follow-up for ischaemic heart disease. Chronic kidney Chronic kidney disease at stage 3, 4 or 5, chronic kidney failure, disease aged six nephritic syndrome, kidney transplantation. months or older Chronic liver disease Cirrhosis, biliary atresia, chronic hepatitis from any cause such as aged six months or Hepatitis B and C infections and other non-infective causes older Chronic neurological Stroke, transient ischaemic attack (TIA). Conditions in which respiratory disease aged six function may be compromised, due to neurological disease (e.g. polio months or older syndrome sufferers). Clinicians should offer immunisation, based on individual assessment, to clinically vulnerable individuals including those with cerebral palsy, learning disabilities, multiple sclerosis and related or similar conditions; or hereditary and degenerative disease of the nervous system or muscles; or severe neurological or severe learning disability. Diabetes aged six Type 1 diabetes, type 2 diabetes requiring insulin or oral hypoglycaemic months or older drugs, diet controlled diabetes. Immunosuppression Immunosuppression due to disease or treatment, including patients aged six months or undergoing chemotherapy leading to immunosuppression, bone marrow older transplant. HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system (eg IRAK-4, NEMO, complement disorder). Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day (any age) or for children under 20kg a dose of 1mg or more per kg per day. It is difficult to define at what level of immunosuppression a patient could be considered to be at a greater risk of the serious consequences of flu and should be offered flu vaccination. This decision is best made on an individual basis and left to the patient’s clinician.

8 Some immunocompromised patients may have a suboptimal immunological response to the vaccine. Consideration should also be given to the vaccination of household contacts of immunocompromised individuals, i.e. individuals who expect to share living accommodation on most days over the winter and therefore for whom continuing close contact is unavoidable. This may include carers (see below). Asplenia or This also includes conditions such as homozygous sickle cell disease dysfunction of the and coeliac syndrome that may lead to splenic dysfunction. spleen Pregnant women at any stage of pregnancy (first, second or third Pregnant women trimesters). Vaccination is recommended for people in long-stay residential care People in long-stay homes or other long-stay care facilities where rapid spread is likely to residential care or follow the introduction of infection, and cause high morbidity and homes mortality. This does not include, for instance, prisons, young offender institutions, university halls of residence etc. Someone who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to age, physical or mental illness, addiction or Unpaid Carers and disability. A young carer is a child or young person under the age of 18 young carers carrying out significant caring tasks and assuming a level of responsibility for another person, which would normally be taken by an adult. Vaccination can also be given on an individual basis at the GP’s discretion following a risk assessment after discussion with the carer. Health care workers who are in direct contact with patients/service users Health care workers should be vaccinated. Morbid obesity Adults with a Body Mass Index ≥ 40 kg/m² (class III obesity)*

45. The list above is not exhaustive, and clinicians should apply clinical judgement to take into account the risk of flu exacerbating any underlying disease that a patient may have or compromise their care due to illness of their carer, as well as the risk of serious illness from flu itself. Seasonal flu vaccine can be offered in such cases even if the individual is not in the clinical risk groups specified above.

Call and recall of patients aged 65 and over

46. As in previous years the Scottish Government will arrange for a national call-up letter to be sent to all those who will be aged 65 years and over by 31 March 2021. These letters will be delivered from w/c 14 September 2020.

Call and recall of patients under 65 years “at-risk”

47. National call-up letters for those aged under 65 at-risk are under further consideration and further information will be provided in due course.

New Eligible Groups 20/21

48. In 2020/21 the seasonal flu vaccine should be offered to the new cohorts set out in the table below:

9 Eligible groups Further detail Social care workers Social care workers who provide direct personal care in the following settings; adult care homes, children’s residential or secure care or care at home including Personal Assistants. This is targeted at those delivering direct personal care in these settings no matter of whether they are employed by Local Authorities, private or third sector employers. Households of those Those who live in the same home as individuals falling within the shielding Covid-19 shielding group. All patients aged 55 This is defined as those who will be aged 55 to 64 years old by 31 March to 64 years old 2021. The older age group are covered as an existing group above. Those within this group who are not otherwise eligible (i.e those with qualifying health conditions etc) should be vaccinated in a second phase as detailed below.

49. Health and social care workers and households of those shielding should be vaccinated from the commencement of the flu vaccination programme. Patients aged 55-64 years old, not otherwise eligible through qualifying health condition or employment, should be vaccinated in a second phase in December at the latest. This phased approach is aligned to the availability of vaccines, and prioritisation of the cohorts who are most at risk from the seasonal flu.

50. Scottish Ministers have indicated that the programme should be extended to those aged 50-54, if vaccine supply allows. We will review this in line with uptake rates and vaccine supply as the programme progresses.

Call and recall of households of those shielding

51. Scottish Government is currently considering the possibility of sending a national call-up letter to be sent to all households of those shielding. Further information on this will be provided in due course.

Call and recall of patients aged 55-64

52. Scottish Government is currently considering the possibility of sending a national call-up letter patients aged 55-64. Further information on this will be provided in due course.

Health and Social Care Workers

Healthcare Workers

53. Immunisation against flu should be considered an integral component of infection prevention and control. As in previous years, free seasonal flu vaccination should be offered by NHS organisations to all employees directly involved in delivering care. This is not an NHS service, but an occupational health responsibility being provided to NHS staff by the NHS as their employers.

54. Uptake of seasonal flu vaccination by health care workers continues to be below the CMO target - in 2019/20 in Scotland this was 53.8% in territorial boards compared with a minimum target of 60%.

10 55. While vaccination of NHS staff remains voluntary, we will look to all NHS Boards to do everything they can to increase uptake which should include offering the vaccine in an accessible way, helping all staff understand the seriousness of being vaccinated for themselves, their family contacts, their patients and the NHS in helping to reduce the potential for the spread of flu.

56. GP, dental and optometry practices, as well as community pharmacists, should also arrange vaccination of their staff.

Social Care Workers

57. The current Covid-19 situation has highlighted the need to ensure that front line staff across both health and social care settings do not inadvertently transmit infection and should therefore be encouraged and able to access free flu vaccination on a national basis. Scottish Ministers have therefore decided that the policy on flu vaccination for the coming and future seasons should be extended to include social care staff delivering direct personal care to patients/clients. This is in order to protect frontline social care staff and those they care for from flu and to help limit sickness absence amongst the workforce.

58. For clarity, social care staff delivering direct personal care in the following settings should be covered by this programme:  residential care for adults;  residential care and secure care for children; and  community care for persons at home (including housing support and Personal Assistants).

59. This is targeted at those delivering direct personal care in these settings no matter of whether they are employed by Local Authorities, private or third sector employers.

60. A Short Life Working Group was set up within the Scottish Immunisation Programme structure to coordinate expansion of the flu programme to cover social care staff who provide direct personal care. This included representation from Public Health Scotland, NHS Boards, COSLA, HSCP’s, Scottish Care and the Coalition of Care and Support Providers in Scotland.

Immunisation against Infectious Disease (‘The Green Book’)

61. Further guidance on the list of eligible groups can be found in the most recent influenza chapter (chapter 19) of the Green Book available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/796886/GreenBook_Chapter_19_Influenza_April_2019.pdf

62. Chapter 12 of the Green Book provides information on what groups can be considered as directly involved in delivering care and is available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/147882/Green-Book-Chapter-12.pdf

63. Any Green Book updates will be made to the linked pages above.

11 ANNEX B

RECOMMENDED FLU VACCINES, VACCINE COMPOSITION AND ORDERING INFORMATION

Flu vaccines for 2020/21

64. The flu vaccines that have been centrally procured for the forthcoming flu season are in line with the recommendations of the Joint Committee on Vaccination and Immunisation (JCVI) and are set out in the table below.

Eligible Group Vaccine First Phase Individuals aged 65 years and over adjuvanted Trivalent Inactivated Vaccine (aTIV) (Seqiris)

Individuals aged 18-64 years with “at- cell based Quadrivalent Inactivated risk” conditions Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris)

Health and Social Care Workers cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®)(Seqiris) or Egg based Quadrivalent Inactivated Vaccine (QIVe) (brand and manufacturer to be confirmed) dependent on vaccine supply and delivery schedules.

Households of those shielding cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris)

Unpaid/Young carers cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris)

Second Phase Individuals aged 55-64 not otherwise Egg based Quadrivalent Inactivated eligible through a qualifying health Vaccine (QIVe) (brand and condition or employment manufacturer to be confirmed)

65. Some flu vaccines are restricted for use in particular age groups. The Summary of Product Characteristics (SPC) for individual products should always be referred to when ordering vaccines for particular patients.

Vaccine composition for 2020/21

66. Each year the World Health Organization (WHO) recommends flu vaccine strains based on careful mapping of flu viruses as they circulate around the world.

12 67. This monitoring is continuous and allows experts to make predictions on which strains are most likely to cause flu outbreaks in the northern hemisphere in the coming winter. Getting vaccinated is the best protection available against an unpredictable virus that can cause severe illness.

68. For the 2020/21 flu season (northern hemisphere winter) it is recommended that cell based quadrivalent vaccines contain the following strains-:

 an A/Hawaii/70/2019 (H1N1)pdm09-like virus;  an A/Hong Kong/45/2019 (H3N2)-like virus;  a B/Washington/02/2019 (B/Victoria lineage)-like virus; and  a B/Phuket/3073/2013 (B/Yamagata lineage)-like virus.

69. For the 2020/21 flu season (northern hemisphere winter) it is recommended that egg based quadrivalent vaccines contain the following strains-:

 an A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09-like virus;  an A/Hong Kong/2671/2019 (H3N2)-like virus;  a B/Washington/02/2019 (B/Victoria lineage)-like virus; and  a B/Phuket/3073/2013 (B/Yamagata lineage)-like virus.

70. For further information and the full report please see: https://www.who.int/influenza/vaccines/virus/recommendations/2020- 21_north/en/

Egg-free vaccine

71. For individuals with egg allergy the advice in the most recent influenza chapter of the Green Book should be followed: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/796886/GreenBook_Chapter_19_Influenza_April_2019.pdf

72. Any Green Book updates will be made to the linked pages above.

73. Egg-allergic adults and children over age nine years with egg allergy can also be given the quadrivalent inactivated cell based (i.e. egg-free) vaccine, Flucelvax® Tetra, which is licensed for use in this age group.

Vaccine ordering and delivery arrangements

74. Information on ordering and delivery arrangements for the flu vaccine will be provided within further correspondence. Details of the supply arrangements for community pharmacies supporting this year’s immunisation programme will be shared directly via relevant NHS Boards.

75. Orders for the flu vaccine should be placed on the Movianto online ordering system - Marketplace: (https://ommarketplace.co.uk/Orders/Home). Log-in details used in previous seasons remain valid and should continue to be used.

13 76. If you have any issues with log-in arrangements or if you have new staff who require access to the system please contact Movianto Customer Services on 01234 248 623 for assistance.

77. NHS Boards and GP practices should plan appropriately and place the minimum number of orders needed, taking into consideration available fridge capacity. NHS Boards are charged for each delivery made to practices.

78. NHS Boards and GP practices must ensure adequate vaccine supplies before organising vaccination clinics.

79. When placing orders for the vaccines in Marketplace, practices should search for the type of vaccine required. For example, if vaccines are required for patients aged 18 to 64 these can be found in Marketplace by entering the search term “QIVc” or on the ‘Orders’ screen. If vaccines are required for patients aged 65 or over, these can be found by searching for “aTIV”.

80. To make it simpler for front line staff in the coming season, all NHS Boards will be allocated the same type of vaccine for each cohort e.g QIVc for most cohorts. The exception to this is for health and social care workers where a mix of QIVc and QIVe will be allocated based on vaccine supply and delivery schedules. Only QIVe should be used for 55-64 year olds, not otherwise eligible due to qualifying health condition or employment, and will be available for ordering later in the season. Those who are egg-allergic should be offered the QIVc vaccine as detailed above.

81. Vaccines are available in packs of 10. On the ordering platform, please read the vaccine information carefully and order the number of packs required rather than the total volume of individual vaccines – for example, if the vaccine is available in packs of 10 and the practice wants to request a delivery of 500 vaccines, an order should be placed for 50 packs of 10.

82. Patient information leaflets for vaccines supplied in packs of 10 will be provided separately to the vaccines. These will be automatically added to orders by Movianto.

Further information and support

83. As with last year, a Procurement Officer within NHS National Procurement will act as a link between GP practices and Movianto to ensure any potential allocation or delivery issues can be minimised and swiftly resolved. Contact details for the Procurement Officer are as follows: [email protected]

84. For queries linked to ordering and deliveries, please contact the Movianto Customer Services Team (01234 248 623). If any delivery service issues cannot be resolved satisfactorily through dialogue with Movianto, the issue should be escalated to NHS National Procurement (contact details as above) in the first instance and thereafter the Immunisation Co-ordinator within the NHS Board. If you require contact details for your NHS Board Immunisation Coordinator please email [email protected] .

14 ANNEX C CONTRACTUAL ARRANGEMENTS AND FURTHER INFORMATION

Contractual arrangements

85. Information on payments associated with the seasonal flu and pneumococcal vaccines will be set out by Primary Care Directorate, Scottish Government in due course.

Pneumococcal immunisation

86. Health professionals are reminded that they should check the immunisation status of those eligible for pneumococcal immunisation when such people receive the flu vaccine. Depending on the availability, the pneumococcal vaccine can be offered at the same time as the flu vaccine or at any other point in the year when vaccine becomes available. Health professionals should note to recall individuals in cases where no vaccine is immediately available. An online leaflet is available and can be accessed at: www.nhsinform.scot/pneumococcalforadults.

Uptake Rates in 2019/20

87. It is important that every effort is made this year to ensure uptake is as high as possible. The benefits of flu vaccination amongst all eligible groups should be communicated and vaccination made as easily accessible as possible.

88. Provisional uptake data for 2019/20 suggests uptake rates of:

 74% in people aged 65 years and over, compared with 73.7% in 2018/19;  42.3% in under 65’s at-risk, compared with 42.4% in 2018/19;  53.8% for healthcare workers, compared with 51.2% in 2018/19  56.9% in pregnant women (with other risk factors), compared with 57.5% in 2018/19; and  42.9% in pregnant women (without other risk factors), compared with 44.5% in 2018/19.  44.7% in unpaid/young carers, compared with 45.1% in 2018/19.

Information on vaccine uptake for this season and previous seasons can be found at: https://www.hps.scot.nhs.uk/a-to-z-of-topics/influenza/. For further information regarding the HPS vaccine uptake monitoring programme, please contact [email protected]

15 From: on behalf of GMSContract Sent: 23 July 2020 10:57 To: GMSContract Subject: Flu Immunisation Update For Practices

Message sent to senior GPs, clinical mailboxes and practice managers in Lothian

Please ensure that all relevant staff are aware of this message

Dear colleagues, I know that HSCPs will be communicating directly with you about flu immunisation plans for this winter in your area, but we thought you would like an overview of some common issues.

HSCP Plans (as things currently stand):

Edinburgh ∙ Planning for HSCP to deliver both all at risk and over 65 years ∙ Circa 67k through 8 sites over 8 weeks with walk through or drive through arrangements. After care and anaphylaxis is being taken into account in discussions about drive through options due to COVID19 ∙ Assumes c 5k can be done by Community Pharmacy (see below). ∙ 700 or so per day per site would give capacity required ∙ Assuming that GPs will vaccinate opportunistically through the course of the programme to deliver c 14k immunisations. ∙ Anticipated increase in uptake by 10% ‐ this is allowed for in Edinburgh’s plans. ∙ Staffing: being reviewed – practice nurses, district nurses including weekend working. Circa 50 nurses have been identified as available.

Care Homes and Housebound ‐ a team is planned for home visiting and care homes – this is in planning and may also incorporate District Nursing staff. This will deliver c8k vaccines.

East Lothian ∙ 65yrs and over will be delivered by GP practices ∙ Under 65yrs via HSCP staff Walk in/drive thru centres for <65’s geographically organised ∙ GP practices are also looking at their own models for >65s in light of COVID restrictions. ∙ Administration staff will be available support the plans

Care Homes ‐ included in the above HSCP Care Home Team arrangements Housebound ‐ via Community Treatment And Care Centre staff

Midlothian ∙ GP Practices will provide most of the activity with some HSCP support ∙ Expectation will have in hours and out of hours clinics. ∙ Will work with GP practices to provide guidance on social distancing. ∙ For some practices, it may not be possible to run in ‐house clinics and where not feasible, the HSCP be looking at venues and options for them. ∙ Instead of single practice, will likely look at hub model in these situations. ∙ For additional staff, hoping to have funded hours for practice staff. ∙ SOP for vaccine storage and cold chain is being developed

Care Homes ‐ will be carried out with existing care home teams

1 Housebound – HSCP will still require assistance and will not be able to fully take this on.

West Lothian ∙ GP practices will continue to provide flu vaccination to those aged over 65yrs and those aged under 65yrs at risk. Some support from HSCP may be required ∙ Staffing ‐ scoping additional hours for practice nurses and bank nurses. ∙ Proposing a team of 12 WTE nurses that would be part of public health nursing. Initially they will work on flu and then work on the COVID 19 vaccine and also linking in with the childhood immunisations. Considering a whole public health model. Care homes ‐ via HSCP team Housebound ‐ via HSCP team Community ∙ Offer option to >65 and <65 Pharmacy ∙ Expansion of 2019/20 pilot to include all Community Pharmacies and all GP Practices across Lothian. 154 Community Pharmacies have expressed an interest in participating. ∙ 70 vaccines per pharmacy proposed. Circa 10,000 total

Primary School ∙ The Community Vaccination Team will continue to provide this service and will attempt to provide some mop‐up. ∙ The mop‐up option has previously been within the remit of GP practices as per the national influenza Directed Enhanced Service (DES). In addition, NHS Lothian has an local enhanced service (LES) for primary school children to cover the following groups: o At risk children where the parent requests early vaccination in the season when their child’s school may be scheduled later in the season o Children requiring a second dose of vaccine o Home schooled children o Children requiring intramuscular flu vaccine for clinical or faith reason ∙ Agreement is required to continue this arrangement this year with GP practices 2‐5yrs and not at Each HSCP (Children’s Partnership for Edinburgh) is committed to delivering this school and removing this work from general practice this winter. Planning to deliver this via either childhood immunisation teams or incorporating into their other HSCP flu vaccination arrangements Staff Flu This will be organised by a member of staff from Corporate Nursing, with local Vaccination and leads identified across acute and community settings. Delivery will have to be Social Care adapted due to COVID restrictions and an increase focus on peer vaccinators will Workers be key. Consent form processing continues to be a challenge and work is ongoing to address this as the Occupational Health system is unable to be used to assist this due to access to records restrictions. HSCP Chief Nurses are being contacted to agree the option to include social care workers in their service delivery models. Pregnant A mixed model will be required with the midwifery service providing some of Women this service. GP practices or HSCPs are likely to need to retain some of this work as maternal vaccinations have not yet moved in entirely from GP practices.

Common Issues:

Finance ‐ it is assumed that practices that do less activity than last year will retain 100% of income as agreed under the MOU. This is not necessarily the same as the final figure that will be agreed for the transfer of residuals once all work is taken on by HSCPs since that is usually an average of a number of years. There is an issue of how to properly finance practices that do more than 100% of last years work. There is also discussion on going about the real costs of

2 delivering immunisations with physical distancing and PPE requirements. No agreement has been reached and it is not clear whether there will be national direction on this issue.

Uptake and Age Groups ‐ It is assumed that uptake will rise by 10% in the current groups. We are also planning that all >55s will be offered the vaccine. There is no national confirmation on this yet.

CMO Letter ‐ we do not yet have a CMO letter setting out the details of this year's programme. This is partly because these issues are still being discussed.

Data ‐ since HSCPs will be doing large volumes of immunisations this year especially in Edinburgh and East Lothian, the issue of data extraction for at risk groups and providing data back to practice systems for those who have been immunised is crucial. Both HSCPs have been working locally on how to do this and there is also there is work underway nationally to adapt SIRS to do this and we will provide more information as soon as we have it.

David Small Chair GP Sub Director of Primary Care Transformation Committee

David Small Director of Primary Care Transformation NHS Lothian 2‐4 Waverly Gate Edinburgh EH1 3EG

3 From: on behalf of GMSContract Sent: 05 October 2020 15:09 To: GMSContract Subject: Child Flu Communication to Practices Attachments: child flu grid.pdf

Importance: High

Message sent to senior GPs, clinical mailboxes and practice managers in Lothian

Please ensure that all relevant staff are aware of this message

Dear colleagues

Please find information attached on service provision of flu vaccination for children in Lothian.

 Please note that for cohorts where provision is by non‐GP services, general practice payments may still be possible according to your HSCP Local Enhanced Services (LES) agreements.

 Please be aware that for the small numbers of children where GP provision is indicated, parents will be directed from the NHS Inform website to phone the practice.

 We would be very grateful if parents were not directed to phone the Community Vaccination Team where GP provision is indicated. Many thanks for your co‐operation.

Ordering Vaccine:

 There is no change to the recommendation of the quadrivalent live attenuated intranasal vaccine Fluenz Tetra ® (LAIV) for children (2‐5 year olds not yet in school, all primary school aged children and those in clinical risk groups in secondary school).

 Ordering for children is via Area Stores including any inactivated should the intranasal vaccine be unsuitable.

 As previously, egg based quadrivalent influenza vaccine (QIVe) Sanofi Pasteur will be available for:  the 6 months to under two years at risk group  for those 2 years to under 9 years unsuitable for LAIV

 Cell based quadrivalent influenza vaccine (QIVc) (Flucelvax Tetra®) (Seqiris) is licensed from age 9 years upwards.

