Our data are presented under three overarching themes: 1) transition to the new health system; 2) applying the new arrangements for immunisation; and 3) regrouping and making the new arrangements work. These themes narrate participants’ experiences of the transition of the immunisation programme into a new health system structure, document how they learned to work within the new management and delivery arrangements in this structure and identify the mechanisms they used to make these arrangements work.
Transition to the new health system
This theme documents participants’ initial experiences of the transition process and how they sought to understand, adapt and make sense of organisational and individual responsibilities for delivering the immunisation programme within a new health structure.
Fragmentation in the delivery of the immunisation programme
Rhetorical devices like "in the old world", "in the PCT world", and now "in the new world" were used by many interviewees to describe the transition to a different health system, and convey the extent of change that had occurred in the organisation of the immunisation programme. The reallocation of immunisation functions across new or reformed organisations was viewed as having fragmented the delivery of the immunisation programme.
“Since April last year (2013), this system of immunisations is fractured; it really is fractured. So, you’ve got Public Health England, and the Department of Health and the JCVI creating the strategy or policy; you’ve got NHS England commissioners … trying to implement, and then at the side of that you’ve got local authority colleagues holding us to account for assurance purposes … Three organisations are trying to inspire general practice or primary care, or providers, to jab more. It’s a complex mesh, so it’s trying to hold that mesh together, at the moment.” (NHS England, 59)
Interviewees reported that immunisation, as a public health programme, did not slot neatly into the new health structure. To quote a national stakeholder, (19) it was “the bit that didn’t fit.” According to participants, it took a significant amount of deliberation to decide a way forward. These decisions included retaining responsibility for immunisation within the NHS, even though the 2012 HSCA had delegated the management of public health programmes to local government, and embedded PHE-led screening and immunisation teams within local NHS England commissioning bodies. These teams in turn had to develop effective working relationships with partners in LA Public Health Teams, CCGs, and PHE Health Protection Teams in order to make sense of the new delivery arrangements for immunisation. This dispersal of responsibilities across multiple organisations raised questions about: “who’s got that overarching leadership and accountability.” (LA Public Health Team, 44)
Whilst changes to the provider landscape were viewed as having created opportunities for testing new ways of delivering certain programmes, they also resulted in some schools having to host different immunisation providers for different school age vaccination programmes (e.g. school leaver boosters, cervical cancer, flu). One commissioning manager (SIT, 48) described changes to the provider landscape as “a second level of fragmentation”, and highlighted the risks fragmentation posed to effective communication with parents and schools, and between partners in the management of contracts and data.
According to those involved in managing and assuring the quality of the immunisation programme, this kind of complexity required them to “work very hard to pull it [the system] back together” (LA Public Health Team, 28), and streamline processes within and across organisations in order to “bring them together somehow.” (SIT, 48).
Redeployment and shifts in working practice
The implementation of the health reforms resulted in a significant movement of human resources in terms of teams, organisations or individuals. For some this involved a loss of independence, a change in contract and working culture, and a move from a technical to a more political role. For example, Directors of Public Health (DPH) were removed from PCTs and tasked with establishing public health teams within the much more political arena of local authorities. This required them to negotiate public health priorities and funding decisions with elected council members whose primary business is not health. In terms of contracts, staff who transferred from the Health Protection Agency to PHE became civil servants (albeit in most cases on NHS terms and conditions), which was reported to have had wide ranging repercussions, including increased scrutiny of publications and reduced freedom to question national government policy decisions. Reflecting on this cultural shift, one participant felt that PHE had become an “upward facing, not outward facing” organisation with different priorities:
“…having to answer Parliamentary questions, and briefing Ministers, and it’s…because we’re civil servants, that’s seen as a bigger priority than supporting the frontline, which is a huge cultural shift that I don’t feel comfortable with, because I see my job as supporting the frontline, because I want children to be vaccinated.” (National interviewee, 4)
Interviewees’ experience of staff redeployment was shaped by where they moved to, whether they moved with a team or alone, and how much their role changed. Moving from DH into PHE as part of the immunisation implementation team was described as disruptive but manageable. Moving to NHS England was experienced as more challenging since this new organisation had to rapidly assume responsibility for commissioning the delivery of Section 7a programmes. Moving from an active role in immunisation activities in PCTs to more indirect support in local authorities required individuals to acquire new skills in assurance and relinquish valued hands-on duties, such as implementing projects aimed at increasing the uptake of immunisation in vulnerable populations. Moving from PCT immunisation teams to SITs was described as less challenging since the work was similar, albeit on a wider scale, with new commissioning responsibilities, and less "hands on" capacity for interacting with immunisation providers.
