Influenza vaccination policy and high risk subjects: Targeting and delivery should remain in general practice

Editor—Watkins criticises the existing general practice based influenza immunisation programme.1 He declares no conflict of interest but his study was funded by the Association for Influenza Monitoring and Surveillance, which is a publicity organisation funded by manufacturers of influenza vaccines. Watkins is a member of the association’s advisory board. Interestingly, the association has been deleted from the BMA’s information service database. A similar survey was conducted in this area, also in 1994-5. It was financed by the medical audit advisory group and the health authority (now South Humber Health Authority), and the results were different from those reported by Watkins. Lists of inpatients aged over 60 who had been discharged with heart failure, chronic lung disease, and diabetes were obtained from two local hospitals. The general practice records of each patient were then examined for details of influenza vaccination. A group at genuine high risk was identified. Overall, 68% of the patients had been immunised during the previous winter, and 15 out of 37 practices achieved a coverage of 75% or more. The conclusion was that well organised practices could do this job well. The maximum coverage achieved was 84%, and general practitioners participating in the survey agreed that a hard core of patients who refuse vaccination makes any higher coverage impracticable. Watkins found little evidence of practices using vaccination registers. However, most practices now have computer systems, all of which have a diary or recall system for immunisations. All general practitioners know that a lot of vaccine is wasted on patients at low risk, and the current system of remuneration clearly does nothing to discourage this wastage. However, organisations such as the Association for Influenza Monitoring and Surveillance and vaccine manufacturers’ other public relations efforts are also responsible for the hordes of patients who ring their general practitioner as soon as the first leaf turns brown, demanding to know when their “flu jab” will arrive. General practitioners are better placed to assess the whole patient in terms of risk of influenza than is a public health department using central morbidity data that rapidly become outdated. Watkins’ assessment of the present system is overly pessimistic because he included a lot of patients who were not really at high risk. It is also potentially biased. He suggests reform of the present system. Any such reform should build on the strength of the current general practice based system. Central purchasing might well be efficient and save money, but targeting and delivery should be left to general practice.