Many thanks

David Small Maureen Reid Director of Primary Care Transformation Pharmaceutical Consultant in Public Health

1

Lothian NHS Board Waverley Gate 2-4 Waterloo Place Edinburgh EH1 3EG Telephone 0131 536 9000

www.nhslothian.scot

To: GPs, Practice Managers, Date 3 September 2020 Practice Nurses Your Ref HPT/JM/SF Our Ref Health Protection Team cc: VTP Adult Flu group, HSCP Flu Leads, HSCP Chief Nurses, Clinical Directors, Enquiries to Health Protection Team Pharmacists, HPT, CVT Extension 35420/35422 Direct Line 0131 465 5422/5420 Email [email protected]. nhs.uk

Dear Colleague

Seasonal Flu Vaccine Arrangements 2020/21

We are writing to update you on arrangements for this autumn’s flu season on behalf of Dr Lorna Willocks, Immunisation Co-ordinator. CMO letters for the adult and childhood programmes are available at the following links: Adult Flu CMO Letter 2020/21 and Scottish Childhood Seasonal Flu Vaccination Programme. You will be aware that there has been discussion with your HSCP about flu vaccination this season and there are some major changes to service delivery and call / recall arrangements as part of the Vaccination Transformation Programme (VTP).

Adult Flu Vaccination: Ordering is now open via the OM Movianto web based ordering platform who will distribute the vaccine. See attached information for more details. Please only order what has been agreed with your HSCP based on service delivery. Deliveries will start in Lothian week commencing 21 September 2020. Vaccines are based on age groups.  Vaccine for adults over 65yrs is: adjuvanted trivalent inactivated vaccine (aTIV) (Seqiris)  Vaccine for adults aged 18-64yrs at risk is: cell based quadrivalent inactivated vaccine (QIVc) (Flucelvax Tetra®) (Seqiris)  Vaccine for household contacts of people who are shielding is: cell based quadrivalent inactivated vaccine (QIVc) (Flucelvax Tetra®) (Seqiris) (licensed from age 9 years upwards)

Please only order what you need and ensure vaccine fridge capacity for this. Ensure that you remove any of last year’s stock and dispose in blue lidded sharps waste. Vaccines are supplied in packs of 10.  Vaccine for adults aged 55-64yrs (applicable from December onwards) is quadrivalent inactivated vaccine (brand and manufacturer to be confirmed).

Health Care Workers and Social Care Workers Depending on service delivery for your area / HSCP, the vaccine will be available from Area Pharmacy Store for general practice to order. Please check arrangements with your HSCP.

 Vaccine for this group is: Cell based quadrivalent inactivated vaccine (QIVc) (Flucelvax Tetra®)(Seqiris) or Egg based quadrivalent inactivated vaccine (QIVe) (brand and manufacturer to be confirmed) dependent on vaccine supply and delivery schedules.

Childhood Flu Vaccination

 Vaccine for children 2 years – 17 years is: Live attenuated influenza vaccine (LAIV) (Fluenz®) (AstraZeneca UK) (nasal spray)

There is no change to the recommendation of the quadrivalent live attenuated intranasal vaccine Fluenz Tetra ® (LAIV) for children (2-5 year olds not yet in school, all primary school aged children and those in clinical risk groups in secondary school). Ordering for children is via Area Stores including any inactivated should the intranasal vaccine be unsuitable. The intranasal vaccine is expected early and should be available for services able to start this part of the programme during w/c 14 September. Algorithms for flu vaccination are available here: Link to NES algorithms

As previously, egg based quadrivalent influenza vaccine (QIVe) Sanofi Pasteur will be available for the 6 months to under two years at risk group and for those 2 years to under 9 years unsuitable for LAIV. Cell based quadrivalent influenza vaccine (QIVc) (Flucelvax Tetra®) (Seqiris) is licensed from age 9 years upwards.

HSCPs will deliver 2-5s nasal fluenz this year and so GP practice requirement for nasal flu vaccine will be minimal. However, there are some situations where vaccination of 2-5s is still relevant for general practice:  Flu vaccination by intramuscular (IM) injection for clinical or religious reasons For Primary School pupils, according to LES and DES arrangements, there are some situations where vaccinations of primary school pupils are still relevant for general practice:  Flu vaccination early in the season for primary school aged children in clinical ‘at risk’ groups  Flu vaccination by intramuscular (IM) injection for clinical or religious reasons  Home schooled children of primary school age  Primary school-aged children resident in Scotland at the time of the immunisation programme (aged 4 to 11 inclusive) who were not vaccinated during their local school immunisation session. Last year, we had significant wastage of Fluenz vaccine amounting to £34,000. Please only order quantities that you anticipate needing.

National letters for people aged over 65yrs, 2-5yrs (and not at school) and the new national at risk letter for those aged 18-64 years will be sent out from 14 September 2020. The Lothian versions of the over 65yrs and 2-5yrs national letters extended the call to action to direct people to where they can find information for their area / eligible group. This information will be on the NHS Inform Flu Service Directory at: www.nhsinform.scot/flu or via 0800 22 44 88. People will also be directed to their GP Practice website. We are therefore grateful for GP practice websites reflecting the arrangements for your practice / area. The timing of letters will align with national campaign with TV and radio advertising and social media messaging. Please note that we will be utilising the SIRS IT system for appointing adults by letter for some practices / areas – this is dependent on HSCP plans and will result in suppression of national letters to try to avoid two sets of letters being received.

128 community pharmacies in Lothian have signed up to offer adult flu vaccine to the following groups as part of the service delivery:  People aged over 65yrs  People aged 18-64yrs at risk  Pregnant women  Unpaid carers  Household contacts of those shielding  People aged 55-64yrs (when phased into programme)

Monitoring and Reporting Due to the COVID 19 situation, we expect a significantly higher demand for flu vaccine this season and an increased requirement for reporting to the Scottish Government – this will be weekly. It will be important that data is entered into practice systems quickly.

Thank you for the significant work done last year which saw an uptake in Lothian of 75.7% in the over 65 years group (Scotland: 74%). 18-64 years all at risk remained similar to the previous year at 43.4% (Scotland: 42.3%). Adult delivery models will vary by HSCP and practices should refer to updates from the PCCO and HSCP for details. We will write with any further local updates as required.

Many thanks

Maureen Reid VTP Business Change Manager Pharmaceutical Consultant in Public Health Flu vaccines for 2020/21 1. According to the Adult Flu Programme CMO Letter, the flu vaccines that have been centrally procured for the forthcoming flu season are in line with the recommendations of the Joint Committee on Vaccination and Immunisation (JCVI) and are set out in the table below.

Eligible Group Vaccine Adult Flu Programme First Phase Individuals aged 65 years and over Adjuvanted Trivalent Inactivated Vaccine (aTIV) (Seqiris) Individuals aged 18-64 years with “at-risk” Cell based Quadrivalent Inactivated Vaccine (QIVc) conditions (Flucelvax Tetra®) (Seqiris) Health and Social Care Workers Cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®)(Seqiris) or Egg based Quadrivalent Inactivated Vaccine (QIVe) (brand and manufacturer to be confirmed) dependent on vaccine supply and delivery schedules. Households of those shielding Cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris) Unpaid/Young carers Cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris) Second Phase Individuals aged 55-64 not otherwise Egg based Quadrivalent Inactivated Vaccine (QIVe) eligible through a qualifying health (brand and manufacturer to be confirmed) condition or employment

Continued on next page 2. According to the Scottish Seasonal Flu Childhood Flu Programme CMO Letter, the flu vaccines recommended by the Joint Committee on Vaccination and Immunisation (JCVI) are set out in the table below.

Vaccine Type Age Indication Cohort Childhood Flu Programme Fluenz Tetra®, Quadrivalent live From 2 years to  All children aged 2- 5 (not AstraZeneca UK attenuated less than 18 years yet at school) Ltd of age  All primary school aged children in primary 1 to primary 7  All children from 2 years to less than 18 years old in clinical risk groups

Quadrivalent Quadrivalent From 6 months of  Children aged 6 months to Influenza Vaccine inactivated (egg age to less than 9 less than 2 years in a (split virion, based) years of age clinical risk group inactivated)  Children in the above Sanofi Pasteur cohorts aged from 2 years Vaccines to under 9 who are contraindicated for Fluenz Tetra®

Quadrivalent Quadrivalent From 9 years of age  Children in the above Influenza Vaccine inactivated cohorts aged from 9 years (surface antigen, (cell based) who are contraindicated inactivated) for Fluenz Tetra® Flucelvax Tetra® Seqirus Vaccines

Enclosures (2): Movianto Ordering Opening Email Movianto User Guide Provision of Flu Vaccination for Children in Lothian October 2020

6 mos. – 2 2 - 5 yrs. and 2 - < 18 yrs. Primary School Primary School Primary School Primary School Secondary School yrs. not at school Note: Includes Primary Pupils Pupils Pupils Pupils Pupils School and Secondary At risk School Pupils

If Intramuscular (IM) Home schooled In clinical at risk Mop Up* At risk injection for clinical or groups with school religious reasons session date late in the season

City of GP Children’s GP GP In School - CVT GP GP GP Edinburgh Partnership

East GP HSCP GP GP In School - CVT GP GP GP Lothian

Midlothian HSCP HSCP GP GP In School - CVT GP GP HSCP if previously shielding, GP for remainder

West HSCP HSCP GP GP In School - CVT GP GP GP Lothian

*Community Vaccination Team (CVT) providing in school sessions for primary pupils. In addition, CVT will be providing in school and community mop up sessions for pupils absent on the day. Only the remaining pupils will attend GP for mop up.

Parents will phone GP where GP delivery is indicated. Please ensure reception staff are aware. Many thanks. COVID-19: Guidance for the remobilisation of services within health and care settings Infection prevention and control recommendations

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About this guidance

The guidance is issued jointly by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS)/National Services Scotland, Public Health England (PHE) and NHS England as official guidance.

Whilst this guidance seeks to ensure a consistent and resilient UK wide approach, some differences in operational details and organisational responsibilities may apply in Northern Ireland, England, Wales and Scotland.

Please note that this guidance is of a general nature and that an employer should consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.

Previous Guidance: Version 3.2 18 June 2020. ‘COVID-19: Infection Prevention and Control Guidance’ Archived 20 August 2020. This guidance has been superseded by this publication.

New Guidance: Version 1 ‘COVID-19 Guidance for the Remobilisation of services within health and care settings: infection prevention and control (IPC) recommendations’ August 20 2020.

The IPC principles in this document apply to all health and care settings, including acute, diagnostics, independent sector, mental health and learning disabilities, primary care, care homes, maternity and paediatrics (this list is not exhaustive).

NB: This guidance does NOT apply to adult social care settings in England. Adult social care providers in England should refer to existing guidance already in place. DHSC/PHE will continuously review this guidance and update as needed.

This IPC guidance will be updated in line with service need and as the evidence evolves. The administrative measures outlined in the guidance are consistent with World Health Organization (WHO) guidance.

© Crown copyright 2020 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v3.0. To view this licence, visit OGL. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

First published 20 August 2020 (Version 1.0)

PHE publications gateway number: GW-1502 COVID-19: infection prevention and control guidance

Key messages

This guidance supersedes the COVID-19 UK IPC guidance (18 June 2020).

Local and national prevalence and incidence data will be used to guide returning services as advised by Country specific/public health organisations.

Patients/Individuals treatment, care and support to be managed in 3 COVID-19 pathways:

• High risk: There is no change in recommendations for IPC or for the use of PPE by staff when managing patients/individuals who have, or are likely to have, COVID-19 • Medium risk: This includes patients/individuals who have no symptoms of COVID-19 but do not have a COVID-19 SARS- CoV-2 PCR test result. • Low risk: Patients/individuals with no symptoms and a negative COVID-19 SARS- CoV-2 PCR test who have self-isolated prior to admission for example following NICE guidance

Sessional use of single use personal protective equipment (PPE) items has been minimised and only applies to extended use of facemasks for healthcare workers.

The use of face masks (for staff) or face coverings1 (England and Scotland) is recommended in addition to social distancing and hand hygiene for staff, patients/individuals and visitors in both clinical and non-clinical areas to further redcue the risk of transmission.

Physical distancing of 2 metres is considered standard practice in all health and care settings.

Patients/individuals on a low risk pathway require Standard Infection Prevention Control Precautions for surgery or procedures.

The IPC principles in this document apply to all health and care settings including acute, diagnostics, independent sector, mental health and learning disabilities, primary care, care homes, care at home, maternity and paediatrics (this list is not exhaustive).

1 You must wear a face covering by law in some public places unless you are exempt from wearing a face covering due to your age, health or other condition.

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NB. This guidance does NOT apply to Adult Social Care settings in England. Adult social care providers in England should refer to existing guidance already in place.DHSC/PHE will continuously review this guidance and update as needed.

The IPC measures recommended are underpinned by the National Infection Prevention and Control Manual (NIPCM) practice guide and associated literature reviews. NHS England is using this an opportunity to introduce and adopt the NICPM as set out in the “UK Five-year Tackling Antimicrobial Resistance National Action Plan (2019-2024).”

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Contents

1. Explanation of the updates to infection prevention and control guidance 6 2. Introduction 7 2.1 Scope and purpose 7 3. Governance and responsibilities 9 4. Care pathways 10 4.1 Administration measures for the pathways 12 4.2 Community settings 14 4.3 Outpatient/primary/day care 14 5. Standard Infection Prevention Control Precautions (SICPs): all pathways or settings 15 5.1 Personal Protective Equipment (PPE) 15 6. Aerosol Generating Procedures: procedures that create a higher risk of respiratory infection transmission 19 7. Low Risk Pathway: Key principles 21 7.1 Maintaining physical distancing 21 7.2 Personal protective equipment** 22 7.3 Safe management of environment/equipment and blood/body fluids 22 7.4 Aerosol Generating Procedures (AGPs): procedures that create a higher risk of respiratory infection transmission 23 7.5 Visitor guidance 23 7.6 Discharge or transfer 23 8. Transmission Based Precautions (TBPs) 25 9. Medium Risk Pathway: Key principles 26 9.1 Maintaining physical distancing and patient placement 26 9.2 Personal protective equipment 27 9.3 Safe management of care environment/equipment/blood and body fluids 27 9.4 Aerosol Generating Procedures (AGPs): procedures that create a higher risk of respiratory infection transmission 29 9.5 Duration of transmission based precautions 29 9.6 Visitor guidance 29 9.7 Discharge or transfer 30 10.High Risk Pathway: Key principles 31 10.1 Patient placement 31 10.2 Personal protective equipment 32 10.3 Safe management of care environment/equipment/blood and body fluids 33 10.4 Aerosol Generating Procedures (AGPs): procedures that create a higher risk of respiratory 34 10.5 Duration of precautions 34 10.6 Visitor guidance 34 10.7 Discharge or transfer 35 11. Occupational health and staff deployment 36 12. Glossary of terms 37 Appendix 1. Sample triage tool 43

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1. Explanation of the updates to infection prevention and control guidance

Process for updating the guidance (as published on August 20 2020)

The guidance is issued jointly by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS)/National Services Scotland, Public Health England (PHE) and NHS England for health and care organisations as the UK moves to remobilise healthcare services. The content is consistent with the administrative measures outlined in WHO IPC during healthcare when coronavirus disease (COVID-19) is suspected or confirmed: Interim Guidance, June 2020.

The IPC measures recommended are underpinned by the National Infection Prevention and Control Manual practice guide and associated literature reviews http://www.nipcm.hps.scot.nhs.uk/

The remobilisation of services will require ‘new ways’ of working during the continued pandemic. Having assessed the available evidence and the feedback received from guidance users, professional bodies and associations, this guidance outlines the changes required to assist in restoring services in this ‘new’ health and care environment whilst COVID-19 remains a threat. This is based upon emerging evidence, experience and expert opinion.

The main changes to the guidance are:

1. Local and national prevalence and incidence data will be used to guide returning services as advised by Country specific/public health organisations. 2. Patients/individuals to be managed in 3 COVID-19 pathways, high, medium and low risk. 3. Sessional use of single use PPE items has been minimised and only applies to extended use of facemasks for healthcare workers. 4. The use of facemasks (for staff) and face coverings (if tolerated by the individual) is recommended in England and Scotland, in addition to social distancing and hand hygiene for staff, patients/individuals and visitors in both clinical and non-clinical areas to further reduce transmission risk. 5. Physical distancing of 2 metres is considered standard practice in all health and care settings. 6. Patients/individuals on a low risk pathway require Standard Infection Prevention & Control Precautions for surgery or procedures.

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2. Introduction

2.1 Scope and purpose

This document sets out the infection prevention and control (IPC) advice for health and care organisations as the UK moves to remobilise healthcare services.

The IPC principles in this document apply to all health and care settings, including the independent/private sector, mental health and learning disabilities, primary care areas, care homes, care at home, maternity and paediatrics (this list is not exhaustive, please refer to specific country resources for setting specific guidance). It includes key IPC control recommendations and includes risk assessed patient pathway scenarios to help guide the implementation of measures to provide safe and effective care locally and is based on the best available evidence.

This revised guidance supersedes the COVID-19 IPC guidance (18 June 2020) on the GOV.UK website and has been drafted to support services to restart safely. The challenge facing the NHS is to remobilise healthcare services and increase NHS capacity whilst providing a safe and equitable service for staff, visitors and patients/individuals including those who may present with COVID-19, those who have recovered from COVID-19 and those with no history of COVID-19.

The remobilisation (restarting) of services requires new ways of working during the continued pandemic and, as COVID-19 becomes endemic; guidance for working in a new healthcare environment will need to be developed and updated based upon emerging evidence, experience and expert opinion.

Whilst this document seeks to ensure a consistent and resilient UK wide approach, some differences in operational details and organisational responsibilities may apply, where current legislation, guidance, for example clinical definitions, already exists. Links can be accessed in the resources below.

NB. This guidance does not apply to Adult Social Care settings in England given existing guidance for adult social care settings has already been provided and continues to be relevant. DHSC/PHE will continuously review this guidance and update as needed.

This document does not provide links throughout the sections, please follow the country specific resources, for example visiting guidance, testing, discharge policies.

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IPC COVID-19 resources for: • England can be found here and here • Scotland can be found here • Wales can be found here • Northern Ireland can be found here

Further updates may be made to this document as new detail/evidence on COVID-19 emerges and as the pandemic phases/levels change. Link to current Alert Levels

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3. Governance and responsibilities

Organisations and employers including NHS Trusts, NHS Boards, Health and Social Care Trusts (Northern Ireland), Local Authorities, Independent Sector providers, through their Chief Executive Officer (CEO) or equivalent must ensure:

• monitoring of IPC practices, as recommended in this guidance, and ensure that resources are in place to implement good IPC practice. This must include all care areas and all staff (permanent, agency and external contractors). • testing and self-isolation strategies are in place with a local policy for the response if transmission rates of COVID-19 increase. • training in IPC measures are provided to all staff, including: the correct use of PPE (including a face fit test if wearing a filtering face piece (FFP3), respirator, and the correct technique for putting on and removing (donning/doffing) safely. • risk assessment(s) is undertaken for any staff members in at risk or shielding groups, including Black, Asian and Minority Ethnic (BAME) staff. • patients/individuals at high risk/ extremely high risk of severe illness are protected from COVID-19. This must include consideration of families and carers accompanying patients/individuals for treatments/procedures. • health and care settings are COVID-19 secure workplaces as far as practical, that is, that any workplace risk(s) are mitigated maximally for everyone.

DISCLAIMER

When an organisation adopts practices that differ from those recommended/stated in this national guidance, that individual organisation is responsible for ensuring safe systems of work, including the completion of a risk assessment(s) approved through local governance procedures, for example Integrated Care System level, Health Board.

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4. Care pathways

These pathways are specific to the COVID-19 pandemic and are examples of how organisations may separate COVID-19 risks. It is important to note, that these pathways do not necessarily define a service to a particular pathway and should not impact the delivery and duration of care for the patient or individual. Implementation strategies must be underpinned by patient/procedure risk assessment, appropriate testing regimens (as per organisations or country specific) and epidemiological data.

Additional information on specific settings can be found in: NICE (2020) ‘COVID-19 rapid guideline: arranging planned care in hospitals and diagnostic services’

Screening and triaging within all health and other care facilities must be undertaken to enable early recognition of COVID-19 cases. See Appendix 1 for an example of triage questions. Triage should be undertaken by clinical staff who are trained and competent in the application of the clinical case definition prior to arrival at a care area, or as soon as possible on arrival, and allocated to the appropriate pathway. This should include screening for other infections/multi-drug resistant organisms, including as per national screening requirements.

Infection risk and infection prevention and control precautions, for example Standard Infection Control Precautions (SICPs) or Transmission Based Precautions (TBPs) must be communicated between care areas.

