Published 4 January 2021
The Covid-19 vaccination enhanced service launched in December 2020 is subject to amendment as the programme is developed. Below is a summary of the key details. Latest update: 25 February 2021
NHS England agreed the initial specification for the general practice Covid-19 vaccination service, to be nationally commissioned as an enhanced service (ES), on 4 December 2020.
Practices are being asked to work collaboratively to deliver vaccinations, because of challenging vaccine characteristics and complex logistics in the supply chain. More specifically, they have to collaborate with neighbouring practices and established primary care networks (PCNs) in a ‘PCN Grouping’ to deliver the ES. This applies to all practices that participate, whether they are members of an established PCN or not.
The ES began on 8 December 2020 and is set to continue until 31 August 2021 (unless it is terminated by the commissioner, or the GP practice withdraws, before that date).
The ES is subject to amendment over time, as the Covid-19 vaccination programme develops. This may include amendments to eligible cohorts and prioritisation of cohorts of patients, and ongoing adaption of the requirements. NHS England is sending out regular letters and bulletins updating the specific requirements for vaccine supply delivery and storage, as well as administration.
The ES specification was updated on 7 January and subsequently NHS England announced on 24 February that further updates have been made to the Enhanced Service – see Version 4 of the specification here.
Changes from 24 February expanded the circumstances in which a PCN grouping can vaccinate eligible patients registered with other practices/another PCN grouping. This means a PCN grouping can vaccinate patients registered with another PCN grouping in a residential setting, eg, care homes for patients with a learning disability.
To reflect the additional supplements for vaccinations in care homes and other residential settings (see Payment section below) the updated specification also makes provision for these additional discretionary payments available to GP practices – which are ‘to support the delivery of or to incentivise vaccinations to under-represented groups in exceptional circumstances’.
Payment for vaccination administration
Practices will be paid £12.58 per dose of vaccine administered. (The IoS fee of £12.58 is 25% more than usual, to cover extra requirements, including training, the need for post-vaccine observation and any associated costs thereafter.)
The two vaccines currently in use – the Pfizer/BioNTech mRNA vaccine and the Oxford/AstraZeneca adenoviral vaccine – are given as a course of two doses. In an update to the vaccination programme announced on 30 December, practices were advised to vaccinate as many at-risk people as possible with their first dose of vaccine, with the second dose to be scheduled within 12 weeks (instead of 3-4 weeks as originally planned).
In light of this, practices are being paid £12.58 after each dose (rather than receiving £25.16 only after the second dose is completed, as originally agreed).
A primary care bulletin emailed to practices on 30 December stated: ‘To recognise that a delayed second dose will also delay payment to an unreasonable extent under the terms of the current Enhanced Service, we will agree with the British Medical Association (BMA) an amendment to offer payment for each dose instead. We are exploring ways to support rebooking of this cohort, recognising the complexity.’
Payment to support rebooking second doses
An NHS England letter dated 31 December outlined support for PCN groupings to rebook appointments where needed to postpone second doses from 4 January onwards, including payment of £1,000 to PCNs.
NHS England is providing the extra support to rebook the second dose appointments, following its advice to cancel appointments already made for patients to have their second Pfizer/BioNTech vaccine dose within three weeks, so that more people can receive the first dose sooner.
A system letter published on 30 December stated: ‘For those who have received their first dose and are scheduled to receive their second after Monday 4 January, the second dose appointment should be rescheduled in most instances (with clinical discretion applied locally if needed) for between three (Pfizer BioNtech vaccine) and four (Oxford/AstraZeneca vaccine) and 12 weeks’ time, with most recipients to be booked in the last week of that 12 week period. For those scheduled to receive their first vaccination from tomorrow (31 December), an appointment to receive the second dose should be scheduled for between three (Pfizer BioNtech vaccine) and four (Oxford/AstraZeneca vaccine) and 12 weeks’ time, with most recipients to be booked in the last week of that 12 week period.’