When describing the process of redeployment at local level, interviewees talked about being “slotted and matched”, or “shifted and lifted”. For some, this involved competing for positions that suited their skills, for others a straightforward transfer occurred, and a few people ended up being put at risk or made redundant since an equivalent role could not be identified. For SIT leads, key challenges were finding staff with skills and experience in immunisation, screening and commissioning, and “developing a team, that is embedded within NHS England employed by Public Health England, and that ultimately don’t feel like they belong in either” (SIT, 65) A significant consequence of the redeployment was the removal of budgets and decision-making from local players to regional ones and a loss of local knowledge (the historical memory gained from working in an area for a long time and the relationships built over time between providers and service managers), insights into underperforming areas and practices, and the understanding of contextual factors that affected the uptake of immunisations. In one LA, a DPH sought to mitigate this loss by assigning a former PCT immunisation coordinator the responsibility for "keeping an eye on what was going on with immunisation and keeping a steady ship" (Provider & LA Public Health Team, 69).
Adapting to the new infrastructure
Adapting to the new modus operandi for immunisation required people to revise previous patterns of working, adopt new roles and responsibilities, acquire new skills and make new connections. Many interviewees found it difficult to establish new working rhythms and commented on how long it had taken for the system to settle.
“We’ve been here nearly two years and it just about feels we’re beginning to manage it appropriately.” (SIT, 23)
A couple of years in, many interviewees were still grieving for their old jobs, particularly if their redeployment had resulted in a loss of autonomy, or left them less able to improve practice or influence policy.
“We had far more autonomy and far more responsibility and it was great. It was a really satisfying job actually and it was great to feel that you’d managed to get those figures, those rates up in that specific area.” (SIT, 41)
One participant (LA Public Health Team) also suggested that the effort expended in adapting to the new system obscured opportunities for improved practice, and made people more reticent about ongoing structural changes (e.g. CCG ‘co-commissioning’ of primary care). Mechanisms for coping with the change included establishing contact with past immunisation colleagues who had moved to different organisations and building informal relations alongside official channels in order to establish the partnerships, which were perceived by participants as core to the management of the new system. From a provider’s perspective, it meant turning to the people who used to provide advice even if this was no longer in their remit.
Applying the new arrangements for immunisation
This theme documents participants’ experiences of learning to implement the new arrangements for the immunisation programme in a more complex health infrastructure.
Tripartite working at national level
One of the most significant changes at national level was the introduction of tripartite working. Immunisation was no longer solely led by DH, instead accountabilities were shared with NHS England and PHE. This required national leaders to develop a completely different way of working: whereas previously policies had been agreed and executed by one organisation in a ‘command and control style’, they were now reviewed by partners who provided detailed input on implications for implementation and commissioning. Although the new governance arrangements made rapid responses to public health contingencies more challenging, annual revisions of Section 7a agreements were viewed by some as having helped national partners make sense of tripartite immunisation planning and cross-organisational collaboration.
“We’ve got strong governance arrangements in place to support the delivery of the 7a agreement that locks everybody into a way of working that ensures we work collaboratively together in a strategic way.…The Section 7a agreement forces you to have a proper strategic conversation with the NHS… whereas that didn’t really happen.” (National interviewee, 8)
Despite the emphasis placed on joint responsibility, questions arose about how to manage mutual accountabilities. Diverse opinions were tendered about which organisation wielded greatest influence, with some attributing greater command to DH, as the delegating authority, and others to NHS England, because of its responsibility for the assigned budget. The process of clearing and checking each other’s contributions to official correspondence was mentioned as an example of difficulties encountered in balancing power and exercising trust in tripartite relationships.
“Under tripartite working all three organisations have equal rights to change the letter…so that would delay things…and the kind of “I must be the last to sign this off” syndrome is very much existing in all three organisations.” (National interviewee, 15).
Applying the local operating model for immunisation
The application of operational guidance for the immunisation programme at local level was not straightforward, according to a wide range of interviewees. The dispersal of duties and the creation of new teams and roles resulted in a lack of clarity and varying interpretations as to who was responsible for what, and how the system should be implemented collaboratively.
“There was a lack of clarity about what do these new roles actually mean … Okay, we can say, well, ours is the assurance role and the area team commissions, but actually in terms of divvying up the tasks, what does that mean, who does what, how does it come together and make a whole?” (LA Public health team, 27)
“… there’s an operating framework, there’s job descriptions and, as I said, I think it’s absolutely clear within that what we’re supposed to be doing, but people are not working in those ways and I think there’s different interpretations.” (SIT, 65)
The management of vaccine preventable disease outbreaks was cited as an example of where there was a lack of clarity about responsibilities; i.e. who should lead the response, who should be mobilised to immunise or provide chemoprophylaxis, and who should cover the costs. Similarly, the existence of different organisational reporting procedures was viewed as having complicated the management of incidents such as errors in the administration of vaccines or failures in cold chain storage.