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High-Risk COVID-19 Pathway Medium Risk COVID-19 Low Risk COVID-19 Pathway Section 10: SICPs & TBPs Pathway Section 7: SICPs Section 9: SICPs & TBPs

Any care facility where: Any care facility where: Any care facility where: a) untriaged individuals a) triaged/clinically assessed a) triaged/clinically assessed present for assessment or individuals are asymptomatic individuals with no symptoms or treatment (symptoms and are waiting a SARS- known recent COVID-19 contact unknown) CoV-2 (COVID-19) test who have isolated/shielded OR result with no known recent AND b) confirmed SARS-CoV-2 COVID-19 contact have a negative SARS-CoV-2 (COVID-19) positive OR (COVID-19) test within 72 hours individuals are cared for b) testing is not required or of treatment and, for planned OR feasible on asymptomatic admissions, have self-isolated c) symptomatic or individuals and infectious from the test date suspected COVID-19 status is unknown OR individuals including those OR b) Individuals who have with a history of contact with c) asymptomatic individuals recovered from COVID-19 and a COVID-19 case, who have decline testing have had at least 3 consecutive been triaged/clinically days without fever or respiratory assessed and are waiting symptoms and a negative test results COVID-19 test OR OR d) symptomatic individuals c) patients or individuals are who decline testing regularly tested (remain negative)

Examples of patient (individual) groups/facilities within these pathways: these lists are not exhaustive

• Designated areas within • Designated areas within • Planned/elective surgical Emergency/Resuscitation Emergency/Resuscitation, GP procedures including day cases Departments surgeries and walk-in centres • Oncology/chemotherapy patients • GP surgeries/walk in centres • Non elective admissions and/or facilities • Facilities where confirmed or • Primary care facilities, for • Planned in -patient admissions suspected/symptomatic example general dental and (adult and children), Mental COVID-19 individuals are general practice health, Maternity cared, for example • Facilities where individuals are • Outpatients including o emergency admissions cared, for example in-patients; Diagnostics/Endoscopy to in-patient areas (adult adult and children, Mental • Care homes* and children) health, Maternity, Critical Care • Prisons o Mental health Units o Maternity • Outpatient depts. including o Critical Care Units Diagnostics and Endoscopy o Renal dialysis units • Care homes* • Prisons *This guidance does NOT apply to Adult Social Care settings in England

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4.1 Administration measures for the pathways

1. Establish separation of patient pathways and staff flow to minimise contact between pathways. For example, this could include provision of separate entrances/exits (if available) or use of one-way entrance/exit systems, clear signage, and restricted access to communal areas: • hospital care areas (for example, ward, clinic, GP practice, care home) may designate, self-contained area(s) or ward(s) for the treatment and care of patients/individuals at high, medium and low risk of COVID-19. Temporal separation may be used in clinics/primary care settings • as a minimum in smaller facilities or primary care outpatient settings physical/ or temporal separation of patients/departments at high risk of COVID-19 from the rest of the facility/patients

2. Ensure that hygiene facilities (IPC measures) and messaging are available for all patients/individuals, staff and visitors to minimise COVID-19 transmission such as: • hand hygiene facilities including instructional posters • good respiratory hygiene measures • maintaining physical distancing of 2 metres at all times (unless wearing PPE due to clinical or personal care) • frequent decontamination of equipment and environment • clear advice on use of face coverings and facemasks by patients/individuals, visitors and by staff in non-patient facing areas. This will include: o use of face coverings by all outpatients (if tolerated) and visitors when entering a hospital or GP/dental surgery o use of a surgical facemask (Type II or Type IIR) by all inpatients in the medium and high-risk pathways if this can be tolerated and does not compromise their clinical care, such as when receiving oxygen therapy, to minimise the dispersal of respiratory secretions and reduce environmental contamination o extended use of facemasks by all staff (England /Scotland) in both clinical and non-clinical areas within the healthcare setting o all visitors should wear a face covering in healthcare settings o where visitors are unable to wear face coverings due to physical or mental health conditions or a disability, clinicians should consider what other IPC measures are in place, such as physical distancing, to ensure sufficient access depending on the patient’s condition and the care pathway

3. Where possible and clinically appropriate remote consultations rather than face-to- face should be offered to patients/individuals.

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4. Ensure restricted access between pathways if possible, (depending on size of the facility, prevalence/incidence rate low/high) by other patients/individuals, visitors or staff, including patient transfers, communal staff areas (changing rooms/restaurant). As the prevalence/incident rates decline this may not be necessary between pathways providing the IPC measures are maintained.

5. Ensure areas/wards are clearly signposted, using physical barriers as appropriate to ensure patients/individuals and staff understand the different risk areas.

6. Ensure local standard operating procedures detail the measures to segregate equipment and staff including planning for emergency scenarios as the prevalence/incidence of COVID-19 may increase and decrease until cessation of the pandemic.

7. Ensure a rapid and continued response through ongoing surveillance of rates of infection transmission within the local population and for hospital/organisation onset cases (staff and patients/individuals). Positive cases identified after admission who fit the criteria for investigation should trigger a case investigation. Two or more positive cases linked in time and place trigger an outbreak investigation.

8. If prevalence/incidence rate for COVID-19 is high, where possible, assign teams of medical/nursing and domestic staff to care for individuals in isolation/cohort rooms/areas/pathways. If a member of staff is required to move between sites/hospitals due to the unique function of their role, all IPC measures including physical distancing must be maintained.

9. Providers of planned services should be responsive to local and national prevalence/incidence data on COVID-19 and adapt processes so that services can be stepped-up or down. This can be assessed using weekly COVID-19 surveillance report from the respective countries and depending on the data, the pressure on the healthcare services and local capacity and resources.

10. Safe systems of working including administrative, environmental and engineering controls are an integral part of IPC measures. Standards for ventilation2 will apply to specific areas in a healthcare setting for example, theatres and endoscopy suites.

2 A number of UK short life working groups led by NHS Estates are undertaking further work on theatre, endoscopy, dental ventilation requirements and fallow periods following Aerosol Generating Procedures (AGPs) which will be published on completion.

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4.2 Community settings

Areas where triaging for COVID-19 is not possible for example, community pharmacy:

• signage at entry points advising of the necessary precautions • staff should maintain 2 metres physical distance with customers / service users, using floor markings, clear screens or wear surgical face masks (Type IIR) where this is not possible. Patients/individuals with symptoms should be advised not to enter the premises

4.3 Outpatient/primary/day care

In outpatient, primary care and day care settings:

• where possible services should utilise virtual consultation • if attending outpatients or diagnostics, service providers should consider timed appointments and strategies such as asking patients/individuals to wait to be called to the waiting area with minimum wait times • patients/individuals should not attend if they have symptoms of COVID-19 and communications should advise actions to take in such circumstances for example for patients/individuals receiving chemotherapy and renal dialysis • communications prior to appointments should provide advice on what to do if patients/individuals suspect they have come into contact with someone who has COVID-19 prior to their appointment • outpatient letters should be altered to advise patients/individuals of parking, entrances, IPC precautions and COVID-19 symptoms • patients/individuals must be instructed to remain in waiting areas and not visit other parts of the facility • prior to admission to the waiting area, all patients/individuals and accompanying persons should be screened for COVID-19 symptoms and assessed for exposure to contacts • patients/individuals and accompanying persons will also be asked to wear a mask / face covering at all times

NB. In some clinical outpatient settings, such as vaccination/injection clinics, where contact with individuals is minimal, the need for single use PPE items for each encounter, for example, gloves and aprons is not necessary. Gloves and aprons are recommended when there is (anticipated) exposure to blood/body fluids or non-intact skin. Staff administering vaccinations/injections must apply hand hygiene between patients and wear a sessional facemask.

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5. Standard Infection Prevention Control Precautions (SICPs): all pathways or settings

SICPs are the basic IPC measures necessary to reduce the risk of transmitting infectious agents from both recognised and unrecognised sources of infection and are required across ALL COVID-19 pathways.

SICPs must therefore be used by all staff, in all care settings, at all times and for all patients/individuals, whether infection is known or not, to ensure the safety of patients/individuals, staff and visitors. This section highlights the key measures for the COVID-19 pathways. Please refer to the practical guide* for additional information on the other elements which remain unchanged.

The elements of SICPs are:

• patient placement and assessment for infection risk (screening/triaging) • hand hygiene • respiratory and cough hygiene • personal protective equipment (see below) • safe management of the care environment (see below) • safe management of care equipment (see below) • safe management of healthcare linen • safe management of blood and body fluids • safe disposal of waste (including sharps) • occupational safety: prevention and exposure management • maintaining social/physical distancing (new SICP due to COVID-19)

*Practice guides and literature reviews to support SICPs can be found here for England and Scotland, here for Wales and here for Northern Ireland

5.1 Personal Protective Equipment (PPE)

For the purpose of this document, the term ‘personal protective equipment’ is used to describe products that are either PPE or medical devices that are approved by the Health and Safety Executive (HSE) and the Medicines and Healthcare products Regulatory Agency (MHRA) as protective solutions in managing the COVID-19 pandemic. Local or national uniform policies should be considered when wearing PPE.

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All PPE should be:

• located close to the point of use (where this does not compromise patient safety, for example, mental health/learning disabilities). In domiciliary care PPE must be transported in a clean receptacle • stored safely and in a clean, dry area to prevent contamination • within expiry date (or had the quality assurance checks prior to releasing stock outside this date) • single use unless specified by the manufacturer or as agreed for extended/sessional use including surgical facemasks • changed immediately after each patient and/or after completing a procedure or task • disposed into the correct waste stream depending on setting, for example domestic waste/offensive (non-infectious) or infectious clinical waste • discarded if damaged or contaminated • safely doffed (removed) to avoid self-contamination. See here for guidance on donning (putting on) and doffing (removing) • decontaminated after each use following manufactures guidance if reusable PPE is used, such as non-disposable goggles/face shields/visors

Gloves must be:

• worn when exposure to blood and/or other body fluids, non-intact skin or mucous membranes is anticipated or likely • changed immediately after each patient and/or after completing a procedure/task even on the same patient • never decontaminated with Alcohol Based Hand Rub (ABHR) or soap between use

NB. Double gloving is NOT recommended for routine clinical care of COVID-19 cases and vinyl medical gloves should only be worn in care situations where there is no anticipated exposure to blood and/or body fluids

Aprons must be:

• worn to protect uniform or clothes when contamination is anticipated or likely • worn when providing direct care within 2 metres of suspected/confirmed COVID-19 cases • changed between patients and/or after completing a procedure or task

Full body gowns or fluid repellent coveralls must be:

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• worn when there is a risk of extensive splashing of blood and/or body fluids • worn when undertaking aerosol generating procedures • worn when a disposable apron provides inadequate cover for the procedure or task being performed • changed between patients /individuals and immediately after completing a procedure or task unless sessional use is advised due to local/national data

Eye or face protection (including full-face visors) must:

• be worn if blood and/or body fluid contamination to the eyes or face is anticipated or likely – for example, by members of the surgical theatre team and always during aerosol generating procedures, regular corrective spectacles are not considered eye protection • not be impeded by accessories such as piercings or false eyelashes • not be touched when being worn

Fluid resistant surgical face mask (FRSM Type IIR) masks must:

• be worn with eye protection if splashing or spraying of blood, body fluids, secretions or excretions onto the respiratory mucosa (nose and mouth) is anticipated or likely • be worn when delivering direct care within 2 metres of a suspected/confirmed COVID-19 case • be well-fitting and fit for purpose, fully cover the mouth and nose (manufacturers’ instructions must be followed to ensure effective fit and protection) • not touched once put on or allowed to dangle around the neck • be replaced if damaged, visibly soiled, damp, uncomfortable or difficult to breathe through

Surgical face masks Type II must be:

• worn for extended use by healthcare workers when entering the hospital or care setting, a Type IIR is also suitable. Type I are suitable in some settings, refer to the resource section for country specific guidance (England and Scotland)

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Head/footwear

• headwear is not routinely required in clinical areas (even if undertaking an AGP) unless part of theatre attire or to prevent contamination of the environment such as in clean rooms • headwear worn for religious reasons (for example, turban, kippot veil, headscarves) are permitted provided patient safety is not compromised. These must be washed and/or changed between each shift or immediately if contaminated and comply with additional attire in, for example theatres • foot/shoe coverings are not required or recommended for the care of COVID-19 cases

NB. PPE may restrict communication with some individuals and other ways of communicating to meet their needs should be considered.

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6. Aerosol Generating Procedures: procedures that create a higher risk of respiratory infection transmission

An Aerosol Generating Procedure (AGP) is a medical procedure that can result in the release of airborne particles (aerosols) from the respiratory tract when treating someone who is suspected or known to be suffering from an infectious agent transmitted wholly or partly by the airborne or droplet route.

This is the list of medical procedures for COVID -19 that have been reported to be aerosol generating and are associated with an increased risk of respiratory transmission:

• tracheal intubation and extubation • manual ventilation • tracheotomy or tracheostomy procedures (insertion or removal) • bronchoscopy • dental procedures (using high speed devices, for example ultrasonic scalers/high speed drills • non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP) • high flow nasal oxygen (HFNO) • high frequency oscillatory ventilation (HFOV) • induction of sputum using nebulised saline • respiratory tract suctioning • upper ENT airway procedures that involve respiratory suctioning • upper gastro-intestinal endoscopy where open suction of the upper respiratory tract occurs • high speed cutting in surgery/post-mortem procedures if respiratory tract/paranasal sinuses involved

Certain other procedures or equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk for COVID-19. Procedures in this category include administration of humidified oxygen, administration of Entonox or medication via nebulisation.

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The New and Emerging Respiratory Viral Threat Assessment Group (NERVTAG) advised that during nebulisation, the aerosol derives from a non-patient source (the fluid in the nebuliser chamber) and does not carry patient-derived viral particles. If a particle in the aerosol coalesces with a contaminated mucous membrane, it will cease to be airborne and therefore will not be part of an aerosol. Staff should use appropriate hand hygiene when helping patients to remove nebulisers and oxygen masks. In addition, the current expert consensus from NERVTAG is that chest compressions are not considered to be procedures that pose a higher risk for respiratory infections including COVID-19.

Literature review for AGPS during COVID-19 can be found here:

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7. Low Risk Pathway: Key principles

This pathway applies to: a) Individuals triaged/clinically assessed prior to treatment (inpatient/outpatient) with no COVID-19 contacts or symptoms who have isolated/shielded AND b) patients who have a negative SARS-CoV-2 (COVID-19) test result within 72 hours of care and, for planned admissions, have self-isolated since the test date OR c) individuals who have recovered from COVID-19 AND have had at least 3 consecutive days without fever or respiratory symptoms AND a negative SARS-CoV- 2 test result OR d) patients or individuals in any care facility where testing is undertaken regularly (remains negative)

Clinicians should advise people who are at greater risk of getting COVID-19, or having a poorer outcome from it, that they may want to self-isolate for a longer period before a planned procedure. The length of self-isolation will depend on their individual risk factors and requires individualised care and shared decision making.

7.1 Maintaining physical distancing

All staff and other care workers must maintain social/physical distancing of 2 metres where possible (unless providing clinical or personal care and wearing PPE).

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7.2 Personal protective equipment**

Personal Protective Equipment required for SICPs is as follows: this includes the use of a surgical face mask for extended use.

SICPS/PPE Disposable Disposable Face masks Eye/face (all gloves apron/gown protection(visor) settings/all patients/indi viduals) If contact Single use Surgical mask Risk assess and use with blood Single use apron (gown Type II for if required for care and/or body if risk of extended use* procedure/task where fluids is spraying / FRSM Type IIR for anticipated anticipated splashing) direct patient care * blood/body fluids spraying/splashes *extended use of facemasks in England/Scotland for HCW when in any healthcare facility **Airborne precautions are NOT required for AGPs on patients/individuals in the low risk COVID-19 pathway, providing the patient has no other infectious agent transmitted via the droplet or airborne route.

7.3 Safe management of environment/equipment and blood/body fluids

During the pandemic, the frequency of cleaning of both the environment and equipment in patient areas should be increased to at least twice daily, in particular, frequently touched sites/points.

In the low risk COVID-19 pathway organisations may choose to revert to general purpose detergents for cleaning, as opposed to widespread use of disinfectants (with the exception of blood and body fluids, where a chlorine releasing agent (or a suitable alternative) solution should be used).

7.3.1 Operating theatres and procedure rooms

Within the low risk COVID-19 pathway, standard theatre cleaning and time for air changes provides appropriate levels of IPC and there is no requirement for additional cleaning or theatre down time unless the patient has another infectious agent that requires additional IPC measures.

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7.4 Aerosol Generating Procedures (AGPs): procedures that create a higher risk of respiratory infection transmission

Airborne precautions are NOT required for AGPs on patients/individuals in the low risk COVID-19 pathway, providing the patient has no other infectious agent transmitted via the droplet or airborne route.

There is no additional requirement for ventilation or downtime in this pathway, providing safe systems of work, including engineering controls are in place.

7.4.1 Critical care areas

As numbers of COVID-19 cases decline, providing suspected/confirmed COVID-19 cases can be cared for in single rooms or isolation rooms, the department should no longer be classified as an AGP ‘hot spot’ or ‘high risk area.’ This should be defined locally depending on prevalence/incidence data and the subsequent pathway assigned. This negates the requirement for the routine wearing of airborne PPE including a respirator in the low risk COVID-19 pathway.

7.4.2 Operating theatres

Patients/individuals in the low risk COVID-19 pathway do not need to be anaesthetised or recovered in the operating theatre if intubation/extubation (AGP) is required.

7.5 Visitor guidance

As outlined in Section 4.1 (2), hand hygiene and respiratory hygiene, and the wearing of a face covering (if tolerated) along with social distancing should be promoted and maintained and therefore visitors require no additional PPE.

7.6 Discharge or transfer

There is no restriction on discharge unless the patient/individual is entering a long-term care facility when testing may be required.

In England, to ensure testing does not delay a timely discharge, testing for patients due to be discharged to a care home will need to be planned up to 48 hours before the scheduled

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discharge time. The information from the test results, with any supporting care information, must be communicated and transferred to the relevant care home. No-one should be discharged from hospital directly to a care home without the involvement of the local authority.

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8. Transmission Based Precautions (TBPs)

Transmission Based Precautions (TBPs) are additional measures (to SICPs) required when caring for patients/ individuals with a known or suspected infection such as COVID-19.

TBPs are based upon the route of transmission and include: a) Contact precautions

Used to prevent and control infections that spread via direct contact with the patient or indirectly from the patient’s immediate care environment (including care equipment). This is the most common route of cross-infection transmission. COVID-19 can be spread via this route. b) Droplet precautions

Used to prevent and control infections spread over short distances (at least 3 feet/1metre) via droplets (>5μm) from the respiratory tract of individuals directly onto a mucosal surfaces or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level. COVID-19 is predominantly spread via this route and the precautionary distance has been increased to 2 metres. c) Airborne precautions

Used to prevent and control infection spread without necessarily having close patient contact via aerosols (≤5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar level. COVID-19 has the potential to spread via this route when Aerosol Generating Procedures (AGPs) are undertaken

Transmission Characteristics

Transmission of SARs-CoV-2 implications for infection prevention precautions is contained within the WHO scientific briefing paper

Literature reviews to support TBPs can be found here

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9. Medium Risk Pathway: Key principles

This pathway applies to the following: a) any facility where triaged/clinically assessed individuals are asymptomatic and are waiting a SARS-CoV-2 (COVID-19) test result and have no known recent COVID-19 contact OR b) any care facility where testing is not required or feasible on asymptomatic individuals and therefore infectious status is unknown OR c) asymptomatic individuals who decline testing in any care facility

9.1 Maintaining physical distancing and patient placement

It is important to:

• maintain physical distancing of 2 metres at all times (unless the member of staff is wearing appropriate PPE to provide clinical care) and advise other patients/visitors to comply • ensure cohorted patients/individuals are physically separated from each other, for example use screens, privacy curtains between the beds to minimise opportunities for close contact, this should be locally risk assessed to ensure patient safety is not compromised

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9.2 Personal protective equipment

DROPLET/CONTACT Disposable Disposable Face masks Eye/face PPE gloves apron/gown protection (visor) Single use FRSM Type Single use or PATIENTS/INDIVIDUALS Single use apron (gown IIR for direct re-usable WITH NO COVID-19 required if risk patient care1 SYMPTOMS and NO of spraying / TEST RESULT splashing) AIRBORNE Disposable Disposable Respirator Eye/face gloves apron/gown protection (visor) WHEN UNDERTAKING FFP3 or Hood Single use or AGPS ON Single use Single use for AGPs re-usable PATIENTS/INDIVIDUALS gown with NO COVID-19 SYMPTOMS AND NO TEST RESULT 1 FRSM can be worn sessionally if providing care for COVID-19 cohorted patients/individuals

9.3 Safe management of care environment/equipment/blood and body fluids

9.3.1 Equipment

Important considerations in the use of equipment are: • patient care equipment should be single-use items where practicable • reusable (communal) non-invasive equipment should be allocated to an individual patient or cohort of patients/individuals • all reusable (communal) non-invasive equipment must be decontaminated: o between each and after patient/individual o after blood and body fluid contamination o at regular intervals as part of routine equipment cleaning • decontamination of equipment must be performed using either: o a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.)); or o a general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1,000ppm av.cl. • alternative cleaning agents/disinfectant products may be used with agreement of the local IPC Team/HPT

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9.3.2 Environment

Important considerations for environmental cleaning and disinfection are:

• cleaning of care equipment as per manufacturers guidance/instruction and recommended product ‘contact time’ must be followed for all cleaning/disinfectant solutions/products • an increased frequency of decontamination should be considered for all reusable non-invasive care equipment when used in isolation/cohort areas. • the use of fans in high and medium risk pathways should be risk assessed. Refer to Estates guidance • cleaning frequencies of the care environment in COVID-19 care areas must be enhanced and single rooms, cohort areas and clinical rooms (including rooms where PPE is removed) cleaned at least twice daily • routine cleaning must be performed using either: o a combined detergent/disinfectant solution at a dilution of 1,000 parts per million available chlorine (ppm available chlorine (av.cl.)); or o a general-purpose neutral detergent in a solution of warm water followed by a disinfectant solution of 1,000ppm av.cl • alternative cleaning agents/disinfectants may be used with agreement of the local IPC/HPT • if there are clusters or outbreaks of COVID-19 (2 or more cases linked by time and place) with significant respiratory symptoms in communal settings this frequency should be increased to a minimum of twice daily • the increased frequency of decontamination/cleaning should be incorporated into the environmental decontamination schedules for all COVID-19 areas, including where there may be higher environmental contamination rates, including for example: o toilets/commodes particularly if patients/individuals have diarrhoea o ‘frequently touched’ surfaces such as medical equipment, door/toilet handles, locker tops, patient call bells, over bed tables, bed rails, phones, lift buttons/communal touch points and communication devices (for example, mobile phones, tablets, desktops, keyboards) particularly where these are used by many people, should be cleaned at least twice daily with solution of detergent and 1000ppm chlorine or an agreed alternative when known to be contaminated with secretions, excretions or body fluids • dedicated or disposable equipment (such as mop heads, cloths) must be used for environmental decontamination • reusable equipment (such as mop handles, buckets) must be decontaminated after use with a chlorine-based disinfectant or locally agreed disinfectant • single (isolation) rooms must be terminally cleaned as above following resolution of symptoms, discharge or transfer (this includes removal and laundering of all curtains and bed screens)

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9.4 Aerosol Generating Procedures (AGPs): procedures that create a higher risk of respiratory infection transmission

AGPs should only be carried out when essential and only staff who are needed to undertake the procedure should be present, wearing airborne PPE/ respiratory protective equipment (RPE) precautions (See section 10: High Risk Pathway).