The BMA advised practices it would back them if they decided to honour existing appointments for patients to receive their second dose, rather than rebook them. In addition, the Government minister responsible for the vaccination programme roll-out confirmed practices could use their discretion based on local circumstances as to whether to rebook appointments.
However, in a letter dated 11 January, NHS England instructed PCN practice groupings to ensure all second dose appointments are rebooked, and to ensure administration in week 12 after the first dose.
The letter stated: ‘All vaccination sites must with immediate effect, ensure all second dose appointments that have not already been rescheduled must be rearranged.
‘This means all appointments to receive the second dose must be rescheduled, with recipients to be booked in for a second dose in the 12th week.’
For PCN groupings rebooking appointments, support available included:
Additional payment for vaccinating in care homes
Practices will receive a supplementary payment for each vaccine dose administered in care homes as follows:
NHS England announced the £10 supplement intially in an email bulletin on 23 December, in recognition of ‘the additional time and resources needed to deliver this complex vaccine in a care home setting, especially at such a busy time of the year’.
In a subsequent letter on 13 January, NHS England announced it expected all PCN local vaccination services to administer the first dose of the COVID-19 vaccine to care home residents and staff in older adult care homes ‘by the end of this week wherever possible and, at the latest, by the end of next week (Sunday 24th January)’.
The letter added: ‘To ensure the fastest possible coverage of care homes, first doses delivered in a care home setting from 14 December 2020 to close Sunday 17 January will now carry an enhanced additional payment of £30 instead, and doses delivered in the week beginning 18 January a payment of £20.’
Additional payment for home visits to vaccinate housebound
NHS England announced on 4 February that practices would receive an extra £10 supplementary payment for each home visit made to vaccinate housebound patients, backdated to all visits from mid-December onwards.
This supplement is on top of the £12.58 Item of Service fee. If a housebound patient is vaccinated at the same time as vaccinating other members of the household, only one £10 supplement per visit can be claimed.
The £10 supplement applies retrospectively to any first dose vaccinations in the housebound that have taken place since 14 December 2020, and will also apply to second dose vaccinations that take place in line with these arrangements.
The Pinnacle system is to be updated to allow staff to record when patients are being vaccinated at home to trigger the additional payments.
However, vaccinations that have already been administered are already being processed and further guidance will be provided on how to make retrospective claims. See more details here.
Additional payment for vaccinating in residential settings
In a letter dated 13 February 2021, NHS England advised there will be a £10 supplementary payment for vaccinating in residential settings.
The letter stated that PCN groupings will be able to claim an additional supplement of £10 for each vaccination administered to eligible residents and staff in these settings, on top of the £12.58 Item of Service fee.
The payment will apply where vaccination has to be delivered in residential settings such as care homes for people with learning disabilities or mental health problems, or hostel/hotel accommodation for the homeless, where it would not be possible for these patients to attend vaccination sites.
NHS England said guidance on how to submit claims would be published shortly on the FutureNHS workspace.
The Pinnacle/Outcomes4Health Point of Care System will be updated to include an additional field relating to the collection of data to support payment of the £10 residential settings supplement.
Any vaccinations recorded as ‘Long-stay care home or long-stay residential facility’ will automatically flow to the NHS Business Services Authority to support the payment of the £10 supplement alongside the Item of Service fee.
GP practices must nominate a host GP practice for the PCN Grouping which will receive payments due under the ES for and on behalf of the GP practice. See here for more details on how the payments will be generated.
There is no other funding specifically for delivery of vaccinations under the ES. However, NHS England has set aside £20m to fund additional off-site venue hire and related set-up costs where required. It also said it would ‘take action to ensure appropriate cash flow to practices’ to help cover costs incurred before receipt of the first payment, in light of the fact that payment is made following the administration of the second dose. More details on those commitments in this letter.
NHS England has also announced £150m funding to support practices to keep up other work. The £150m general practice Covid fund will run from now until March to keep normal services running. It will be up to CCGs and ICSs to decide how this money is used, but they have been given suggestions including hiring pools of extra salaried GPs.
Accessing the fund is conditional on practices continuing to complete national appointment and workforce data in line with existing contractual requirements.