LA Public Health Teams found discharging assurance responsibilities challenging due to limited access to data and a lack of operational involvement in the immunisation programme, including an inability to take part in outreach to under-vaccinated local populations. They also had to ensure that any immunisation support they provided to CCGs, as part of their core public health function/intelligence work, did not overlap with SITs work.
SITs, which had been envisioned as a public health resource within NHS England ATs, reported that they were less able to apply their clinical expertise and were more focussed on commissioning and logistics.
“I think they saw us as just extensions of their commissioning team, and I felt that my professional role was being dumbed down from band 7 clinical specialist to band 4 admin assistant, because the, I think, the feeling in NHS England was as long as there’s a contract, everything’s good.” (SIT, 18)
SITs increased ‘footprint’ (the term used by participants to denote their geographical areas of responsibility), and difficulties in recruiting and retaining appropriately qualified staff had limited their ability to support immunisation providers. Consequently, they were not confident about understanding provider performance, and thus less able to monitor and reinforce good practice.
“…we are trying to solve issues that we don’t fully understand because we don’t actually have the resource to go out there and do the investigative work that is required. So we are, in a way, working blindly.” (SIT, 40)
On the other hand, SITs larger ‘footprint’ was thought to have supported a more equitable distribution of resources and strengthened commissioning processes by introducing a more consistent approach across larger geographical areas. Several SIT members also stated that the broader “helicopter” or “pan area” view enabled them to identify and share good practice across localities facing similar problems.
Although their role had been less affected by the changes, immunisation providers generally found it difficult to access advice, support and training in the new system, and many were unclear about the differences between SITs and LA PH teams. Providers of school-based immunisation programmes were more affected by the changes since they now had to tender for contracts. Decisions regarding tenders were usually made by LAs but NHS England commissioners could also be consulted, and this led some community providers to feel less able to discuss operational problems openly with SITs.
Reflecting on his experience of working in the new system, an interviewee from a LA Public Health Team (66) described how “everyone feels very insular in all sorts of ways”; each organisation attended to its own responsibilities, which could be positive, but in the absence of effective collaborative processes, this could also increase the potential for “territorial silo issues” and “friction”.
Regrouping and making the new arrangements work
This theme describes what participants did in order to be able to deliver the immunisation programme in the new more complex health care system and take any opportunities presented by the new system.
Working in partnership: “To join up different bits of the system”
Interviewees underscored the need to build effective collaborative processes and strong relationships to make the national framework and local operating model work tolerably well. Establishing and maintaining partnership working reportedly required significant time, effort and creativity but it also increased programme accountability and created opportunities for sharing good practice and troubleshooting. Some mechanisms for partnership working were set up as part of the implementation of the HSCA in April 2013, others were developed more iteratively. Examples of the former were the National Immunisation Programme Board (IPB) and LA Health Protection Forums. These governance structures proved useful for supporting strategic collaboration, but often needed to be complemented by more operational committees, for example, a newly formed national implementation group.
“The Health Protection Forum wants to make its priorities things that it can do together, so the whole point is that different people are responsible for different bits of the system now, and there is some fragmentation. But obviously there are lots of areas that we all need to work together on, so that forum is a way strategically of joining up some of those dots.” (LA Public Health Team, 28)
Whilst Health Protection Forums were recognised by local participants as a core mechanism for partnership working, they were not the only means used to foster multi-agency collaboration in improving local immunisation outcomes. At Site 1 (see Table 2), regular strategic meetings between senior SIT members and LA DPHs were organised, and four pre-existing immunisation committees re-appointed. SIT and LA public health leads felt the latter had provided opportunities to commence constructive conversations, and a community provider valued the transparency and joint problem solving they facilitated. However, difficulties were reported in achieving CCG and general practice committee representation.
“I think we’re struggling to make the collaboration work, because we’ve been finding our feet, the local authorities have been finding their feet and the CCGs are also doing it, so I do not think that we’ve got it right. We’ve made progress, we have conversations. I think now that we begin to understand a bit more about where we’re going, we can have better conversations.” (SIT, 23)
At site 2, the SIT established an immunisation board with senior representation from NHS England, CCGs, PHE health protection teams, academia, pharmacy, LA Public Health Teams and NHS Trusts. A local partnership component was added in 2015, with each LA area asked to agree an action plan for improving immunisation coverage. Initial experience indicated that this worked best in areas where there were existing local immunisation groups (carried over from pre 2013), or where immunisation was a standing item at Health Protection Forums. Other local areas were more resistant about accepting responsibility for leading plans and owning actions, and some expected a separate budget to underpin this work.