9.4.1 Critical care areas

Droplet precautions apply. However, consideration may need to be given to the application of airborne precautions where the number of cases of suspected/confirmed COVID-19 requiring AGPs increases and patients/individuals cannot be managed in single or isolation rooms.

9.4.2 Operating theatres

Patients/individuals should be anaesthetised and recovered in the operating theatre if intubation/extubation (AGP) is required. For local, neuraxial or regional anesthesia the patient is not required to be anaesthetised/ recovered in theatre.

9.5 Duration of transmission based precautions

Transmission based precautions should only be discontinued in consultation with clinicians and should take into consideration the individual’s test results and clinical symptoms. If test results are not available (for example the patient/individual declines) TBPs can be discontinued after 14 days (inpatients) depending on contact exposure and providing the patient/individual remains symptom free.

9.6 Visitor guidance

Visiting has been limited during the peak of the pandemic however as cases decline and restrictions ease, visitors should be permitted to enter the facility and be educated in the IPC measures required as outlined in Section 4.1 (2)

This includes accompanying individuals when attending outpatient appointments such as, antenatal appointments and therapy groups.

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9.7 Discharge or transfer

There is no restriction on discharge if the patient/individual is well, unless the patient/individual is entering a long-term facility and testing may be required.

In England, to ensure testing does not delay a timely discharge, testing for patients due to be discharged to a care home will need to be planned up to 48 hours before the scheduled discharge time. The information from the test results, with any supporting care information, must be communicated and transferred to the relevant care home. No-one should be discharged from hospital directly to a care home without the involvement of the local authority.

Advice on any self-isolation post discharge will be provided by the clinician if this is required.

Discharge information for patients/individuals should include an understanding of their need for any self-isolation and/or quarantine, as well as their family members.

Ambulance services and the receiving facilities must be informed of the infectious status of the individual.

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10.High Risk Pathway: Key principles

This pathway applies to any emergency/urgent care facility where: a) untriaged individuals present for assessment or treatment (symptoms unknown*) OR b) confirmed SARS-CoV-2 (COVID-19) positive patients are cared for OR c) symptomatic or suspected COVID-19 individuals including those with a history of contact with a COVID-19 case who have been triaged / clinically assessed and are waiting test results OR d) symptomatic individuals who decline testing

*Once assessed, if asymptomatic with no contact history, patients/individuals may move to the Medium risk pathway awaiting test result.

10.1 Patient placement

If the patient/individual has symptoms or a history of contact with a case, they should be prioritised for single room isolation OR cohorted (if an isolation room is unavailable) until their test results are known, for example use privacy curtains between bed spaces to minimise opportunities for close contact between patients/individuals. This should be locally risk assessed to ensure this does not compromise patient safety.

If single rooms are in short supply, priority should be given to patients with excessive cough and sputum production, diarrhoea or vomiting and to those in the high risk/extremely high risk of severe illness.

Local risk assessments and clinical decisions must be made regarding placement of surgical patients/individuals with availability of single rooms taken into consideration.

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10.2 Personal protective equipment

DROPLET/CONTACT Disposable Disposable Face masks Eye/face PPE gloves apron/gown protection (visor) IF SUSPECTED/ Single use FRSM Type Single use or re- CONFIRMED COVID- Single use apron (gown IIR for direct usable 19 required if patient care1 PATIENT/INDIVIDUAL risk of spraying / splashing) AIRBORNE* Disposable Disposable Respirator Eye/face gloves apron/gown protection (visor) WHEN FFP3 or Single use or re- UNDERTAKING Single use Single use Hood for usable AGPS ON gown AGPs CONFIRMED OR SUSPECTED COVID- 19 PATIENTS/INDIVIDUA L 1 FRSM can be worn sessionally if providing care for COVID -19 cohorted patients/individuals *Consideration may need to be given to the application of airborne precautions where the number of cases of COVID-19 requiring AGPs increases and patients/individuals cannot be managed in single or isolation rooms.

10.2.1 Respiratory protective equipment (RPE) FFP3 (filtering face piece or hood):

Respirators are used to prevent inhalation of small airborne particles arising from AGPs.

Respirators should:

• be well fitting, covering both nose and mouth • always worn when undertaking an AGP on a COVID-19 confirmed or suspected patient/individual • not be allowed to dangle around the neck of the wearer after or between each use • not be touched once put on • be removed outside the patient’s/individual’s room or cohort area or COVID-19 ward • respirators can be single use or single session use (disposable or reusable) and fluid-resistant

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• valved respirators are not fully fluid-resistant unless they are also ‘shrouded’. Valved non-shrouded FFP3 respirators should be worn with a full-face shield if blood or body fluid splashing is anticipated • all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to ensure an adequate seal or fit (according to the manufacturers’ guidance). Fit checking (according to the manufacturers’ guidance) is necessary when a respirator is put on (donned) to ensure an adequate seal has been achieved • where fit testing fails, suitable alternative equipment must be provided, or the healthcare worker should be moved to an area where FFP3 respirators are not required • respirators should be compatible with other facial protection used (protective eyewear) so that this does not interfere with the seal of the respiratory protection • the respirator should be discarded and replaced and NOT be subject to continued use if the facial seal is compromised, it is uncomfortable, or it is difficult to breathe through • reusable respirators can be utilised by individuals if they comply with HSE recommendations. Reusable respirators should be decontaminated according to the manufacturer’s instructions

Literature on RPE can be found here.

10.2.2 Full body gowns or fluid repellent coveralls:

Full body gowns or fluid repellent coveralls must be:

• worn when there is a risk of extensive splashing of blood and/or body fluids; • worn when undertaking aerosol generating procedures • worn when a disposable apron provides inadequate cover for the procedure or task being performed • changed between patients/individuals and immediately after completing a procedure or task unless sessional use is advised due to local/national data

10.3 Safe management of care environment/equipment/blood and body fluids

Please refer to Section 9.3.

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10.4 Aerosol Generating Procedures (AGPs): procedures that create a higher risk of respiratory infection transmission

10.4.1 Critical care

Droplet precautions would apply however, consideration may need to be given to the application of airborne precautions where the number of cases of COVID-19 requiring AGPs increases and patients/individuals cannot be managed in single or isolation rooms.

10.4.2 Operating theatres (including day surgery)

Patients/individuals should be anaesthetised and recovered in the theatre if intubation/extubation (AGP) is required using airborne precautions. This is not required for regional, neuraxial or local anaesthesia.

Ventilation in both laminar flow and conventionally ventilated theatres should remain fully on during surgical procedures where patients/individuals have suspected/confirmed COVID-19. Air passing from operating theatres to adjacent areas will be highly diluted and is not considered to be a risk.

10.5 Duration of precautions

Patients/individuals should remain in isolation/cohort with TBPs applied for at least 14 days after onset of symptoms and at least 3 consecutive days without a fever or respiratory symptoms. For asymptomatic patients/individuals, TBPs may be discontinued 14 days after initial positive result. The decision to modify the duration of, or ‘stand down’ TBPs (Contact/Droplet/Airborne) should be made by the clinical team managing the Individual s care.

Step down of TBPs for COVID-19 for home discharge may require some individual clinical assessment at local level depending on the severity of the disease and underlying conditions, including testing requirements.

10.6 Visitor guidance

In this pathway, visiting should continue to be limited to only essential visitors, for example birthing partner, carer/parent/guardian.

The need for visitors to wear PPE should be assessed.

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10.7 Discharge or transfer

Discharge from an inpatient facility can occur when the individual is well enough and the clinician has provided them with advice to self -isolate for 14 days post discharge from the date of the positive SARS-CoV-2 PCR test (providing their symptoms resolve).

In England, to ensure testing does not delay a timely discharge, testing for patients due to be discharged to a care home will need to be planned up to 48 hours before the scheduled discharge time. The information from the test results, with any supporting care information, must be communicated and transferred to the relevant care home. No-one should be discharged from hospital directly to a care home without the involvement of the local authority.

Discharge to another care area may be dependent on testing and/or isolation facilities available.

Discharge information for patients/individuals should include an understanding of their need for any self-isolation and/or quarantine, as well as their family members.

Ambulance services and the receiving facilities must be informed of the infectious status of the individual.

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11. Occupational health and staff deployment

Prompt recognition of cases of COVID-19 among healthcare staff is essential to limit the spread.

Health and social care staff with symptoms of COVID-19 should not come to work.

As a general principle, healthcare staff who provide care in areas for suspected or confirmed patients/individuals should not care for other patients. However, this has to be a local decision based on local epidemiology and the configuration of the organisation.

A risk assessment is required for health and social care staff at high risk of complications from COVID-19, including pregnant staff. Employers should:

• discuss with employees who are at risk or are pregnant the need to be deployed away from areas used for the care of those who have, or are clinically suspected of having, COVID-19; or, in the primary care setting, from clinics set up to manage people with COVID-19 symptoms – refer to the guidance published by the Royal College of Obstetricians & Gynaecology • ensure that advice is available to all health and social care staff, including specific advice to those at risk from complications

Bank, agency and locum staff should follow the same deployment advice as permanent staff.

As part of their employer’s duty of care, providers have a role to play in ensuring that staff understand and are adequately trained in safe systems of working, including donning and doffing of personal protective equipment. A fit testing programme should be in place for those who may need to wear respiratory protection.

In the event of a breach in infection control procedures, staff should be reviewed by occupational health.

Occupational health departments should lead on the implementation of systems to monitor staff illness and absence.

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12. Glossary of terms

Aerosol-generating procedures (AGPs) Certain medical and patient care activities that can result in the release of airborne particles (aerosols). AGPs can create a risk of airborne transmission of infections that are usually only spread by droplet transmission.

Airborne transmission The spread of infection from one person to another by airborne particles (aerosols) containing infectious agents.

Airborne particles Very small particles that may contain infectious agents. They can remain in the air for long periods of time and can be carried over long distances by air currents. Airborne particles can be released when a person coughs or sneezes, and during aerosol generating procedures (AGPs). ‘Droplet nuclei’ are aerosols formed from the evaporation of larger droplet particles (see droplet transmission). Aerosols formed from droplet particles in this way behave as other aerosols.

Airborne precautions Measures used to prevent and control infection spread without necessarily having close patient contact via aerosols (less than or equal to 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Aerosols can penetrate the respiratory system to the alveolar level.

BS/EN standards Mandatory technical specifications created by either the British Standards Institute (BS) or European Standardisation Organisations (EN) in collaboration with government bodies, industry experts and trade associations. They aim to ensure the quality and safety of products, services and systems.

Cohort area An area (room, bay, ward) in which 2 or more patients (a cohort) with the same confirmed infection are placed. A cohort area should be physically separate from other patients.

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Contact precautions Measures used to prevent and control infections that spread via direct contact with the patient or indirectly from the patient’s immediate care environment (including care equipment). This is the most common route of infection transmission.

Contact transmission Contact transmission is the most common route of transmission and consists of 2 distinct types: direct contact and indirect contact. Direct transmission occurs when microorganisms are transmitted directly from an infectious individual to another individual without the involvement of another contaminated person or object (fomite). Indirect transmission occurs when microorganisms are transmitted from an infectious individual to another individual through a contaminated object or person (fomite) or person.

COVID-19 COVID-19 is a highly infectious respiratory disease caused by a novel coronavirus. The disease was discovered in China in December 2019 and has since spread around the world.

Droplet precautions Measures used to prevent, and control infections spread over short distances (at least 1 metre or 3 feet) via droplets (greater than 5μm) from the respiratory tract of one individual directly onto a mucosal surface or conjunctivae of another individual. Droplets penetrate the respiratory system to above the alveolar level.

Droplet transmission The spread of infection from one person to another by droplets containing infectious agents.

Eye or face protection Worn when there is a risk from splashing of secretion (including respiratory secretions). Eye or face protection can be achieved by the use of any one of:

• a surgical mask with integrated visor • a full face visor or shield • polycarbonate safety spectacles or equivalent

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Fluid-resistant (Type IIR) surgical face mask (FRSM) A disposable fluid-resistant mask worn over the nose and mouth to protect the mucous membranes of the wearer’s nose and mouth from splashes and infectious droplets. FRSMs can also be used to protect patients. When recommended for infection control purposes a ‘surgical face mask’ typically denotes a fluid-resistant (Type IIR) surgical mask.

Fluid-resistant A term applied to fabrics that resist liquid penetration, often used interchangeably with ‘fluid-repellent’ when describing the properties of protective clothing or equipment.

Frequently touched surfaces Surfaces of the environment which are commonly touched or come into contact with human hands.

Healthcare or clinical waste Waste produced as a result of healthcare activities for example soiled dressings, sharps.

High-flow nasal cannula (HFNC) therapy HFNC is an oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 litres per minute.

Higher risk acute care area risk units Intensive care units, intensive therapy units, high dependency units, emergency department resuscitation areas, wards with non-invasive ventilation; operating theatres; endoscopy units for upper Respiratory, ENT or upper GI endoscopy; and other clinical areas where AGPs are regularly performed.

Incubation period The period between the infection of an individual by a pathogen and the manifestation of the illness or disease it causes.

Induction of sputum Induction of sputum typically involves the administration of nebulised saline to moisten and loosen respiratory secretions (this may be accompanied by chest physiotherapy (percussion and vibration)) to induce forceful coughing.

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Infectious linen Linen that has been used by a patient who is known or suspected to be infectious and or linen that is contaminated with blood and or other body fluids, for example faeces.

Long term health condition This covers:

• chronic obstructive pulmonary disease, bronchitis, emphysema or asthma • heart disease • kidney disease • liver disease • stroke or a transient ischaemic attack (TIA) • diabetes • lowered immunity as a result of disease or medical treatment, such as steroid medication or cancer treatment • a neurological condition, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), cerebral palsy, or a learning disability • any problem with the spleen, including sickle cell disease, or had spleen removed • a BMI of 40 or above (obese)

Personal Protective Equipment (PPE) Equipment a person wears to protect themselves from risks to their health or safety, including exposure to infection agents. The level of PPE required depends on the:

• suspected or known infectious agent • severity of the illness caused • transmission route of the infectious agent • procedure or task being undertaken

Respiratory droplets A small droplet, such as a particle of moisture released from the mouth during coughing, sneezing, or speaking.

Respiratory protective equipment Respiratory protection that is worn over the nose and mouth designed to protect the wearer from inhaling hazardous substances, including airborne particles (aerosols). There are 2 types of respiratory protection that can be used, tight-fitting disposable FFP respirators and loose-fitting powered hoods (TH2).

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FFP stands for filtering face piece. There are 3 categories of FFP respirator: FFP1, FFP2 and FFP3. FFP3 and loose fitting powered hoods provide the highest level of protection and are recommended when caring for patients in areas where high risk aerosol generating procedures (AGPs) are being performed. Where the risk assessment shows an FFP2 respirator is suitable, they are recommended as a safe alternative. N95 respirators are tested against different standards but are broadly equivalent to a FFP2.

Respiratory symptoms Respiratory symptoms include:

• rhinorrhoea (runny nose) • sore throat • cough • difficulty breathing or shortness of breath

Segregation Physically separating or isolating from other people.

SARS-CoV Severe acute respiratory syndrome coronavirus, the virus responsible for the 2003 outbreak of human coronavirus disease.

SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2, the virus responsible for the COVID- 19 pandemic.

Standard infection control precautions (SICPs) SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of an infectious agent from both recognised and unrecognised sources of infection.

Single room A room with space for one patient and usually contains (as a minimum) a bed, a locker or wardrobe and a clinical wash-hand basin.

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Staff cohorting When staff care for one specific group of patients and do not move between different patient cohorts. Patient cohorts may include for example ‘symptomatic’, ‘asymptomatic and exposed’, or ‘asymptomatic and unexposed’ patient groups.

Transmission based precautions Additional precautions to be used in addition to SICPs when caring for patients with a known or suspected infection or colonisation.

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Appendix 1. Sample triage tool

Example of triage questions for COVID-19

If No to all questions proceed with treatment/testing and follow low risk pathway.

YES NO 1.Do you or any member of your household/ family have a confirmed diagnosis of COVID-19? If yes, wait for the agreed period of time depending on date of onset (10-14 days) before treatment or if urgent care is required, follow the High/Medium pathway. 2.Are you or any member of your household/family waiting for a COVID-19 test result? If yes, ascertain if treatment can be delayed until results are known. If urgent care is required, follow the High/Medium risk pathway. 3. Have you travelled internationally in the last 14 days? If yes, confirm where and if this is a country that has been agreed as safe for travel by the government. If this is not on the list then 14 days quarantine will apply. If urgent care is required, follow the High/Medium risk pathway. 4. Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 14 days? If yes, wait for the agreed period of time depending on what date of the isolation period the patients is at (ideally, 14 days) before treatment or if urgent care is required, follow High/Medium risk pathway. 5. Do you have any of the following symptoms? • high temperature or fever • new, continuous cough • a loss or alteration to taste or smell If yes, provide advice on who to contact (GP/NHS111) or, if admission required, follow High/Medium risk pathway

Uncontrolled if printed. 43 CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd 46A BRIDGE 0131-441 2186 Edinburgh SW COLINTON PHARMACY LTD RD EH13 0LQ [email protected] 2352 EDINBURGH YES 2 PENTLAND VIEW COURT 0131-449 2225 Edinburgh SW LINDSAY & GILMOUR CHEMIST EH14 5NP [email protected] CURRIE 2707 EDINBURGH YES

84 COLINTON 0131-441 2243 Edinburgh SW COLINTON MAINS PHARMACY MAINS DRIVE EH13 9BJ [email protected] 3388 EDINBURGH YES 26 WESTER HAILES CRESCENT 0131-442 2368 Edinburgh SW LLOYDS PHARMACY EH14 2SW [email protected] SHOPPING 3118 CENTRE EDINBURGH YES 10 POLWARTH 0131-229 2397 Edinburgh SW POLWARTH PHARMACY EH11 1LW [email protected] GARDENS 3199 EDINBURGH YES 4 STENHOUSE 0131-443 2475 Edinburgh SW WELL PHARMACY EH11 3JY [email protected] CROSS 2222 EDINBURGH YES 483A CALDER 0131-442 2503 Edinburgh SW LLOYDS PHARMACY ROAD EH11 4AW [email protected] 2894 EDINBURGH YES