It is also to be used to:
The two vaccines currently in use are the Pfizer/BioNTech mRNA vaccine and the Oxford/AstraZeneca adenoviral vaccine.
Pfizer/BioNTech mRNA vaccine
Storage and handling
The Pfizer/BioNTech mRNA vaccine requires long-term storage at -70 degrees C and has a limited ‘shelf-life’ at fridge temperature. NHS England’s specifications require GP practice groupings to have refrigeration to store vaccinations at 2-8 degrees C and to have capacity to administer a minimum of 975 doses per week.
In a letter sent to practices on Monday 7 December, NHS England advised that the first sites would receive their initial vaccine delivery of 975 doses from the following week. Vaccine-related consumables (eg, syringes, diluents) and post-vaccination record cards will be delivered together with the vaccine.
Vaccines need to be used quickly in the days following delivery, with the remaining vaccine shelf life once delivered and stored at 2-8°C in the range of 86 hours (3 days 14 hours) to 99 hours (4 days 3 hours).
The NHS Specialist Pharmacy Service has published a number of guides and aide memoires regarding vaccine storage, handling and disposal – including how to document any wasted vaccine. See here for more info.
NHS England has advised that healthcare staff must aim to secure five full 0.3ml doses of this Pfizer-BioNTech COVID vaccine in line with manufacturer instructions and as outlined in Information for Healthcare Professionals. After this there may be potential for a sixth full dose, due to variances in fill volume and the syringe/needle hold up volume combinations used. Where a full 0.3 mL dose cannot be extracted, the contents should be discarded.
NHS England also advises, as outlined in the regularly updated Standard Operating Procedure (SOP), that GP practices must allow for a 15-minute post-observation period with the Pfizer/BioNTech vaccine, and that all vaccination sites must have one healthcare professional trained in anaphylaxis, cardiopulmonary resuscitation and use of an automated defibrillator. This follows the UK Medicines and Healthcare products Regulatory Agency (MHRA) advice following reports of anaphylactic responses in the initial wave of vaccinations. The MHRA initially advised that patients with a history of significant allergy should not be given the Pfizer/BioNTech vaccine, but an update to the SOP on 6 January stated that individuals with a history of anaphylaxis to food, an identified drug or vaccine, or an insect sting can receive any COVID-19 vaccine, as long as they are not known to be allergic to any component (excipient) of the vaccine. In addition, anyone who experiences an urticarial reaction to the first dose can have the second but must be observed for a prolonged 30-minute period.
NHS England has said all designated sites will be provided with resuscitation equipment and medications. PHE has included resuscitation training within Covid-19 vaccination programme training resources.
Patient Group Direction/Patient Specific Direction
The Patient Group Direction (PGD) for the Pfizer/BioNTech vaccine is available here. Clinicians who can administer the vaccine under the PGD include: nurses and midwives; pharmacists; chiropodists/podiatrists; dieticians; occupational therapists; orthoptists; orthotists/prosthetists; paramedics; physiotherapists.
NHS England has advised that GPs can supply prescription only medicines without prescriptions and administer injectables without directions (Human Medicines Regulations reg.214(1) and (2)(a)) so they do not need a Patient Specific Direction (PSD) or another type of direction written or otherwise, as long as the GP is carrying out the whole process of clinical assessment, consent and administration. A clinical record of this should be made (in this case on the Pinnacle system) as normal. If tasks are being split with a different healthcare professional carrying out the clinical assessment and then the GP administering the vaccine, then this would require a written PSD to be in place to cover the other healthcare professional or trained member of staff administering the vaccine. With a PGD, the clinical assessment cannot be split from the administration so both must be done by the same healthcare professional authorised to work under the PGD.
Practices can order Pfizer/BioNTech vaccines for use in care homes, as follows, as outlined in Annex D of the SOP:
The Oxford/AstraZeneca vaccine received approval from the MHRA on 30 December. At that time the Government announced that vaccinations with the Pfizer/BioNTech vaccine will continue as the Oxford/AstraZeneca is also rolled out.