“But it’s, from the perception I get from some local authorities, it’s like it’s your responsibility NHS England, what are you doing about it? But we can’t be out there on the ground because that’s not our role. Our role is as commissioners, we’re contracting, we’re providing service providers to do it. We’re working in partnership with you. So it’s all our roles to ensure this happens.” (SIT, 73)
At Site 3, Health Protection Forums were cited as the main means of promoting partnership working across the AT. In addition, SIT members attended flu vaccine provider meetings run by CCGs and were asked to support a pre-existing district immunisation committee run by a paediatrician and a practice nurse. A new committee involving different CCGs and LAs was also planned to help reverse historically low immunisation uptake rates in one area.
National and local level interviewees agreed that the success of the immunisation programme hinged on developing strong working relationships with key individuals based in different organisations. This was challenging for SITs which covered a large number of LAs and CCGs, and difficult for national partners who had limited opportunities to meet in person and who communicated mainly by email or phone. The importance of face to face workshops as a means of nurturing trust “… building the sort of confidence and individual relationships up which I think is very important to any of this’ (National interviewee, 12) was highlighted, and partnership skills training identified as an important workforce development programme.
“I think for a future workforce it is really about bearing in mind that partnership working is part of someone’s job description…being able to have that knowledge of tapping into those different structures and things. I think that is a core skill… to promote the uptake of immunisation.” (LA PHT, 27)
Building on opportunities and addressing gaps
Professionally led SITs embedded within NHS England ATs were considered to be an important resource and potential strength of the new system. National leaders have supported them by running fortnightly teleconferences and six monthly meetings for team leads. SITs dual accountability to PHE and NHS England was however also viewed as having contributed to difficulties in defining their role, and achieving the right balance between commissioning and supporting providers. This lack of definition was maintained to have resulted in a huge variation in the way SITs operate. Many SITs had also been functioning below capacity due to staff attrition and problems in attracting professionals with the right skill sets to civil service posts. This lack of capacity and SITs increased footprint has had a knock-on effect on SITs ability to respond to local needs and performance manage immunisation providers. NHS England has sought to address the latter by providing SITs with real time immunisation uptake statistics via a data management system, and data sharing agreements have also been developed to enable LA Public health teams fulfil their assurance responsibilities. The following mitigating strategies were also observed at local level: 1) at Site 3, a CCG had allocated funding to immunisation as a priority area and established an influenza immunisation service for nursing home residents; 2) at all sites, the LA Public Health Team linked SITs with schools and community based children’s centres (tailored services for families with children ≤5), and 3) at Site 3, the SIT had enlisted the support of CCG quality improvement staff to enhance provider performance and a CCG had independently appointed an infection control nurse to assess the quality and uptake of immunisation services in GP surgeries. These local strategies, though well intentioned, tended to be informal and in the case of the last, was short lived since funding constraints meant that the role was not sustained.
The ad hoc manner in which problems tended to be resolved was even more apparent in relation to the provision of training for immunisation providers. The local operating model was not clear about the role SITs should play in helping health care professionals and their employers ensure that they had been trained in accordance with the mandatory requirements.
“…what does facilitate mean? It doesn’t say who’s actually responsible. So yes, the SIT could be responsible for facilitating training, but that doesn’t necessarily mean to say they’ve got to do it.” (National interviewee, 18)
Sites adopted different approaches to fill this gap. At Site 1, CCGs and the SIT lobbied local universities to provide essential skills courses for practice nurses that would cover immunisation, and CCG practice nurse leads either secured internal funding, or bid for Local Education Training Board funds to be able to conduct immunisation training at protected learning events. At Site 2, the SIT commissioned health care academics to provide introductory courses and the health protection team were starting to provide updates, while at Site 3, practice nurses had set up monthly training sessions which were supported by their CCG and a management company. There was recognition that, whilst these initiatives helped fill critical gaps, it might not be possible to replicate them elsewhere.
“…there is huge inconsistency about [training] provision, including no provision, and there is a lack of clarity and a lack of understanding about who should be providing it, who should be commissioning it and who should be funding it.” (National interviewee, 18)
Concerns about inconsistencies in the delivery of the immunisation programme were raised by many interviewees. In addition to clarifying roles and functions and strengthening governance processes, a few interviewees suggested that a redistribution of roles might be necessary. For instance, a national interviewee argued for a strengthened role for CCGs to use their position as local peer leaders to oversee and encourage improved uptake. Aversion to further change however dampened local implementers’ responses to these types of suggestions.