3 ARDMILLAN 0131-337 2509 Edinburgh SW OMNICARE PHARMACY TERRACE EH11 2JN [email protected] 1604 EDINBURGH YES 2 CRAIGLOCKH 0131-455 2511 Edinburgh SW CRAIGLOCKHART PHARMACY EH14 1BU [email protected] ART RD N 7168 EDINBURGH YES 107 0131-337 2522 Edinburgh SW LINDSAY & GILMOUR CHEMIST SLATEFORD EH11 1QY [email protected] 3405 ROAD YES 7 OXGANGS 0131-445 2533 Edinburgh SW DEARS PHARMACY BROADWAY EH13 9LQ [email protected] 1925 EDINBURGH YES 291 CALDER 0131-455 2534 Edinburgh SW MACKINNON PHARMACY ROAD EH11 4RH [email protected] 7073 EDINBURGH YES 64 NORTH ST 0131-333 2552 Edinburgh SW LUNN PHARMACY RATHO EH28 8RR [email protected] 1397 EDINBURGH YES 179 DUNDEE 0131-229 2559 Edinburgh SW FOUNTAINBRIDGE PHARMACY STREET EH11 1BY [email protected] 8281 EDINBURGH YES CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd 164 HIGH STREET MUSSELBUR 0131-665 2036 East Lothian W BOOTS UK LTD EH21 7DZ [email protected] GH 3139 EAST LOTHIAN YES ORMISTON MEDICAL CENTRE TYNEMOUNT 01875- 2067 East Lothian W WELL PHARMACY EH35 5AB [email protected] ROAD 610412 ORMISTON EAST LOTHIAN YES 42 LINKS ROAD 01875- 2069 East Lothian W WELL PHARMACY(Bestway) PORT SETON EH32 0EA [email protected] 811454 EAST LOTHIAN YES 115 HIGH STREET 01875- 2070 East Lothian W WELL PHARMACY TRANENT EH33 1LW [email protected] 615453 EAST LOTHIAN YES 123 NORTH HIGH STREET MUSSELBUR 0131-653 2170 East Lothian W WELL PHARMACY EH21 6JE [email protected] GH 2855 EAST LOTHIAN YES 49-51 HIGH STREET 01875- 2369 East Lothian W LLOYDS PHARMACY TRANENT EH33 1LN [email protected] 610321 EAST LOTHIAN YES 176 HIGH STREET PRESTONPAN 01875- 2409 East Lothian W WELL PHARMACY EH32 9AZ [email protected] S 815280 EAST LOTHIAN YES 25 HIGH STREET 01368- 2425 East Lothian E LLOYDS PHARMACY DUNBAR EH42 1EN [email protected] 862305 EAST LOTHIAN YES 22 MARKET STREET HADDINGTO 01620- 2482 East Lothian E MARKET STREET PHARMACY EH41 3JE [email protected] N 823557 EAST LOTHIAN YES HAWTHORN ROAD PRESTONPAN 01875- 2513 East Lothian W BANKTON PHARMACY EH32 9QW [email protected] S 811280 EAST LOTHIAN YES LINKS ROAD LONGNIDDRY 01875 2518 East Lothian W LONGNIDDRY PHARMACY EH32 0NH [email protected] EAST 853328 LOTHIAN YES 20 HIGH STREET HADDINGTO 01620- 2525 East Lothian E RIGHT MEDICINE PHARMACY EH41 3ES [email protected] N 822361 EAST LOTHIAN YES 66 HIGH STREET NORTH 01620- 2529 East Lothian E FERGUSON PHARMACY EH39 4HF [email protected] BERWICK 894650 EAST LOTHIAN YES 121 SALTER'S 0131 665 2540 East Lothian W WALLYFORD PHARMACY ROAD EH21 8AQ [email protected] YES 5499 WALLYFORD 165 HIGH STREET MUSSELBUR 0131-665 2563 East Lothian W ESKSIDE DISPENSING CHEMIST EH21 7DE [email protected] GH 2146 EAST LOTHIAN YES CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd 173 PIERSFIELD 0131-669 2175 Edinburgh NE NUCHEM EH8 7BT [email protected] TERRACE 8109 EDINBURGH YES 11 ELM ROW 0131-556 2231 Edinburgh NE LINDSAY & GILMOUR CHEMIST EH7 4AA [email protected] EDINBURGH 4316 YES 257A LEITH 0131-554 2232 Edinburgh NE LINDSAY & GILMOUR CHEMIST WALK EH6 8NY [email protected] 6591 EDINBURGH YES 7 BROUGHTON 0131 289 2338 Edinburgh NE TESCO INSTORE PHARMACY EH7 4EW [email protected] ROAD 0017 EDINBURGH YES UNIT 1 FORT RETAIL PARK 0131-669 2396 Edinburgh NE BOOTS UK LTD NEWCRAIGH EH15 3HS [email protected] 4428 ALL EDINBURGH YES 6 MILTON 0131-669 2444 Edinburgh NE LINDSAY & GILMOUR CHEMIST ROAD WEST EH15 1LF [email protected] 1532 EDINBURGH YES 29-31 PARSON'S 0131-661 2455 Edinburgh NE BOOTS UK LTD EH8 7AF [email protected] GREEN 3591 TERRACE YES UNIT 22 OCEAN 0131-554 2458 Edinburgh NE BOOTS UK LTD TERMINAL EH6 6JJ [email protected] 6834 OCEAN DRIVE EDINBURGH YES 1 RESTALRIG 0131-554 2470 Edinburgh NE WELL PHARMACY ROAD EH6 8BB [email protected] 2689 EDINBURGH YES 100 CRAIGENTIN 0131-661 2471 Edinburgh NE WELL PHARMACY EH7 6RN [email protected] NY ROAD 2523 EDINBURGH YES 12A LOCHEND 0131-467 2473 Edinburgh NE WELL PHARMACY EH7 6BP [email protected] ROAD SOUTH 4509 EDINBURGH YES 7 GREAT JUNCTION GREAT JUNCTION STREET 0131-554 2528 Edinburgh NE STREET EH6 5HX [email protected] PHARMACY 2196 LEITH EDINBURGH YES 92-96 EASTER 0131-659 2532 Edinburgh NE DEARS PHARMACY ROAD EH7 5RQ [email protected] 6095 EDINBURGH YES 96 NIDDRIE 0131-661 2550 Edinburgh NE LINDSAY & GILMOUR CHEMIST MAINS RD EH16 4DT [email protected] 2578 EDINBURGH YES 58-60 NIDDRIE 0131-661 2551 Edinburgh NE LINDSAY & GILMOUR CHEMIST EH16 4BG [email protected] MAINS ROAD 2662 EDINBURGH YES 332 PORTOBELLO 0131-669 2557 Edinburgh NE LINDSAY & GILMOUR CHEMIST EH15 2DA [email protected] HIGH ST 4331 EDINBURGH YES 168 PORTOBELLO 0131-669 2560 Edinburgh NE WOOTON PHARMACY EH15 1EX [email protected] HIGH STREET 3100 EDINBURGH YES 1 LINDSAY 0131-554 2562 Edinburgh NE CLARK CHEMIST ROAD EH6 4EP [email protected] 2258 EDINBURGH YES CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd

129 ST 0131-334 2032 Edinburgh NW BOOTS UK LTD JOHN'S ROAD EH12 7SB [email protected] 4520 EDINBURGH YES

228-230 CREWE ROAD 0131-552 2229 Edinburgh NW LINDSAY & GILMOUR CHEMIST EH5 2NS [email protected] NORTH 4253 EDINBURGH YES 7-9 DEANHAUGH 0131-332 2362 Edinburgh NW LLOYDS PHARMACY EH4 1LU [email protected] STREET 5721 EDINBURGH YES UNIT 33 THE LOAN 0131-331 2379 Edinburgh NW LLOYDS PHARMACY SOUTH EH30 9SD [email protected] 4347 QUEENSFERR Y YES 58-60 MAIN STREET 0131-312 2380 Edinburgh NW BOOTS UK LTD DAVIDSON'S EH4 5AA [email protected] 8600 MAINS EDINBURGH YES 22 HILLHOUSE 0131-332 2398 Edinburgh NW LINDSAY & GILMOUR CHEMIST ROAD EH4 2AG [email protected] 3602 BLACKHALL EDINBURGH YES 5A FEATHERHAL 0131-334 2417 Edinburgh NW ROWLANDS PHARMACY EH12 7TG [email protected] L AVENUE 4694 EDINBURGH YES 24 SOUTH GROATHILL AVENUE 0131-332 2438 Edinburgh NW BOOTS UK LTD EH4 2LN [email protected] CRAIGLEITH 6114 RETAIL PARK EDINBURGH YES 2 FERRYBURN SOUTH 0131-331 2441 Edinburgh NW LLOYDS PHARMACY QUEENSFERR EH30 9QS [email protected] 2579 Y EDINBURGH YES 38 MAIN 0131-333 2456 Edinburgh NW WELL PHARMACY STREET EH29 9AA [email protected] 3352 KIRKLISTON YES BUGHTLIN MARKET 0131-339 2465 Edinburgh NW LLOYDS PHARMACY EH12 8XP [email protected] EAST CRAIGS 1188 EDINBURGH YES 114-116 GRANTON 0131-552 2472 Edinburgh NW WELL PHARMACY EH5 3RE [email protected] ROAD 3569 EDINBURGH YES 146 SAUGHTON 0131-334 2499 Edinburgh NW CARRICK KNOWE PHARMACY EH12 7DS [email protected] ROAD NORTH 2087 EDINBURGH YES 38 DUART 0131-339 2508 Edinburgh NW OMNICARE PHARMACY CRESCENT EH4 7JP [email protected] 6525 EDINBURGH YES Unit 4 527 0131-336 2510 Edinburgh NW OMNICARE PHARMACY QUEENSFERR EH4 7QD [email protected] 2861 Y RD EDINBURGH YES 9-11 ROSEBURN 0131-337 2514 Edinburgh NW RIGHT MEDICINE PHARMACY EH12 5NG [email protected] TERRACE 4084 EDINBURGH YES 195 WHITEHOUSE 0131-339 2516 Edinburgh NW BARNTON PHARMACY EH4 6BU [email protected] ROAD 3449 EDINBURGH YES

35-37 NORTH 0131-220 2517 Edinburgh NW STOCKBRIDGE PHARMACY WEST CIRCUS EH3 6TW [email protected] 9150 PLACE YES 645 FERRY 0131-332 2531 Edinburgh NW DEARS PHARMACY ROAD EH4 2TX [email protected] 2851 EDINBURGH YES 159 ST 0131-334 2538 Edinburgh NW CORSTORPHINE PHARMACY JOHN'S ROAD EH12 7SD [email protected] 8106 EDINBURGH YES

6 EYRE PLACE 0131-556 2545 Edinburgh NW HONEY PHARMACY EH3 5EP [email protected] EDINBURGH 1908 YES 37 SOUTH TRINITY ROAD 0131-552 2555 Edinburgh NW GAM STUART LTD LE HARTLEY EDINBURGH EH5 3PN 3183 [email protected] YES 5 0131-552 2556 Edinburgh NW GAM stuart MONTAGUE EH3 5QX [email protected] 4098 TERRACE YES CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd

14 CAMERON TOLL CENTRE 0131-666 2023 Edinburgh SE BOOTS UK LTD EH16 5PB [email protected] 6 LADY ROAD 1111 EDINBURGH YES 101-103 PRINCES 0131-225 2029 Edinburgh SE BOOTS UK LTD EH2 3AD [email protected] STREET 8331 EDINBURGH YES 46-48 SHANDWICK 0131-225 2030 Edinburgh SE BOOTS UK LTD EH2 4SA [email protected] PLACE 6757 EDINBURGH YES UNIT 16,MULTREES 0131-556 2031 Edinburgh SE BOOTS UK LTD EH1 3DQ [email protected] WALK,EDINB 2119 URGH YES

UNIVERSITY OF ED'BURGH 0131-668 2247 Edinburgh SE BRISTO SQUARE PHARMACY 6 BRISTO EH8 9AL [email protected] 2182 SQUARE EDINBURGH YES 28-30 NEWINGTON 0131-667 2332 Edinburgh SE BOOTS UK LTD EH9 1QS [email protected] ROAD 3008 EDINBURGH YES 6 ST PATRICK 0131-667 2343 Edinburgh SE BOOTS UK LTD STREET EH8 9HB [email protected] 1698 EDINBURGH YES 18-20 COMISTON 0131-447 2344 Edinburgh SE LINDSAY & GILMOUR CHEMIST EH10 5QE [email protected] ROAD 2336 EDINBURGH YES 129 BRUNTSFIELD 0131-228 2358 Edinburgh SE LLOYDS PHARMACY EH10 4EQ [email protected] PLACE 3725 EDINBURGH YES 177 BRUNTSFIELD 0131-229 2405 Edinburgh SE PATON & FINLAY EH10 4DG [email protected] PLACE 2110 EDINBURGH YES 2 HOME 0131-229 2442 Edinburgh SE OMNICARE PHARMACY STREET EH3 9LY [email protected] 7778 EDINBURGH YES 37 MOREDUN 0131-664 2449 Edinburgh SE LINDSAY & GILMOUR CHEMIST EH17 7ES [email protected] PARK ROAD 2119 EDINBURGH YES 45 FORREST 0131-225 2453 Edinburgh SE RIGHT MEDICINE PHARMACY ROAD EH1 2QP [email protected] 7770 EDINBURGH YES 55A MAYFIELD 0131-667 2476 Edinburgh SE WELL PHARMACY EH9 3AA [email protected] ROAD 1992 EDINBURGH YES 153 MORNINGSID 0131-447 2478 Edinburgh SE LORIMER PHARMACY EH10 4AX [email protected] E ROAD 2041 EDINBURGH YES 142 MARCHMON 0131-447 2481 Edinburgh SE RIGHT MEDICINE PHARMACY EH9 1AQ [email protected] T ROAD 2198 EDINBURGH YES 46-48 CLERK 0131-667 2495 Edinburgh SE NEWINGTON PHARMACY STREET EH8 9JB [email protected] 2368 EDINBURGH YES 2 FOUNTAINHA 0131-667 2496 Edinburgh SE OMNICARE PHARMACY EH9 2NN [email protected] LL ROAD 2151 EDINBURGH YES 67 HIGH 0131-556 2497 Edinburgh SE RIGHT MEDICINE PHARMACY STREET EH1 1SR [email protected] 1971 EDINBURGH YES 102 WALTER SCOTT 0131-664 2507 Edinburgh SE OMNICARE PHARMACY EH16 5RL [email protected] AVENUE 2363 EDINBURGH YES 105 BROUGHTON 0131-556 2547 Edinburgh SE HONEY PHARMACY EH1 3RZ [email protected] STREET 1054 EDINBURGH YES CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd

14 CAMERON TOLL CENTRE 0131-666 2023 Edinburgh SE BOOTS UK LTD EH16 5PB [email protected] 6 LADY ROAD 1111 EDINBURGH YES 230-232 GORGIE 0131-337 2026 Edinburgh SW BOOTS UK LTD EH11 2PN [email protected] ROAD 1818 EDINBURGH YES 101-103 PRINCES 0131-225 2029 Edinburgh SE BOOTS UK LTD EH2 3AD [email protected] STREET 8331 EDINBURGH YES 46-48 SHANDWICK 0131-225 2030 Edinburgh SE BOOTS UK LTD EH2 4SA [email protected] PLACE 6757 EDINBURGH YES UNIT 16,MULTREES 0131-556 2031 Edinburgh SE BOOTS UK LTD EH1 3DQ [email protected] WALK,EDINB 2119 URGH YES

129 ST 0131-334 2032 Edinburgh NW BOOTS UK LTD JOHN'S ROAD EH12 7SB [email protected] 4520 EDINBURGH YES 173 PIERSFIELD 0131-669 2175 Edinburgh NE NUCHEM EH8 7BT [email protected] TERRACE 8109 EDINBURGH YES 46A BRIDGE 0131-441 2186 Edinburgh SW COLINTON PHARMACY LTD RD EH13 0LQ [email protected] 2352 EDINBURGH YES 2 PENTLAND VIEW COURT 0131-449 2225 Edinburgh SW LINDSAY & GILMOUR CHEMIST EH14 5NP [email protected] CURRIE 2707 EDINBURGH YES 228-230 CREWE ROAD 0131-552 2229 Edinburgh NW LINDSAY & GILMOUR CHEMIST EH5 2NS [email protected] NORTH 4253 EDINBURGH YES 11 ELM ROW 0131-556 2231 Edinburgh NE LINDSAY & GILMOUR CHEMIST EH7 4AA [email protected] EDINBURGH 4316 YES 257A LEITH 0131-554 2232 Edinburgh NE LINDSAY & GILMOUR CHEMIST WALK EH6 8NY [email protected] 6591 EDINBURGH YES

84 COLINTON 0131-441 2243 Edinburgh SW COLINTON MAINS PHARMACY MAINS DRIVE EH13 9BJ [email protected] 3388 EDINBURGH YES

UNIVERSITY OF ED'BURGH 0131-668 2247 Edinburgh SE BRISTO SQUARE PHARMACY 6 BRISTO EH8 9AL [email protected] 2182 SQUARE EDINBURGH YES SIGHTHILL HEALTH CENTRE 0131-453 2283 Edinburgh SW S H C PHARMACY LTD EH11 4AU [email protected] CALDER 4782 ROAD EDINBURGH YES UNIT 10 GYLE 0131-317 2320 Edinburgh NW BOOTS UK LTD SHOPPING EH12 9JS [email protected] 1288 CENTRE EDINBURGH YES 28-30 NEWINGTON 0131-667 2332 Edinburgh SE BOOTS UK LTD EH9 1QS [email protected] ROAD 3008 EDINBURGH YES 7 BROUGHTON 0131 289 2338 Edinburgh NE TESCO INSTORE PHARMACY EH7 4EW [email protected] ROAD 0017 EDINBURGH YES 6 ST PATRICK 0131-667 2343 Edinburgh SE BOOTS UK LTD STREET EH8 9HB [email protected] 1698 EDINBURGH YES 18-20 COMISTON 0131-447 2344 Edinburgh SE LINDSAY & GILMOUR CHEMIST EH10 5QE [email protected] ROAD 2336 EDINBURGH YES 129 BRUNTSFIELD 0131-228 2358 Edinburgh SE LLOYDS PHARMACY EH10 4EQ [email protected] PLACE 3725 EDINBURGH YES 7-9 DEANHAUGH 0131-332 2362 Edinburgh NW LLOYDS PHARMACY EH4 1LU [email protected] STREET 5721 EDINBURGH YES 26 WESTER HAILES CRESCENT 0131-442 2368 Edinburgh SW LLOYDS PHARMACY EH14 2SW [email protected] SHOPPING 3118 CENTRE EDINBURGH YES UNIT 33 THE LOAN 0131-331 2379 Edinburgh NW LLOYDS PHARMACY SOUTH EH30 9SD [email protected] 4347 QUEENSFERR Y YES 58-60 MAIN STREET 0131-312 2380 Edinburgh NW BOOTS UK LTD DAVIDSON'S EH4 5AA [email protected] 8600 MAINS EDINBURGH YES UNIT 1 FORT RETAIL PARK 0131-669 2396 Edinburgh NE BOOTS UK LTD NEWCRAIGH EH15 3HS [email protected] 4428 ALL EDINBURGH YES 10 POLWARTH 0131-229 2397 Edinburgh SW POLWARTH PHARMACY EH11 1LW [email protected] GARDENS 3199 EDINBURGH YES 22 HILLHOUSE 0131-332 2398 Edinburgh NW LINDSAY & GILMOUR CHEMIST ROAD EH4 2AG [email protected] 3602 BLACKHALL EDINBURGH YES 177 BRUNTSFIELD 0131-229 2405 Edinburgh SE PATON & FINLAY EH10 4DG [email protected] PLACE 2110 EDINBURGH YES 5A FEATHERHAL 0131-334 2417 Edinburgh NW ROWLANDS PHARMACY EH12 7TG [email protected] L AVENUE 4694 EDINBURGH YES 24 SOUTH GROATHILL AVENUE 0131-332 2438 Edinburgh NW BOOTS UK LTD EH4 2LN [email protected] CRAIGLEITH 6114 RETAIL PARK EDINBURGH YES 2 FERRYBURN SOUTH 0131-331 2441 Edinburgh NW LLOYDS PHARMACY QUEENSFERR EH30 9QS [email protected] 2579 Y EDINBURGH YES

2 HOME 0131-229 2442 Edinburgh SE OMNICARE PHARMACY STREET EH3 9LY [email protected] 7778 EDINBURGH YES 6 MILTON 0131-669 2444 Edinburgh NE LINDSAY & GILMOUR CHEMIST ROAD WEST EH15 1LF [email protected] 1532 EDINBURGH YES 37 MOREDUN 0131-664 2449 Edinburgh SE LINDSAY & GILMOUR CHEMIST EH17 7ES [email protected] PARK ROAD 2119 EDINBURGH YES 45 FORREST 0131-225 2453 Edinburgh SE RIGHT MEDICINE PHARMACY ROAD EH1 2QP [email protected] 7770 EDINBURGH YES 29-31 PARSON'S 0131-661 2455 Edinburgh NE BOOTS UK LTD EH8 7AF [email protected] GREEN 3591 TERRACE YES 38 MAIN 0131-333 2456 Edinburgh NW WELL PHARMACY STREET EH29 9AA [email protected] 3352 KIRKLISTON YES UNIT 22 OCEAN 0131-554 2458 Edinburgh NE BOOTS UK LTD TERMINAL EH6 6JJ [email protected] 6834 OCEAN DRIVE EDINBURGH YES BUGHTLIN MARKET 0131-339 2465 Edinburgh NW LLOYDS PHARMACY EH12 8XP [email protected] EAST CRAIGS 1188 EDINBURGH YES 1 RESTALRIG 0131-554 2470 Edinburgh NE WELL PHARMACY ROAD EH6 8BB [email protected] 2689 EDINBURGH YES 100 CRAIGENTIN 0131-661 2471 Edinburgh NE WELL PHARMACY EH7 6RN [email protected] NY ROAD 2523 EDINBURGH YES 114-116 GRANTON 0131-552 2472 Edinburgh NW WELL PHARMACY EH5 3RE [email protected] ROAD 3569 EDINBURGH YES 12A LOCHEND 0131-467 2473 Edinburgh NE WELL PHARMACY EH7 6BP [email protected] ROAD SOUTH 4509 EDINBURGH YES 4 STENHOUSE 0131-443 2475 Edinburgh SW WELL PHARMACY EH11 3JY [email protected] CROSS 2222 EDINBURGH YES 55A MAYFIELD 0131-667 2476 Edinburgh SE WELL PHARMACY EH9 3AA [email protected] ROAD 1992 EDINBURGH YES 153 MORNINGSID 0131-447 2478 Edinburgh SE LORIMER PHARMACY EH10 4AX [email protected] E ROAD 2041 EDINBURGH YES 142 MARCHMON 0131-447 2481 Edinburgh SE RIGHT MEDICINE PHARMACY EH9 1AQ [email protected] T ROAD 2198 EDINBURGH YES 46-48 CLERK 0131-667 2495 Edinburgh SE NEWINGTON PHARMACY STREET EH8 9JB [email protected] 2368 EDINBURGH YES 2 FOUNTAINHA 0131-667 2496 Edinburgh SE OMNICARE PHARMACY EH9 2NN [email protected] LL ROAD 2151 EDINBURGH YES 67 HIGH 0131-556 2497 Edinburgh SE RIGHT MEDICINE PHARMACY STREET EH1 1SR [email protected] 1971 EDINBURGH YES 146 SAUGHTON 0131-334 2499 Edinburgh NW CARRICK KNOWE PHARMACY EH12 7DS [email protected] ROAD NORTH 2087 EDINBURGH YES