A JCVI statement says that with the Oxford/AstraZeneca vaccine, the second dose can be offered 4 to 12 weeks after the first dose.
Storage and handling
The Oxford/AstraZeneca vaccine is expected to be delivered more easily via GP practices, as it can be stored at normal fridge temperature. The SOP published 4 January explained that the vaccine is supplied in packs of 10 vials, each vial containing 8 or 10 doses of the vaccine. The unopened multidose vial can be stored in the fridge (2- 8 degrees C) with a shelf life of 6 months.
A letter on 7 January confirmed that the vaccine can be moved around individual practices, as well as to care homes and to housebound patients, provided the cold chain is maintained; however, it stated that no further transport is permitted once the first dose has been removed from a vial and no opened vial can be returned to stock. A subsequent position statement on 14 January has now modified that advice so that an opened vial can be moved for vaccination of housebound patients, provided the vial is used within 6 hours and certain infection control measures are adhered to.
Advice on storage and handling of the new vaccine is published by the NHS Specialist Pharmacy Service here.
Patient group direction
The PGD for the vaccine is available here. This states that the vaccine comes in 10-dose vials of 5ml or 8-dose vials of 4ml. Each vial may contain an additional dose – the PGD states: ‘Each vial contains at least the number of doses stated. It is normal for liquid to remain in the vial after withdrawing the final dose. When low dead volume syringes and/or needles are used, the amount remaining in the vial may be sufficient for an additional dose.’
Importantly the SOP states that there is no need for the 15-minute post-vaccination observation period with the Oxford vaccination, unless this is indicated after clinical assessment.
Interchangeable use of vaccines
Of note, previous Public Health England guidance advised that the two Covid vaccines could be used interchangeably if a patient attends for their second dose but the same vaccine is not available. However, it also emphasises that there is no evidence for this yet (although studies are underway) so every effort should be made to determine which vaccine the individual received and to complete with the same vaccine.
Co-administration of flu vaccination
NHS England highlighted in a bulletin to primary care that the Green book has confirmed co-administration of a Covid vaccine and flu vaccine is ‘acceptable’ .
The bulletin stated: ‘During national lockdown, it remains very important that people continue to access essential services including vaccinations for babies, children and pregnant women as they are time critical and prevents serious illness and outbreaks. Please continue your efforts to invite and vaccinate as per the routine immunisation schedule. To use appointments efficiently, for adults who have not yet had their flu vaccination and are currently eligible for COVID vaccination, scheduling for both vaccinations to occur at the same visit is acceptable, as per the green book.’
Vaccinations are to be delivered at around 1,000-1,500 nominated GP practice sites (roughly one site per PCN, depending on size). Practices who are not part of a PCN will also be able to sign up in collaboration with their local PCN.
Each PCN grouping has to nominate a single site as a vaccination centre.
Some additional sites may be designated as vaccination centres later in the process.
NHS England initially announced that the vaccinations will need to be carried out with existing staff. However, it said that the additional £150m Covid capacity expansion fund can be used to help extend the hours of salaried staff and to attract people back into general practice.
It has since promised free extra staffing for PCN groupings vaccinating in care homes. A letter to regional directors of workforce said PCNs will not have to pay for additional staff deployed to deliver care home vaccinations, which will be covered by their ‘normal employer’ and then reimbursed.
Registered healthcare professionals will need to carry out the clinical assessment, consent and preparation of the vaccine. However, the vaccine itself can be administered by a suitably trained non-registered staff member – under the clinical supervision of a registered healthcare professional.
The RCGP has produced guidance for PCN groupings on recruiting staff to manage Covid vaccinations, including contractual, legal, training and indemnity requirements as well as resources.
Vaccination clinics are expected to be staffed from 8 til 8, seven days a week, including bank holidays, where needed.
Practices will need to oversee and keep a record confirming all staff have undertaken training prior to vaccination.
Patients eligible to receive the vaccination in general practice and the cohorts will change in line with JCVI recommendations. GP practices are required to keep up to date with these criteria which will change from time to time and will be notified by NHS England of amendments through the Primary Care Bulletin.