483A CALDER 0131-442 2503 Edinburgh SW LLOYDS PHARMACY ROAD EH11 4AW [email protected] 2894 EDINBURGH YES 102 WALTER SCOTT 0131-664 2507 Edinburgh SE OMNICARE PHARMACY EH16 5RL [email protected] AVENUE 2363 EDINBURGH YES 38 DUART 0131-339 2508 Edinburgh NW OMNICARE PHARMACY CRESCENT EH4 7JP [email protected] 6525 EDINBURGH YES 3 ARDMILLAN 0131-337 2509 Edinburgh SW OMNICARE PHARMACY TERRACE EH11 2JN [email protected] 1604 EDINBURGH YES Unit 4 527 0131-336 2510 Edinburgh NW OMNICARE PHARMACY QUEENSFERR EH4 7QD [email protected] 2861 Y RD EDINBURGH YES 2 CRAIGLOCKH 0131-455 2511 Edinburgh SW CRAIGLOCKHART PHARMACY EH14 1BU [email protected] ART RD N 7168 EDINBURGH YES 9-11 ROSEBURN 0131-337 2514 Edinburgh NW RIGHT MEDICINE PHARMACY EH12 5NG [email protected] TERRACE 4084 EDINBURGH YES 195 WHITEHOUSE 0131-339 2516 Edinburgh NW BARNTON PHARMACY EH4 6BU [email protected] ROAD 3449 EDINBURGH YES

35-37 NORTH 0131-220 2517 Edinburgh NW STOCKBRIDGE PHARMACY WEST CIRCUS EH3 6TW [email protected] 9150 PLACE YES 107 0131-337 2522 Edinburgh SW LINDSAY & GILMOUR CHEMIST SLATEFORD EH11 1QY [email protected] 3405 ROAD YES 131 LIBERTON 0131-658 2526 Edinburgh SE FLEMING CHEMIST EH16 6LD [email protected] BRAE 1274 EDINBURGH YES 7 GREAT JUNCTION GREAT JUNCTION STREET 0131-554 2528 Edinburgh NE STREET EH6 5HX [email protected] PHARMACY 2196 LEITH EDINBURGH YES 645 FERRY 0131-332 2531 Edinburgh NW DEARS PHARMACY ROAD EH4 2TX [email protected] 2851 EDINBURGH YES 92-96 EASTER 0131-659 2532 Edinburgh NE DEARS PHARMACY ROAD EH7 5RQ [email protected] 6095 EDINBURGH YES 7 OXGANGS 0131-445 2533 Edinburgh SW DEARS PHARMACY BROADWAY EH13 9LQ [email protected] 1925 EDINBURGH YES 291 CALDER 0131-455 2534 Edinburgh SW MACKINNON PHARMACY ROAD EH11 4RH [email protected] 7073 EDINBURGH YES 159 ST 0131-334 2538 Edinburgh NW CORSTORPHINE PHARMACY JOHN'S ROAD EH12 7SD [email protected] 8106 EDINBURGH YES

6 EYRE PLACE 0131-556 2545 Edinburgh NW HONEY PHARMACY EH3 5EP [email protected] EDINBURGH 1908 YES 105 BROUGHTON 0131-556 2547 Edinburgh SE HONEY PHARMACY EH1 3RZ [email protected] STREET 1054 EDINBURGH YES 96 NIDDRIE 0131-661 2550 Edinburgh NE LINDSAY & GILMOUR CHEMIST MAINS RD EH16 4DT [email protected] 2578 EDINBURGH YES 58-60 NIDDRIE 0131-661 2551 Edinburgh NE LINDSAY & GILMOUR CHEMIST EH16 4BG [email protected] MAINS ROAD 2662 EDINBURGH YES

64 NORTH ST 0131-333 2552 Edinburgh SW LUNN PHARMACY RATHO EH28 8RR [email protected] 1397 EDINBURGH YES 37 SOUTH TRINITY ROAD 0131-552 2555 Edinburgh NW GAM STUART LTD LE HARTLEY EDINBURGH EH5 3PN 3183 [email protected] YES 5 0131-552 2556 Edinburgh NW GAM stuart MONTAGUE EH3 5QX [email protected] 4098 TERRACE YES 332 PORTOBELLO 0131-669 2557 Edinburgh NE LINDSAY & GILMOUR CHEMIST EH15 2DA [email protected] HIGH ST 4331 EDINBURGH YES 179 DUNDEE 0131-229 2559 Edinburgh SW FOUNTAINBRIDGE PHARMACY STREET EH11 1BY [email protected] 8281 EDINBURGH YES 168 PORTOBELLO 0131-669 2560 Edinburgh NE WOOTON PHARMACY EH15 1EX [email protected] HIGH STREET 3100 EDINBURGH YES 1 LINDSAY 0131-554 2562 Edinburgh NE CLARK CHEMIST ROAD EH6 4EP [email protected] 2258 EDINBURGH YES CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd 17-19 HIGH STREET 0131-663 2022 Midlothian E BOOTS UK LTD EH22 1JB [email protected] DALKEITH 3158 MIDLOTHIAN YES 18/20 WOODBURN 0131-663 2226 Midlothian E LINDSAY & GILMOUR CHEMIST AVENUE EH22 2BP [email protected] 0372 DALKEITH MIDLOTHIAN YES 17 ESKDAILL COURT 0131-663 2371 Midlothian E LLOYDS PHARMACY EH22 1AG [email protected] DALKEITH 6789 MIDLOTHIAN YES 105 HUNTERFIEL 01875- 2372 Midlothian E LLOYDS PHARMACY D ROAD EH23 4TS [email protected] 820345 GOREBRIDGE MIDLOTHIAN YES

2 BOGWOOD COURT 0131-663 2375 Midlothian E LLOYDS PHARMACY EH22 5DG [email protected] MAYFIELD 3523 MIDLOTHIAN YES 44a JOHN STREET 01968- 2376 Midlothian W LLOYDS PHARMACY EH26 8AB [email protected] PENICUIK 673633 MIDLOTHIAN YES 48 HIGH STREET 0131-663 2445 Midlothian W ROWLANDS PHARMACY EH19 2AB [email protected] BONNYRIGG 8353 MIDLOTHIAN YES 55 CLERK STREET 0131-440 2450 Midlothian W ROWLANDS PHARMACY EH20 9RE [email protected] LOANHEAD 0511 MIDLOTHIAN YES STRAITON MAINS 0131-440 2554 Midlothian W LLOYDS PHARMACY EH20 9PW [email protected] STRAITON 4205 MIDLOTHIAN YES

122 PENICUIK 0131-440 2558 Midlothian W ROSLIN PHARMACY EH25 9NT [email protected] ROAD ROSLIN 2596 YES CC HSCP LOCALITY PHARMACY ADDRESS POSTCODE TELEPHONE eMAIL Service Spec rcvd Units 8-9 ARGYLE COURT 114 EAST MAIN 01506- 2021 West Lothian E BOOTS UK LTD EH52 5EQ [email protected] STREET 852648 BROXBURN WEST LOTHIAN YES ALMONDVAL E CENTRE 01506- 2035 West Lothian E BOOTS UK LTD LIVINGSTON EH54 6HR [email protected] 436997 WEST LOTHIAN YES 2 MAIN STREET 01501- 2169 West Lothian W WELL PHARMACY FAULDHOUSE EH47 9JA [email protected] 770243 WEST LOTHIAN YES

173 MAIN STREET 01506- 2227 West Lothian E LINDSAY & GILMOUR CHEMIST EAST CALDER EH53 0EL [email protected] 881935 WEST LOTHIAN YES HEALTH CENTRE BURNGRANG 01506- 2239 West Lothian W LINDSAY & GILMOUR CHEMIST EH55 8EJ [email protected] E 871232 WEST CALDER YES 7-9 SYCAMORE WALK 01506- 2307 West Lothian W BOOTS UK LTD EH47 7LQ [email protected] BLACKBURN 652378 WEST LOTHIAN YES 12 WEST MAIN STREET 01501- 2309 West Lothian W BOOTS UK LTD WHITBURN EH47 0QZ [email protected] 740168 WEST LOTHIAN YES

BATHGATE PRIMARY CARE CENTRE 01506- 2377 West Lothian W LLOYDS PHARMACY EH48 2SS [email protected] BATHGATE 631601 WEST LOTHIAN YES 25 KING STREET 01506- 2378 West Lothian W LLOYDS PHARMACY BATHGATE EH48 1AZ [email protected] 630806 WEST LOTHIAN YES 5 CANAL ROAD WINCHBURG 01506- 2394 West Lothian E RIGHT MEDICINE PHARMACY EH52 6FD [email protected] H 890313 WEST LOTHIAN YES STRATHBROC K CENTRE 01506- 2429 West Lothian E LLOYDS PHARMACY BROXBURN EH52 5LH [email protected] 771757 WEST LOTHIAN YES 157 NIGEL RISE - DEDRIDGE 01506- 2430 West Lothian E LLOYDS PHARMACY EH54 6LX [email protected] LIVINGSTON 461732 WEST LOTHIAN YES 286 HIGH STREET 01506- 2431 West Lothian E LLOYDS PHARMACY LINLITHGOW EH49 7ER [email protected] 670280 WEST LOTHIAN YES 21 WEST MAIN STREET 01501- 2432 West Lothian W LLOYDS PHARMACY ARMADALE EH48 3PZ [email protected] 732638 WEST LOTHIAN YES 34 MAIN STREET WEST 01506- 2436 West Lothian W LINDSAY & GILMOUR CHEMIST EH55 8DR [email protected] CALDER 871164 WEST LOTHIAN YES 6 MAIN STREET 01506- 2457 West Lothian E OMNICARE PHARMACY EH54 8DF [email protected] DEANS 411570 LIVINGSTON YES DEDRIDGE ROAD NORTH 01506- 2463 West Lothian E MORRISONS PHARMACY LIVINGSTON EH54 6DB [email protected] 462003 WEST LOTHIAN YES CARMONDEA N CENTRE 01506- 2464 West Lothian E MORRISONS PHARMACY LIVINGSTON EH54 8PT [email protected] 430449 WEST LOTHIAN YES 67 MAIN STREET 01501- 2484 West Lothian W JAMES WHITE CHEMIST STONEYBURN EH47 8BY [email protected] 762274 WEST LOTHIAN YES

F'HOUSE P'SHIP CENTRE 01501- 2491 West Lothian W WELL PHARMACY EH47 9JD [email protected] LANRIGG 770143 ROAD FAULDHOUSE YES 103 CHAPELTON 2498 West Lothian W RIGHT MEDICINE PHARMACY EH55 8SQ 01506 8732 [email protected] DRIVE POLBETH YES HOWDEN HEALTH CENTRE 01506- 2501 West Lothian E LLOYDS PHARMACY EH54 6TP [email protected] LIVINGSTON 410161 WEST LOTHIAN YES 27 ELIZABETH DRIVE 01506 2515 West Lothian W DUNAMIS PHARMACY BOGHALL EH48 1SJ [email protected] 653867 WEST LOTHIAN YES 45 FERNBANK LADYWELL 2520 West Lothian E LADYWELL PHARMACY EH54 6DT 01506 4371 [email protected] LIVINGSTON WEST LOTHIAN YES 23 -25 WEST 01506 2521 West Lothian E OMNICARE PHARMACY MAIN STREET EH52 5DN [email protected] 857516 UPHALL YES

24 MAIN 01506 2543 West Lothian E KIRKNEWTON PHARMACY STREET EH27 8AH [email protected] 883048 KIRKNEWTON YES

2 SYCAMORE 2561 West Lothian W BLACKBURN PHARMACY WALK EH47 7LH 01506 [email protected] BLACKBURN 813720 YES Chief Medical Officer Directorate E: [email protected] 

Dear Colleagues From Chief Medical Officer ADULT FLU IMMUNISATION PROGRAMME 2020/21 Chief Nursing Officer Chief Pharmaceutical 1. We are writing to provide you with information about Officer the adult seasonal flu immunisation programme. 07 August 2020 2. We would like to begin by thanking you for all the SGHD/CMO(2020)19 hard work you are doing as part of the health and For action social care response to the global Covid-19 Chief Executives, NHS Boards pandemic. We know that this has been an extremely Medical Directors, NHS Boards Nurse Directors, NHS Boards challenging time for staff across the health and social Primary Care Leads, NHS Boards care sector. Directors of Nursing & Midwifery, NHS Boards Chief Officers of Integration 3. Given the impact of Covid-19 on the most vulnerable Authorities Chief Executives, Local Authorities in society, it is imperative that we do all that we can Directors of Pharmacy to reduce the impact of seasonal flu on those most at Directors of Public Health General Practitioners risk. It is therefore essential that we have effective Practice Nurses plans in place to deliver the flu immunisation Immunisation Co-ordinators CPHMs programme this winter to protect those at risk, Scottish Prison Service prevent ill health in the population and minimise Scottish Ambulance Service Occupational Health Leads further impact on the NHS and social care services. For information Chairs, NHS Boards Planning Infectious Disease Consultants Consultant Physicians Public Health Scotland 4. We recognise that delivering the programme this Chief Executive, Public Health year will be more challenging than ever before Scotland NHS 24 because of the impact of Covid-19 on our health and Further Enquiries social care sector. We are working through the Policy Issues Scottish Immunisation Programme Group to develop Vaccination Policy Team guidance on vaccination service delivery to ensure [email protected] that all who will benefit most from the flu vaccine will have the opportunity to receive it in a timely manner while maintaining good Infection Prevention & t Control practices and appropriate physical distancing. The provision of appropriate Personal Medical Issues Protective Equipment (PPE) to those involved in the St Andrew’s House delivery of the flu vaccination programme will also form an important part of the programme planning. Pharmaceutical and Vaccine Supply Please refer to the Covid-19 guidance available at: Issues Public Health https://www.hps.scot.nhs.uk/a-to-z-of-topics/covid- Scotland 19/infection-prevention-and-control-ipc-guidance-in- healthcare-settings/#title-container .

1 5. While General Practice will have an essential role to play in the flu immunisation programme, its capacity is likely to be substantially constrained by the need to maintain good Infection Prevention & Control practices and appropriate physical distancing measures. As set out in John Connaghan’s letter of 14 May, flu immunisation preparation is a key clinical priority for Boards and Partnerships. A whole system response, bringing in other parts of the health system, is required if a successful programme is to be delivered.

6. We would expect us all to draw on learning from our experience with Covid-19 and be mindful on how best to deliver a vaccination programme that is prioritised towards protecting the most vulnerable.

Key Objectives

7. The flu programme is a strategic and Ministerial priority. The key objectives of the 2020/21 adult flu programme are summarised below

 To protect those most at risk from flu in the coming season and to ensure that the impact of potential co-circulation of flu and Covid-19 is kept to an absolute minimum.  To plan to deliver the programme building on lessons learnt from previous years and our experience of Covid-19, recognising that arrangements may need to change and putting in place the resource needed to deliver the programme at scale.  To increase flu vaccine uptake across all eligible groups with particular focus on those who are aged 65 years and over; those aged 18-64 years in clinical risk groups, as well as pregnant women (at all stages of pregnancy). Full details of eligibility for flu immunisation this season is set out in Annex A.  To extend the national programme to offer vaccination to households of those who are shielding, social care staff who deliver direct personal care and all those aged 55-64 years old. Some of those aged 55-64 are otherwise eligible due to qualifying health conditions or employment.  To maximise uptake amongst frontline health and social care workers which may require creativity and innovation but is critical to safeguard staff, but also those in their care.

8. The Scottish Government has procured additional vaccine to cover increased uptake amongst existing cohorts, in light of Covid-19, as well as to provide vaccine supply to introduce additional eligible groups to the programme.

9. Scottish Ministers have indicated that the programme should be extended to those aged 50-54, if vaccine supply allows. We will review this in line with uptake rates and vaccine supply as the programme progresses.

10. A separate letter has been issued for the childhood flu immunisation programme, available at https://www.sehd.scot.nhs.uk/cmo/CMO(2020)17.pdf.

11. More information on the flu vaccines for this upcoming season as well as vaccine composition is provided below in Annex B.

2 Extension of the programme

12. Scottish Ministers have decided to extend the eligibility of the flu immunisation programme to social care workers providing direct personal care, households of those shielding and all 55-64 year olds this year. Some of those groups may already be eligible due to being part of one or more other cohorts e.g. those aged 55-64 may be otherwise eligible due to qualifying health conditions or employment.

13. The rationale for expanding to all 55-64 year olds, beyond those who are already eligible through qualifying health conditions or employment, is that it will help to protect an age group who are more vulnerable to both Covid-19 and seasonal flu than those in younger age groups; and will lower the risk for members of this group, of getting concurrent infection with both viruses. The vaccination of those aged 55-64 years who would not be otherwise eligible should commence in a second phase of the programme later in the season as detailed below.

14. Individuals who have been shielding have already been identified at being at a high risk from Covid-19. The health risks are heightened should they contract both Covid-19 and seasonal flu at the same time. Given that a high proportion of those shielding are either over 55, or else have an underlying health condition, it is likely that many of them are already eligible for the seasonal flu vaccine. However, there are some people shielding whose underlying condition may cause them to have a sub-optimal response to the flu vaccine. Vaccinating those who live in households with those in the shielding group for Covid-19 should provide additional indirect protection to individuals who are shielding.

15. The intention is that eligibility would be defined by the shielding list in place at the time of vaccination. Further detail on this will follow.

16. The Covid-19 pandemic has had an effect on every aspect of public health, including vaccine supply at a global level. This means that the Scottish Government has had to make difficult decisions about how we expand eligibility. The pandemic has also meant that situations can change hugely at very short notice. We will adapt our approach to any changes that occur throughout flu season, always prioritising those most at risk from seasonal flu, and always additionally seeking to protect the NHS as far as possible.

17. To allow us to be responsive to the changing context, we will review the availability of vaccine after uptake levels become clear within existing cohorts, household members of those shielding, and frontline social care workers. At that point we will decide whether there is sufficient vaccine supply to allow us to extend eligibility to 50-54 year olds.

18. Scottish Government will remain in regular dialogue with delivery partners through the Scottish Immunisation Programme Group and will update on any significant developments.

3 Phased approach

19. All those initially eligible should be given flu vaccination as soon as possible so that individuals are protected when flu begins to circulate. This is the case for all high-risk cohorts, excluding 55-64 year olds not otherwise eligible, and means starting to vaccinate in late September/October as in previous years.

20. For those aged 55-64, not otherwise eligible due to qualifying health conditions or employment, this will mean starting in December, at the latest. This phased approach is aligned to the availability of vaccines, and prioritisation of the cohorts who are most at risk from the seasonal flu. We will provide further advice, should the programme be extended later in the season to those aged 50-54.

21. NHS Boards and GP practices should aim to schedule their immunisation services to match vaccine supply, as outlined above, if possible: beginning in late September/October, and completing vaccination by the end of November for most high-risk cohorts; and beginning in December at the latest, and completing at the end of January for 55-64 year olds not otherwise eligible.

Health and Social Care Workers

22. Timely immunisation of all health and social care workers in direct contact with patients/clients will be a critical component in our efforts to protect the most vulnerable in our society.

23. High rates of staff vaccination will help to protect individual staff members but also reduce the risks of transmission of flu viruses within health and social care premises which will contribute to the protection of individuals who may have suboptimal response to their own immunisations. Furthermore, it will help to maintain the workforce and minimise disruption to services that provide patient/client care by aiming to reduce staff sickness absence.

24. Senior clinicians, NHS Managers, Directors of Public Health, Local Authorities and Integration Authorities should ensure this work aligns with the prioritisation already being given to our Covid-19 response to the care sector as a means to prevent transmission of the flu virus in an already vulnerable group.

Communication materials

25. The national media campaign (TV, radio, press, digital and social media) will seek to increase uptake rates amongst all groups and retain high uptake rates amongst groups who may now be more cautious about getting vaccinated. Research and insight work will underpin the campaign in light of Covid-19 and potentially changing attitudes to vaccination.

26. A national toolkit will be produced to support the promotion of the flu vaccine to health and social care workers and provide resources such as invitation emails, posters and suggested social media posts. We are also working in partnership with professional bodies and membership organisations to try to increase uptake rates.

4 27. The public should be signposted to http://www.nhsinform.scot/flu for up to date information on the programme.

28. Workforce education materials will soon be made available at https://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/public- health/health-protection/seasonal-flu.aspx.

Resources

29. NHS Boards are asked to ensure that immunisation teams are properly resourced to develop and deliver the extended programme.

30. Any additional costs related to adapting immunisation programmes to meet Covid-19 requirements (e,g. physical distancing, PPE) should be recorded in NHS Boards’ Local Mobilisation Plans, now called Covid-19 finance returns. This is in the form of a single row figure in the return.

31. Additional costs should also be submitted to the Scottish Government policy team directly with a breakdown of spend. The policy team will shortly issue a template to be submitted. Please ensure that costs are not double counted for services already delivered.

Action

32. NHS Boards and GP practices, are asked to note and implement the arrangements outlined in this letter for the 2020/21 adult seasonal flu immunisation programme. It is important that every effort is made this year to maximise uptake as this winter, more than ever, the flu vaccine is going to be a key intervention to reduce pressure on the NHS and protect the most vulnerable in our population.

33. We have procured additional vaccine to support higher uptake, however, ongoing and effective management at a local level is also required. NHS Boards should fully consider the needs of their eligible cohorts and plan appropriately and timeously in order to successfully deliver the programme.

34. We would ask that action is taken to ensure as many people as possible are vaccinated early in the season, and before flu viruses begin to circulate. The benefits of flu vaccination should be communicated and vaccination made as easily accessible as possible. This excludes those 55-64 year olds who are not otherwise eligible, as the commencement of vaccination of this group should be in December at the latest.

35. Integration Authority Chief Officers and Local Authorities are asked to work closely to communicate and promote the flu vaccination programme to social care workers providing direct personal care, and to ensure that they are supported to access the service. A separate letter will be issued to social care membership organisations to communicate the expansion directly to social care providers.

5 36. We would like to take this opportunity to express our gratitude for your continuing support in planning and delivering the flu immunisation programme and a heartfelt thank you for all your hard work in these most challenging of circumstances.

Yours sincerely,

Gregor Smith Chief Nursing Interim Chief Medical Officer Officer Chief Pharmaceutical Officer

6 Annex A

FLU VACCINE: PRIORITISING UPTAKE AND ELIGIBILITY

Prioritising flu vaccine uptake

37. Flu vaccination is one of the key interventions we have to reduce pressure on the health and social care system this winter. Since March 2020 we have seen the impact of Covid-19 on the NHS and social care, and this coming winter we may be faced with co-circulation of viruses causing Covid-19 and flu. We understand that planning this year is more challenging with the uncertainties of staff absences, and how long policies around physical distancing and alternative models of schooling will remain in place. However, it is more important than ever to make every effort to deliver flu vaccination.

38. Those most at risk from flu are also most vulnerable to concurrent infection with Covid-19. The people most at risk from flu are already eligible to receive the flu vaccine, and in order to protect them as effectively as we can, their vaccination should be prioritised.

39. We should also prioritise the vaccination of eligible health and social care workers, to protect them and minimise the likelihood of them spreading Covid-19 and flu to those they care for. We anticipate that concerns about Covid-19 may increase demand for flu vaccination in all groups this year, whilst others may have additional safety concerns around getting vaccinated.

40. All those eligible should be given flu vaccination as soon as possible so that individuals are protected when flu begins to circulate. This is the case for all high-risk cohorts excluding 55-64’s not otherwise eligible, and means starting to vaccinate in late September/October.

41. For those aged 55-64, not otherwise eligible through qualifying health conditions or employment, this will mean starting in December, at the latest. This phased approach is aligned to the availability of vaccines, and prioritisation of the cohorts who are most at risk from the seasonal flu. We will provide further advice, should the programme be extended later in the season to those aged 50-54.

42. NHS Boards and GP Practices should aim to schedule their immunisation services to match vaccine supply, as outlined above, if possible: beginning in late September/October and completing vaccination by the end of November for high- risk cohorts; and beginning in December at the latest, and completing at the end of January for 55-64 year olds not otherwise eligible.

Pregnant women

43. Most NHS Boards and Health and Social Care Partnerships (HSCPs) will be delivering flu vaccine to pregnant women through their local maternity services this year and should keep local practices informed about their plans including how to refer women to the services as appropriate.

7 GP practices however retain responsibility for vaccinating this cohort until alternative arrangements are made by local NHS Boards and HSCPs.

Existing Eligible Groups (those eligible in previous flu seasons)

44. In 2020/21 the seasonal flu vaccine should be offered, from the commencement of the programme, to the existing cohorts set out in the table below:

Eligible groups Further detail Pre-school children The childhood flu CMO letter for the 20/21 programme has further aged 2-5 years; and details. All primary school children in P1-7 All patients aged 65 “Sixty-five and over” is defined as those aged 65 years and over by 31 years and over March 2021. Chronic respiratory Asthma that requires continuous or repeated use of inhaled or systemic disease aged six steroids or with previous exacerbations requiring hospital admission. months or older Chronic obstructive pulmonary disease (COPD) including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD). Children who have previously been admitted to hospital for lower respiratory tract disease. Chronic heart Congenital heart disease, hypertension with cardiac complications, disease aged six chronic heart failure, individuals requiring regular medication and/or months or older follow-up for ischaemic heart disease. Chronic kidney Chronic kidney disease at stage 3, 4 or 5, chronic kidney failure, disease aged six nephritic syndrome, kidney transplantation. months or older Chronic liver disease Cirrhosis, biliary atresia, chronic hepatitis from any cause such as aged six months or Hepatitis B and C infections and other non-infective causes older Chronic neurological Stroke, transient ischaemic attack (TIA). Conditions in which respiratory disease aged six function may be compromised, due to neurological disease (e.g. polio months or older syndrome sufferers). Clinicians should offer immunisation, based on individual assessment, to clinically vulnerable individuals including those with cerebral palsy, learning disabilities, multiple sclerosis and related or similar conditions; or hereditary and degenerative disease of the nervous system or muscles; or severe neurological or severe learning disability. Diabetes aged six Type 1 diabetes, type 2 diabetes requiring insulin or oral hypoglycaemic months or older drugs, diet controlled diabetes. Immunosuppression Immunosuppression due to disease or treatment, including patients aged six months or undergoing chemotherapy leading to immunosuppression, bone marrow older transplant. HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system (eg IRAK-4, NEMO, complement disorder). Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day (any age) or for children under 20kg a dose of 1mg or more per kg per day. It is difficult to define at what level of immunosuppression a patient could be considered to be at a greater risk of the serious consequences of flu and should be offered flu vaccination. This decision is best made on an individual basis and left to the patient’s clinician.

8 Some immunocompromised patients may have a suboptimal immunological response to the vaccine. Consideration should also be given to the vaccination of household contacts of immunocompromised individuals, i.e. individuals who expect to share living accommodation on most days over the winter and therefore for whom continuing close contact is unavoidable. This may include carers (see below). Asplenia or This also includes conditions such as homozygous sickle cell disease dysfunction of the and coeliac syndrome that may lead to splenic dysfunction. spleen Pregnant women at any stage of pregnancy (first, second or third Pregnant women trimesters). Vaccination is recommended for people in long-stay residential care People in long-stay homes or other long-stay care facilities where rapid spread is likely to residential care or follow the introduction of infection, and cause high morbidity and homes mortality. This does not include, for instance, prisons, young offender institutions, university halls of residence etc. Someone who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to age, physical or mental illness, addiction or Unpaid Carers and disability. A young carer is a child or young person under the age of 18 young carers carrying out significant caring tasks and assuming a level of responsibility for another person, which would normally be taken by an adult. Vaccination can also be given on an individual basis at the GP’s discretion following a risk assessment after discussion with the carer. Health care workers who are in direct contact with patients/service users Health care workers should be vaccinated. Morbid obesity Adults with a Body Mass Index ≥ 40 kg/m² (class III obesity)*

45. The list above is not exhaustive, and clinicians should apply clinical judgement to take into account the risk of flu exacerbating any underlying disease that a patient may have or compromise their care due to illness of their carer, as well as the risk of serious illness from flu itself. Seasonal flu vaccine can be offered in such cases even if the individual is not in the clinical risk groups specified above.

Call and recall of patients aged 65 and over

46. As in previous years the Scottish Government will arrange for a national call-up letter to be sent to all those who will be aged 65 years and over by 31 March 2021. These letters will be delivered from w/c 14 September 2020.

Call and recall of patients under 65 years “at-risk”

47. National call-up letters for those aged under 65 at-risk are under further consideration and further information will be provided in due course.

New Eligible Groups 20/21

48. In 2020/21 the seasonal flu vaccine should be offered to the new cohorts set out in the table below:

9 Eligible groups Further detail Social care workers Social care workers who provide direct personal care in the following settings; adult care homes, children’s residential or secure care or care at home including Personal Assistants. This is targeted at those delivering direct personal care in these settings no matter of whether they are employed by Local Authorities, private or third sector employers. Households of those Those who live in the same home as individuals falling within the shielding Covid-19 shielding group. All patients aged 55 This is defined as those who will be aged 55 to 64 years old by 31 March to 64 years old 2021. The older age group are covered as an existing group above. Those within this group who are not otherwise eligible (i.e those with qualifying health conditions etc) should be vaccinated in a second phase as detailed below.

49. Health and social care workers and households of those shielding should be vaccinated from the commencement of the flu vaccination programme. Patients aged 55-64 years old, not otherwise eligible through qualifying health condition or employment, should be vaccinated in a second phase in December at the latest. This phased approach is aligned to the availability of vaccines, and prioritisation of the cohorts who are most at risk from the seasonal flu.

50. Scottish Ministers have indicated that the programme should be extended to those aged 50-54, if vaccine supply allows. We will review this in line with uptake rates and vaccine supply as the programme progresses.

Call and recall of households of those shielding

51. Scottish Government is currently considering the possibility of sending a national call-up letter to be sent to all households of those shielding. Further information on this will be provided in due course.

Call and recall of patients aged 55-64

52. Scottish Government is currently considering the possibility of sending a national call-up letter patients aged 55-64. Further information on this will be provided in due course.

Health and Social Care Workers

Healthcare Workers

53. Immunisation against flu should be considered an integral component of infection prevention and control. As in previous years, free seasonal flu vaccination should be offered by NHS organisations to all employees directly involved in delivering care. This is not an NHS service, but an occupational health responsibility being provided to NHS staff by the NHS as their employers.

54. Uptake of seasonal flu vaccination by health care workers continues to be below the CMO target - in 2019/20 in Scotland this was 53.8% in territorial boards compared with a minimum target of 60%.

10 55. While vaccination of NHS staff remains voluntary, we will look to all NHS Boards to do everything they can to increase uptake which should include offering the vaccine in an accessible way, helping all staff understand the seriousness of being vaccinated for themselves, their family contacts, their patients and the NHS in helping to reduce the potential for the spread of flu.

56. GP, dental and optometry practices, as well as community pharmacists, should also arrange vaccination of their staff.

Social Care Workers

57. The current Covid-19 situation has highlighted the need to ensure that front line staff across both health and social care settings do not inadvertently transmit infection and should therefore be encouraged and able to access free flu vaccination on a national basis. Scottish Ministers have therefore decided that the policy on flu vaccination for the coming and future seasons should be extended to include social care staff delivering direct personal care to patients/clients. This is in order to protect frontline social care staff and those they care for from flu and to help limit sickness absence amongst the workforce.

58. For clarity, social care staff delivering direct personal care in the following settings should be covered by this programme:  residential care for adults;  residential care and secure care for children; and  community care for persons at home (including housing support and Personal Assistants).

59. This is targeted at those delivering direct personal care in these settings no matter of whether they are employed by Local Authorities, private or third sector employers.

60. A Short Life Working Group was set up within the Scottish Immunisation Programme structure to coordinate expansion of the flu programme to cover social care staff who provide direct personal care. This included representation from Public Health Scotland, NHS Boards, COSLA, HSCP’s, Scottish Care and the Coalition of Care and Support Providers in Scotland.

Immunisation against Infectious Disease (‘The Green Book’)

61. Further guidance on the list of eligible groups can be found in the most recent influenza chapter (chapter 19) of the Green Book available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/796886/GreenBook_Chapter_19_Influenza_April_2019.pdf

62. Chapter 12 of the Green Book provides information on what groups can be considered as directly involved in delivering care and is available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/147882/Green-Book-Chapter-12.pdf

63. Any Green Book updates will be made to the linked pages above.

11 ANNEX B

RECOMMENDED FLU VACCINES, VACCINE COMPOSITION AND ORDERING INFORMATION

Flu vaccines for 2020/21

64. The flu vaccines that have been centrally procured for the forthcoming flu season are in line with the recommendations of the Joint Committee on Vaccination and Immunisation (JCVI) and are set out in the table below.

Eligible Group Vaccine First Phase Individuals aged 65 years and over adjuvanted Trivalent Inactivated Vaccine (aTIV) (Seqiris)

Individuals aged 18-64 years with “at- cell based Quadrivalent Inactivated risk” conditions Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris)

Health and Social Care Workers cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®)(Seqiris) or Egg based Quadrivalent Inactivated Vaccine (QIVe) (brand and manufacturer to be confirmed) dependent on vaccine supply and delivery schedules.

Households of those shielding cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris)

Unpaid/Young carers cell based Quadrivalent Inactivated Vaccine (QIVc) (Flucelvax Tetra®) (Seqiris)

Second Phase Individuals aged 55-64 not otherwise Egg based Quadrivalent Inactivated eligible through a qualifying health Vaccine (QIVe) (brand and condition or employment manufacturer to be confirmed)

65. Some flu vaccines are restricted for use in particular age groups. The Summary of Product Characteristics (SPC) for individual products should always be referred to when ordering vaccines for particular patients.

Vaccine composition for 2020/21

66. Each year the World Health Organization (WHO) recommends flu vaccine strains based on careful mapping of flu viruses as they circulate around the world.

12 67. This monitoring is continuous and allows experts to make predictions on which strains are most likely to cause flu outbreaks in the northern hemisphere in the coming winter. Getting vaccinated is the best protection available against an unpredictable virus that can cause severe illness.

68. For the 2020/21 flu season (northern hemisphere winter) it is recommended that cell based quadrivalent vaccines contain the following strains-:

 an A/Hawaii/70/2019 (H1N1)pdm09-like virus;  an A/Hong Kong/45/2019 (H3N2)-like virus;  a B/Washington/02/2019 (B/Victoria lineage)-like virus; and  a B/Phuket/3073/2013 (B/Yamagata lineage)-like virus.

69. For the 2020/21 flu season (northern hemisphere winter) it is recommended that egg based quadrivalent vaccines contain the following strains-:

 an A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09-like virus;  an A/Hong Kong/2671/2019 (H3N2)-like virus;  a B/Washington/02/2019 (B/Victoria lineage)-like virus; and  a B/Phuket/3073/2013 (B/Yamagata lineage)-like virus.

70. For further information and the full report please see: https://www.who.int/influenza/vaccines/virus/recommendations/2020- 21_north/en/

Egg-free vaccine

71. For individuals with egg allergy the advice in the most recent influenza chapter of the Green Book should be followed: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/796886/GreenBook_Chapter_19_Influenza_April_2019.pdf

72. Any Green Book updates will be made to the linked pages above.

73. Egg-allergic adults and children over age nine years with egg allergy can also be given the quadrivalent inactivated cell based (i.e. egg-free) vaccine, Flucelvax® Tetra, which is licensed for use in this age group.

Vaccine ordering and delivery arrangements

74. Information on ordering and delivery arrangements for the flu vaccine will be provided within further correspondence. Details of the supply arrangements for community pharmacies supporting this year’s immunisation programme will be shared directly via relevant NHS Boards.

75. Orders for the flu vaccine should be placed on the Movianto online ordering system - Marketplace: (https://ommarketplace.co.uk/Orders/Home). Log-in details used in previous seasons remain valid and should continue to be used.

13 76. If you have any issues with log-in arrangements or if you have new staff who require access to the system please contact Movianto Customer Services on 01234 248 623 for assistance.

77. NHS Boards and GP practices should plan appropriately and place the minimum number of orders needed, taking into consideration available fridge capacity. NHS Boards are charged for each delivery made to practices.

78. NHS Boards and GP practices must ensure adequate vaccine supplies before organising vaccination clinics.

79. When placing orders for the vaccines in Marketplace, practices should search for the type of vaccine required. For example, if vaccines are required for patients aged 18 to 64 these can be found in Marketplace by entering the search term “QIVc” or on the ‘Orders’ screen. If vaccines are required for patients aged 65 or over, these can be found by searching for “aTIV”.

80. To make it simpler for front line staff in the coming season, all NHS Boards will be allocated the same type of vaccine for each cohort e.g QIVc for most cohorts. The exception to this is for health and social care workers where a mix of QIVc and QIVe will be allocated based on vaccine supply and delivery schedules. Only QIVe should be used for 55-64 year olds, not otherwise eligible due to qualifying health condition or employment, and will be available for ordering later in the season. Those who are egg-allergic should be offered the QIVc vaccine as detailed above.

81. Vaccines are available in packs of 10. On the ordering platform, please read the vaccine information carefully and order the number of packs required rather than the total volume of individual vaccines – for example, if the vaccine is available in packs of 10 and the practice wants to request a delivery of 500 vaccines, an order should be placed for 50 packs of 10.

82. Patient information leaflets for vaccines supplied in packs of 10 will be provided separately to the vaccines. These will be automatically added to orders by Movianto.

Further information and support

83. As with last year, a Procurement Officer within NHS National Procurement will act as a link between GP practices and Movianto to ensure any potential allocation or delivery issues can be minimised and swiftly resolved. Contact details for the Procurement Officer are as follows: [email protected]

84. For queries linked to ordering and deliveries, please contact the Movianto Customer Services Team (01234 248 623). If any delivery service issues cannot be resolved satisfactorily through dialogue with Movianto, the issue should be escalated to NHS National Procurement (contact details as above) in the first instance and thereafter the Immunisation Co-ordinator within the NHS Board. If you require contact details for your NHS Board Immunisation Coordinator please email [email protected] .

14 ANNEX C CONTRACTUAL ARRANGEMENTS AND FURTHER INFORMATION

Contractual arrangements

85. Information on payments associated with the seasonal flu and pneumococcal vaccines will be set out by Primary Care Directorate, Scottish Government in due course.

Pneumococcal immunisation

86. Health professionals are reminded that they should check the immunisation status of those eligible for pneumococcal immunisation when such people receive the flu vaccine. Depending on the availability, the pneumococcal vaccine can be offered at the same time as the flu vaccine or at any other point in the year when vaccine becomes available. Health professionals should note to recall individuals in cases where no vaccine is immediately available. An online leaflet is available and can be accessed at: www.nhsinform.scot/pneumococcalforadults.

Uptake Rates in 2019/20

87. It is important that every effort is made this year to ensure uptake is as high as possible. The benefits of flu vaccination amongst all eligible groups should be communicated and vaccination made as easily accessible as possible.

88. Provisional uptake data for 2019/20 suggests uptake rates of:

 74% in people aged 65 years and over, compared with 73.7% in 2018/19;  42.3% in under 65’s at-risk, compared with 42.4% in 2018/19;  53.8% for healthcare workers, compared with 51.2% in 2018/19  56.9% in pregnant women (with other risk factors), compared with 57.5% in 2018/19; and  42.9% in pregnant women (without other risk factors), compared with 44.5% in 2018/19.  44.7% in unpaid/young carers, compared with 45.1% in 2018/19.

Information on vaccine uptake for this season and previous seasons can be found at: https://www.hps.scot.nhs.uk/a-to-z-of-topics/influenza/. For further information regarding the HPS vaccine uptake monitoring programme, please contact [email protected]

15 NHS Scotland - Marketplace August 2020

Online Ordering User Guide

1 LOGGING ON

• Click on the following link: https://www.ommarketplace.co.uk/.

• Enter your Username and Password. These will be the same as last year. • If you are unsure then select the ‘Forgot password?’ option below the Password field. • If you have any further problems logging on please contact Movianto Customer Services on 01234 248 623.

2 ORDERS SCREEN

• This screen shows your order history, including last year’s orders. • To find the vaccine required please type the following “search term” in the search bar: • “aTIV” – this will display vaccines for patients aged 65 and over • “ QIVc” – this will display vaccines for patients aged 18 to 64 with at risk conditions, healthy pregnant women and health and social care workers • “QIVe” – this will display vaccines for children contraindicated to Fluenz • Note: Like last season, vaccines have been allocated to each practice so you will therefore only have access to this volume of product. Allocation queries should be raised with Movianto. 3 PRODUCTS

Click on “View Details” for any product you want to order.

4 The quantity available is shown. This will display ‘0’ until stock is delivered to Movianto. Enter the number of boxes of 10 you want to order in the Quantity box and click on “Add to Cart” (e.g to order 500 vaccines you must enter the quantity 50) You should always check the pack size in the product description. In this example the vaccines are available in boxes of 10 however ADD TO CART some vaccines are available in single dose packs. If you want to order another vaccine, click the small arrow at the top to return to the previous screen and repeat. You should only order vaccines you have space to store. Note: The price will say £0 as costs will be charged back to your Health Board separately.

5 ADD TO CART This is QIVe

6 ADD TO CART This is the QIVc

7 CHECK OUT

Once you have finished ordering the products you require, then click on the shopping trolley icon at the top which will show a number next to it reflecting how many products you have ordered.

• This will show all of the products you have ordered along with the quantity. In the example above the order is for 1 packs of 10 vaccines (total 10 vaccines). Amend or remove if required, and press “Update Cart” if you do. • Please be aware the unit of measure “EACH-1” is a reflection of how many packs you have ordered, not how many doses. 8 CHECK OUT CONTINUED

• Once you are happy that the quantities and products are correct you must then complete the PO Number box. • Enter your name and the current date eg “Smith 01.08.2019”. • Then click on “Complete Order”

9 ORDER CONFIRMATION

•You will receive an email confirmation which should take no more than 60 minutes to arrive. This will have the details required should you need to contact the Customer Service Team for any reason.