The JCVI currently recommends the following order of priority for the full programme:
*The JCVI has advised that pregnant women, and women who are breastfeeding, who are at high risk of exposure or clinically vulnerable to Covid-19 should be offered vaccination.
The Green Book chapter on COVID-19 is also regularly updated, including on which patients can be offered the vaccine. Regarding children aged 12-16 years on the clinically extremely vulnerable (CEV) shielding list, it explains that ‘vaccination may be considered for children with severe neuro-disabilities who tend to get recurrent respiratory tract infections and who frequently spend time in specialised residential care settings for children with complex needs’. Confirmation has been added that the Oxford/AstraZeneca vaccine is authorised for those over 18 and the Pfizer/BioNTech vaccine for those over 16 years of age. Any vaccination for a patient aged less than 16 requires the authorisation of a prescriber, almost always a doctor. The Patient Group Direction or National Protocol cannot be used.
Vaccination roll-out schedule: JCVI categories one to four
The Government initially set out the aim to have the top four JCVI categories to be vaccinated by 15 February and for all groups to be vaccinated by the autumn.
Practices were initially told to start vaccinating ‘all those 80 years of age and over’ (excluding the housebound). The JCVI also advised vaccination of frontline healthcare workers, prioritising those at highest risk, alongside those 80 years and over.
From 21 December, PCN groupings were also asked to start rolling out the vaccine to their care home staff and residents. Guidance on Covid vaccination in care homes that have cases and outbreaks of Covid was subsequently published at the end of December here.
The Government announced vaccines were to be rolled out to people aged 70 and over and to the clinically extremely vulnerable from 18 January.
Vaccination roll-out schedule: JCVI categories five and six
NHS England advised PCN groupings on 13 February to prepare to vaccinate cohort six (people aged 16-64 years at higher clinical risk) over the next two weeks (ie, the weeks commencing 15 and 22 February).
This cohort includes carers and young adults in residential settings.
The letter also stated that ‘those aged 65-69 are separately being invited to attend Vaccination Centres,’ but added: ‘If you have patients in that age group who fall into one of the categories above, you may also invite them to attend an appointment at the LVS.’
The letter highlighted that the JCVI recommendations place those with severe and profound learning disability in cohort 6. It said GPs should use GP Learning Disability Registers and SNOMED codes to help identify this group, but that they should also use ‘clinical discretion to ensure the right people who meet the severe and profound learning disability definition are on the register.’
The JCVI subsequently advised the government on 24 February that all patients on the GP Learning Disability Register should be vaccinated as part of priority group 6.
(As GP systems may not always capture the severity of someone’s disability, JCVI supports the plan to invite anyone on the GP Learning Disability Register – as well as adults with other related conditions, including cerebral palsy – for vaccination as part of priority group 6.)
NHS England requested practices use the following accessible resources (produced in collaboration with people with lived experience) to support communication about vaccination appointments with people with a learning disability and their family carers:
The letter of 13 February also explained that those with schizophrenia or bipolar disorder, or any mental illness that causes severe functional fall within cohort 6.
The JCVI green book defines SMI as: schizophrenia or bipolar disorder, or any mental illness that causes severe functional impairment. NHS England advised that PCNs should work collaboratively with secondary care services and local VCSE organisations to ensure that all people with SMI can access their COVID-19 vaccination including people with an eating disorder and those with a diagnosis of ‘personality disorder’.
Tailored invitation letters for vaccination sites to use to invite people with SMI to their Covid-19 vaccination are available on the FutureNHS platform.
A separate letter on 16 February announced an additional 1.7 million people would be added to the shielded patient list (SPL) after being identified as at high risk with the QCovid algorithm, some 800,000 of whom will need prioritising for vaccination by GPs. Those aged 16-69 will be added to the list and invited first, followed by the over-70s as they have already been offered the vaccine.
Following concerns from GPs that many patients with a history of gestational diabetes were being captured by QCovid, NHS Digital updated their guidance to support clinicians on advice to patients with previous gestational diabetes newly advised to shield. This is supported by a gestational diabetes flowchart developed by the RCGP.