•First orders – you will receive confirmation of your delivery date in September. •For all other orders – your delivery day will be the day allocated in the Movianto delivery schedule. You must order by the stated cut off time to receive delivery on this day. A copy of the delivery schedule can be found here: https://nhsnss.org/service/practitioner/medical/flu-vaccine-distribution •If you require more than one delivery a week - i.e in addition to your allocated delivery day - please contact the Movianto Customer Services Team on 01234 248 623. 10 CHANGING YOUR PASSWORD

• If you would like to change the password that was auto generated for you then please select the “Administration” drop down at the top and click “Preferences”. • Your details will be shown and at the bottom you can enter a new password and confirm it.

11 27 August 2020

NHS Seasonal Flu 2019/20: Vaccine Ordering Open

Dear Colleague,

Online ordering is now open

The Movianto online ordering system – Marketplace – is now live and ready for you to pre-order your first delivery of vaccines for the 2020/21 season.

First deliveries of vaccines are scheduled for the weeks commencing 14 and 21 September. The first delivery week for your health board is shown in the table below:

Delivery Week Commencing Health Boards Place pre-order by: NHS Ayrshire and Arran NHS Dumfries and Galloway NHS Forth Valley 14 September 2020 NHS Greater Glasgow and Clyde Wednesday 9 September NHS Golden Jubilee NHS Lanarkshire Scottish Ambulance Service. NHS Fife NHS Borders NHS Grampian NHS Highland 21 September 2020 NHS Lothian Wednesday 16 September NHS Orkney NHS Shetland NHS Tayside NHS Western Isles.

To ensure you receive a delivery in in the week for your health board please ensure that you place your pre-order no later than the cut-off day specified above. Practices can place subsequent orders during the season as required.

You can access Marketplace by clicking on this link: https://ommarketplace.co.uk/Orders/Home From the week commencing 28 September the normal weekly delivery schedule will apply to all practices. As with previous seasons your orders should be placed by the agreed cut off day to ensure delivery on your scheduled delivery day the following week.

A copy of the delivery schedule can be found on the Practitioner Services Flu Vaccine Distribution web page https://nhsnss.org/services/practitioner/medical/flu-vaccine-distribution

Log-in details

Your log-in details will be the same as those issued to you last year. If you need to reset your password please click on the “Forgot Password?” link on the Marketplace log-in screen and follow the instructions on screen.

If there are new members of staff who require access to Marketplace or you are having problems logging in to an account established last year, please contact Movianto Customer Services directly on 01234 248 623 or [email protected]

Placing your order – IMPORTANT INFORMATION

Orders for the vaccine should be placed on the Movianto online ordering system - Marketplace: (https://ommarketplace.co.uk/Orders/Home). Log-in details used in previous seasons remain valid and should continue to be used. If you have any issues with log-in arrangements or if you have new staff who require access to the system please contact OM Movianto Customer Services on 01234 248 623 for assistance.

GP practices should plan to place the minimum number of orders needed taking into consideration available fridge capacity. NHS Boards are charged for each delivery made to practices.

You must ensure adequate vaccine supplies are in place before organising vaccination clinics.

Available vaccines

Vaccine Brand Cohort Adjuvanted Trivalent Influenza Vaccine Seqirus 65 and over (aTIV) Cell-culture based Quadrivalent Influenza Flucelvax 18-64 ‘at-risk’, including Vaccine (QIVc) pregnant women. Egg-based Quadrivalent Influenza Vaccine Sanofi Children with contraindications (QIVe) to nasal spray vaccine.

Vaccine allocations Each site in Scotland has been allocated a quantity of aTIV and QIVc for the season. Allocations have been set based on the number of vaccines used in previous flu seasons plus an additional 10% to accommodate any increase in demand. If you reach a point during the season where you have reached your initial allocation limit you may request additional vaccines and these will be provided subject to vaccine availability.

Searching for vaccines in Marketplace When placing orders for the vaccines in Marketplace, practices should search for the type of vaccine required. For example, if vaccines are required for patients aged 18 to 64 these can be found in Marketplace by entering the search term “QIVc” on the ‘Orders’ screen. Similarly, the vaccines for patients aged 65 and over can be found by searching for “aTIV”.

Ordering the correct quantity Vaccines are available in either packs of 10 or single dose packs. On the ordering platform, please read the vaccine information carefully and order the number of packs required rather than the total volume of individual vaccines – for example, if the vaccine is available in packs of 10 and the practice wants to request a delivery of 500 vaccines, and order should be placed for 50 packs of 10. If the vaccine is only available in single dose packs then a practice requiring e.g. 30 vaccines should order 30 single dose packs.

Patient Information Leaflets Patient Information Leaflets for vaccines supplied in packs of 10 will be provided separately to the vaccines. These will be added to orders automatically by Movianto.

Egg-free vaccine The cell-culture based quadrivalent vaccine (QIVc) – Flucelvax – does not contain egg.

QIVe for children who cannot receive the nasal spray vaccine Please contact your Vaccine Holding Centre for advice on where to order QIV for this cohort of patients.

Further Support

Further information and guidance about placing your orders is included in the Frequently Asked Questions document available on the Practitioner Services Flu Vaccine Distribution web page https://nhsnss.org/services/practitioner/medical/flu-vaccine-distribution

If you have any questions that the FAQ document does not address please contact Movianto Customer Services on 01234 248 623 and they will be able to assist you. PCA(M)(2020)14

Directorate of Primary Care General Practice Division 

Chief Executives NHS Boards GP Practices

25 August 2020

Dear Colleagues,

INFLUENZA AND PNEUMOCOCCAL VACCINATION (CORONAVIRUS OUTBREAK) (SCOTLAND) DIRECTIONS 2020

Introduction

1. This Circular provides guidance to NHS Boards and GP Practices on the forthcoming Influenza and Pneumococcal Vaccination (Coronavirus Outbreak) (Scotland) Directions 2020. The directions will replace PCA(M)(2019)09 and amend the Primary Medical Services (Directed Enhanced Services) (Scotland) 2018 in respect of influenza and pneumococcal vaccinations.

2. The Influenza and Pneumococcal Vaccination (Coronavirus Outbreak) (Scotland) Directions 2020 will have the effect of directing Health Boards to deliver those parts of the Influenza and Pneumococcal Immunisation Scheme which GP contractors cannot reasonably deliver under the Influenza and Pneumococcal Directed Enhanced Service (DES).

3. The requirements of social distancing and PPE associated with COVID-19 mean that the level of vaccination activity that most practices can reasonably undertake without impacting on other services to patients or substantially increasing practice workload will be severely curtailed. Minimum expectations for practices participating in the DES are set out later in this circular.

4. This circular gives directions to Health Boards on behalf of Scottish Ministers detailing arrangements for GP contractors who undertake the Influenza and Pneumococcal DES.

5. Scottish Government has agreed the terms of these arrangements with SGPC While GPs will participate on a DES basis, SGPC has agreed that in these PCA(M)(2020)14

specific circumstances GPs will not have “first refusal” of this work and Health Boards should make arrangements that best suit delivery of the Influenza and Pneumococcal Immunisation Scheme. Practices continue to have the right to decline to participate in the DES where it is offered to them.

6. The amendment of the Primary Medical Services (Directed Enhanced Services) (Scotland) 2018 will have the effect of expanding the Influenza and Pneumococcal Immunisation Scheme to include the new target groups detailed in SGHD/CMO(2020)19.

7. SGHD/CMO(2020)19 was issued on 7 August 2020 and contains the clinical arrangements and target groups for the Seasonal Influenza Programme.

8. SGHD/CMO(2020)17 was issued on 26 June 2020 and contains clinical arrangements and target groups for Year Eight of the Childhood Influenza Programme.

9. There is no change to the pneumococcal vaccination clinical arrangements or target groups.

Background

10. In previous years general practice has delivered the Influenza and Pneumococcal Immunisation Scheme as a DES1. Health Boards were directed by Scottish Ministers to offer practices first refusal of nationally agreed terms for delivering the flu programme to their patients. These terms paid GPs a fee rate dependent on meeting targets for patients aged over 65 years and a flat fee for vaccinating at risk patients and pre-school children, “mop up” fees for children missed by the schools programme, and a flat fee for vaccinating patients aged over 65 years against pneumococcal disease.

11. Unlike most other DES, this enhanced service was renewed annually.

12. In recent years the Vaccination Transformation Programme has seen the transition of the childhood element of the programme to Health Board delivery in many areas. Health Boards and Integration Authorities (IAs) have generally left the transition of the adult flu elements of the programme (as well as the pneumococcal element) to the later years of their Primary Care Improvement Plans due to its scale, complexity and seasonal nature.

COVID-19

13. Scottish Government is cognizant that the need to maintain good infection prevention & control practices and appropriate physical distancing measures will substantially constrain the capacity of general practice to deliver the over 65 years, at risk and pre-school children flu elements of the programme to the levels of previous years.

1 Circular PCA(M)(2019)09 set out the historical development of the Influenza and Pneumococcal Immunisation Scheme. PCA(M)(2020)14

14. The impact of not delivering previous levels of flu immunisation this year is likely to be even more significant than it would otherwise be: the wider Health and Social Care system is still recovering from the impact of the pandemic, there may also be a resurgence of COVID-19 and widely prevalent flu symptoms would require more testing for the coronavirus.

15. At the beginning of the pandemic Scottish Government and SGPC recognised that income stability is essential for practices and declared they would agree a mechanism to protect practices from any loss of income should one be required. The Scottish Government also stated2 that it would consider arrangements to enable Health Boards to suspend certain DES if necessary and would monitor the situation as it develops. The arrangements set out in this circular are the first time such a mechanism has been necessary.

16. John Connaghan’s letter of 14th May stated that flu immunisation preparation is a key clinical priority for Health Boards. A whole system response, bringing in other parts of the health system, is required if a successful programme is to be delivered. Health Boards and IAs are already planning to support or deliver the adult elements of the flu programme.

17. The Influenza and Pneumococcal Vaccination (Coronavirus Outbreak) (Scotland) Directions 2020 will have the effect of requiring Health Boards to deliver those parts of the Influenza and Pneumococcal Immunisation Scheme which GP contractors cannot reasonably deliver under the Influenza and Pneumococcal DES. Practices are asked to support the programme in return for a payment based upon their average previous activity. These arrangements are provided below.

18. Scottish Government will not direct Health Boards to offer a target based DES this year. There is instead a DES offering flat fees for all immunisation groups, including the pneumococcal programme (which is not subject to the same seasonal restrictions as the flu programme) and the “mop up” arrangements for children missed in the schools programme.

19. Scottish Government will not reduce the funds allocated to Health Boards for the Scottish Enhanced Services Package: these can be used to pay the average levels of service payments for GP practices.

Commencement

20. The 2020-21 Influenza and Pneumococcal Immunisation Scheme will formally commence on 1 October 2020. Contractual arrangements apply from [date of issue].

21. A central letter will be sent via SIRS to call/recall all children aged 2-5 for vaccination.

2 PCA(M)(2020)02 PCA(M)(2020)14

Mop Up Arrangements

22. GP practices will again offer vaccination to any primary school-aged child resident in Scotland at the time of the immunisation programme (aged 4 to 11 inclusive) who was not vaccinated during their local school immunisation session, unless alternative arrangements have been agreed locally.

Timing

23. Health Boards are required to deliver the influenza immunisation programme between 1 October 2020 and 31 March 2021 but are asked to concentrate the programme before the end of November to maximise the timely immuno- protection of eligible individuals. They should also ensure that participating contractors follow this approach.

24. The pneumococcal immunisation programme can be given at any time in the year, while concentrating mainly around the time of the influenza vaccination, for operational reasons as well as maximising the timely immune protection of eligible individuals over the winter period.

Reporting arrangements

25. Apart from monitoring uptake for payment purposes, it is important to provide timely data in the interest of patient safety, particularly in situations where the vaccination could be offered in more than one setting. Health Boards will require all necessary data from practices to support the delivery of the programme. In addition practices need to enter the vaccination data timeously in to the patient electronic record and assist in monitoring uptake. This includes all vaccination data whether delivered in the practices or through alternative NHS Board organised clinics. This will be a contractual requirement for all practices regardless of whether individual practices will provide support in return for payments, and should be provided timeously to ensure data on uptake rates is up to date and has been agreed with SGPC.

26. Health Boards and contractors are reminded of their need to comply with data protection requirements at all times

Historical commitment and payment for GPs

27. The following section applies to GP practices where the Vaccination Transformation Programme has not already transferred vaccination delivery away from GP practices. GP practices in areas where the programme has already transferred vaccination delivery should continue to be paid on the basis of the Transferred Services Residual mechanism3. In some areas some parts of the Influenza and Pneumococcal Immunisation Scheme have been

3 Scottish Government and SGPC have agreed that practice income will be kept stable as Enhanced Services are transferred from the GMS contract during Phase One and while vaccinations Directed Enhanced Services (DES) are on-going on a national basis. This refers to gross income. However when services are transferred we would expect practices to retain the nursing and other staff paid for by these services and to support the development of their roles so that GPs can refocus on Expert Medical Generalism. PCA(M)(2020)14

transferred and other parts have not. The parts that have been transferred should be excluded from the following arrangements which apply only to parts of the Influenza and Pneumococcal Immunisation Scheme that have not been transferred.

28. To determine the appropriate amount of clinical time that each GP practice should expect to contribute over the course of the 2020 Influenza and Pneumococcal Immunisation Scheme, Scottish Government and SGPC have agreed that a calculation should be made based upon previous levels of performance.

29. The Average Number of Vaccinations (ANV) delivered annually by each GP practice should be determined using the last three years of a GP practice’s participation under the DES (if a particular year is exceptional in the sense that it would distort the average GP practices can agree with their Health Board to discount it from the calculation). Alternatively practices and Health Boards may agree to use the “best” of the last three years; this would commit the practice to contribute a higher amount of time in return for a higher historic income.

30. The ANV is then divided by 135. This number is based on a practice being able to administer 120 does in a 5 hour session in a normal year, plus an allowance for 15 opportunistic doses. This figure, rounded to the nearest whole number, is the number of sessions, or their equivalent in hours, that a practice would be expected to provide during 2020, the Influenza Sessional Commitment (ISC).

31. A separate calculation should be made to calculate the anticipated number of Influenza Opportunistic Vaccinations (IOV) that GP practices are expected to deliver within general practice without additional payment during 2020. This is calculated by dividing the ANV by 135 and multiplying by 15.

Example

32. Practice A carried out 2,812 vaccinations in 2017, 2,802 vaccinations in 2018, and 2,135 vaccinations in 2019. Averaged across three years, this gives an ANV of 2,583 vaccinations. Divided by 135, this gives an ISC of 19.13 sessions, rounded to 19 sessions each of up to 5 hours.

33. The practice and board would agree when and how this time commitment would be contributed to the 2020 Influenza and Pneumococcal Immunisation Scheme, avoiding any pattern that causes significant disruption to normal patient care. The practice can determine who will meet each session in its practice commitment from the qualified clinicians available to it.

34. As Practice A is expected to contribute 19 sessions, this equates to an IOV allowance of 285.

Table 1 – examples

Average of 3 years Excluding a year Best of 3 years # vaccinations in 2,812 2,812 2,812 2017 PCA(M)(2020)14

# vaccinations in 2,802 2,802 2,802 2018 # vaccinations in 2,135 2,135 2,135 2019 ANV 2,583 2,807 2,812 ISC 19 sessions 21 sessions 21 sessions IOV 285 vaccinations 315 vaccinations 315 vaccinations

35. The third column provides an of an exceptional year being excluded. Where the average of the last three years reflects circumstances that were beyond a practice’s control (for example a national shortage of a vaccine or local supply difficulties) or performance that could not be repeated (for example a staff member has left and not been replaced), practices and Health Boards should agree to discount particular years from the calculation.

36. The fourth column provides an example of the best year being chosen.

37. Payment for practices providing the ISC and IOV should be an average of the income earned providing influenza vaccinations for the years included in the ANV, or the best of 3 years where that is the agreed approach. Where practices cannot meet their ISC that income should be reduced on a pro-rata basis.

Participation on an Item of Service basis.

38. The fee for item of service vaccinations is under negotiation and will be announced shortly. Health Boards should continue to plan for the costs of delivery on the basis that additional costs should be submitted to the Scottish Government.

39. GP practices will not be eligible for participation on an Item of Service basis until their commitments under the ISC and IOV have been met. This does not apply to the national mop up arrangements.

40. Contractors can provide these vaccinations on an opportunistic basis but it will assist with Health Board planning if they can agree estimated numbers of vaccinations they expect to deliver with their Health Boards when agreeing to participate.

41. Scottish Government is not directing Health Boards to use a set national rate for sessions agreed with contractors: however Health Boards can agree to pay sessional rates based upon an estimated number of vaccinations during a session.

Claims for Payments

42. Practitioner Services Division will provide separate guidance regarding claims including claim forms

43. Any necessary variation for local circumstances, outwith the arrangements under the national programme, should be agreed between NHS Boards and PCA(M)(2020)14

Local Medical Committees (LMCs). Health Boards should have particular regard to the circumstances of remote and rural GP practices where there may be few or no alternative options to delivery.

Payment Verification

44. Prior to issuing payments in accordance with the above, Health Boards must require contractors and providers who have entered into an arrangement with a Health Board’s Influenza and Pneumococcal Scheme in terms of the DES Directions 2018 to sign a declaration to confirm that they are meeting the requirements of the DES Directions 2018 as amended.

Action

45. NHS Boards are requested to action this guidance and ensure that their primary medical services contractors, are aware of it.

46. GP practices must ensure that they use the “new” vaccine stocks of vaccine and ensure that unused stock from the previous year is disposed of.

Enquiries

47. In the instance of any enquiries on this circular please contact Michael Taylor .

Yours sincerely,

Naureen Ahmad Deputy Director and Head of GP Contract Division Seasonal Influenza Immunisation Programme 2020-21 in Scotland

The seasonal flu immunisation programme helps to protect the most vulnerable and alleviate pressure on the NHS. This will be more important than ever this year, in light of the Covid-19 pandemic. As well as considering those who are most at risk from the seasonal flu; for this year’s vaccination programme, we must also consider who would be most at risk from concurrent infection of Covid-19 and flu. That is why eligibility is expanding for the free seasonal flu vaccine to:

o Social care workers who provide direct care, o Household members of individuals who were shielding, and o Those aged 55 and over (who are not already eligible) The Scottish Government will look to extend the programme to those aged 50-54 if vaccine supplies allow. Further information on this year’s programme can be found in the Chief Medical Officer letter issued on 7 August.

A whole system response, bringing in other parts of the health and social care system, is required if a successful programme is to be delivered this year. Health Boards and Integration Authorities are already planning to support or deliver the adult elements of the flu programme.

Whilst the Scottish Government and SGPC’s direction of travel is to ultimately remove delivery of vaccinations from general practices, practices’ participation in this season’s programme as part of a pan-NHS response will be essential to the successful delivery of the programme.

On this basis, Scottish Government and SGPC are developing an agreement that health boards and integration authorities will take the lead role in providing flu immunisations for 2020, with practices providing support to the equivalent amount of clinician time they would have spent on immunisation in previous years. As part of this agreement, the income that practices would otherwise have received from participation in the immunisation programme will be protected at an agreed level. Health Boards will require all necessary data from practices to support the delivery of the programme and its uptake. Further details of this agreement will be announced shortly.

Delivering the seasonal flu immunisation is one of the key ways that we can support recovery and protect one another this winter. We are both grateful for the practices’ ongoing support in this important endeavour.

Jeane Freeman Dr Andrew Buist The Scottish Government Scottish GP Committee (SGPC)

1 NHS LOTHIAN PHARMACY SERVICES Staff Influenza Vaccine Order Form (Season 2020/2021)

Date required: ______(MIN OF 5 WORKING DAYS FOR DELIVERY)

Delivery days are as below – WE CANNOT DELIVER OUT WITH THESE DAYS and TIME OF DELIVERY CANNOT BE GAURANTEED, IF SPECIFIC DELIVERY TIME IS REQUIRED FOR CLINIC PLEASE TELEPHONE AREA STORE BEFORE PLACING ORDER

Edinburgh – Mon, Wed, Fri East Lothian/Mid Lothian – Tue, Thur West Lothian – Mon to Thur

**Note: All vaccines are transported by refrigerated van and do not contain packaging components to maintain the cold chain. All vaccines received will require immediate refrigeration.

For clinics where a fridge is not available and you require the vaccines to be sent in a vaccine porter please delete as appropriate below – Vaccine porters only maintain temperatures of 2 -8 for max 8 hours

Vaccine porter required YES / NO

Email completed order forms to To: [email protected] Tel: 01506 523472

Delivery Address (please complete)

F.A.O. ………………………………………………………………………………

Health Centre………………………………………………………………………….

Address: …………………………………………………………………………….. ……………………………………………………………………….

Details of Order: Product Qty Influenza Vaccine Quadrivalent Prefilled syringe ______x doses Flucelvax Egg Free FOR THE VACCINATION OF STAFF UP TO AGE 64 Influenza Adjuvanted Trivalent Vaccine Prefilled syringes ______x doses FOR THE VACCINATION OF STAFF 65 YEARS AND OVER

** Authorised by: MUST BE COMPLETED BY REGISTERED NURSE, HEALTH VISITOR OR GP BEFORE SENDING, DELIVERY OF ORDER WILL BE DELAYED IF ORDER FORM IS INCOMPLETE Name: (signature) (print)

Designation: Contact Number: Date:

** NHS Lothian Safe use of Medicines Policy and Procedure January 2018 2.4 The charge nurse must ensure that medicines are only ordered by registered nursing staff or other relevant professionals that he or she has authorised, and that authorised staff are trained and competent in the processes involved in ordering medicines.