Further vaccination roll-out details
From 3 February, people aged 18 and over in the clinically extremely vulnerable cohort were to be sent letters from the national call/recall service inviting them to book their COVID-19 vaccine at a vaccination centre or community pharmacy. The letters make it clear they have a choice of where to get vaccinated and can choose to wait for their GP services to contact them directly, if they haven’t already. A copy of the letter and a PCN letter template is available in the latest letters pack on FutureNHS.
In mid-January GPs were advised they could give the vaccine to people outside the top four cohorts, where necessary to avoid vaccine wastage. A bulletin to practices on 19 January stated: ‘In order to support achievement of a vaccination offer to all individuals within JCVI cohorts 1-4 by 15 February 2021, and guided by the principles of minimising wastage, reducing inequality of access, and maximising pace, we are now moving to a more flexible approach across cohorts 1-4.’
It added: ‘If there is vaccine supply and deployment capacity, but a degree of uncertainty on whether clinics will be full, further invitations can be made to individuals from the next eligible cohort (across cohorts 1-4) in order to utilise available supply.
‘Vaccination beyond the current cohorts (1-4) can be offered if there is a risk that current vaccine stock will become unviable if not used.’
However, it reiterated that only first doses should be given (as announced on 11 January – see ‘Payment’ section above): ‘In line with JCVI guidance and the statement from the Chief Medical Officers on second doses published on 30 December, vaccine supplied should only be used to deliver first doses of vaccine, with second doses being scheduled for the 12th week.’
Guidance published on 25 January, on mutual aid and transfer of vaccines between sites, gave the go ahead for Covid vaccine stocks to be moved between hubs in exceptional circumstances. However it stressed that such measures should not be the option of first resort, with vaccination sites expected to keep standby lists of the eligible JCVI priority cohorts applicable at the time, who can be called in at short notice to be vaccinated.
Patients will be sent a letter by the national call/recall service telling them they are eligible for vaccination and that they have a choice of where they can get their vaccine.
Meanwhile, PCN groupings will also be expected to contact patients eligible for vaccination, using nationally agreed wording.
Patients will be given the choice to book at a GP-led vaccination centre or use the national booking service to be vaccinated by another provider.
PCNs will be given the option to use the national booking service – or they can use their own appointment booking systems and schedule clinics in line with vaccine supply.
Currently there is no way of informing practices automatically when a patient books a vaccination with another provider via the national booking system, but this is being looked into further.
Practices will not be contractually obliged to offer call and recall for patient cohorts that they are unable to reliably identify from their records, eg, health and social care workers – but are encouraged to do so if they can identify them.
NHS England. Enhanced Service Specification: COVID-19 vaccination programme 2020/21. First published 4 December 2020
NHS England. Letter: COVID-19 vaccination – for immediate action. Published 30 December 2020
NHS England. Novel coronavirus (COVID-19) standard operating procedure: COVID-19 local vaccination services deployment in community settings.
Public Health England. COVID-19 vaccine guidance for health and social care workers. First published 27 November
Public Health England. COVID-19 vaccination programme: Information for healthcare practitioners. Published December 2020
Joint Committee on Vaccination and Immunisation: advice on priority groups for COVID-19 vaccination.
NHS Specialist Pharmacy Service. Covid-19 vaccines – including guidance on storage, handling, transfer and administraction of vaccine.
NHS England. Patient Group Direction for COVID-19 mRNA vaccine BNT162b2 (Pfizer/BioNTech). 11 December 2020
UK Government. Collection: Covid-19 vaccination programme. Includes: latest guidance documents; training resources; consent forms and letters; leaflets and posters; protocols and PGDs; programme documents.
NHS England: NHS England and NHS Improvement London » COVID-19 vaccine communication materials. Videos recorded by healthcare professionals in a range of community languages, offering advice on the safety and efficacy of Covid vaccines
Public Health England. Campaign Resource Centre. Includes printable leaflets on Covid-19 vaccination in different community languages.
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