Sample characteristics

The characteristics of the included practices are presented in Table 6. They have been labelled in order of practice list size from A to J, ranging from 4,600 to 20,000 registered patients. Four are in rural areas, three in areas with a mix of urban towns and suburban areas surrounding, and two are in London. The range of deprivation is represented with practice C being in the most deprived decile and practice E in the least deprived. In the practices with larger catchment areas, particularly in London, the ranked decile is an average of the local population, which is likely to have a mix of very wealthy and very deprived populations. There is similarly a range of ethnic diversity within the catchment populations, with the practices in London (G and J) having a very high proportion of minority ethnic groups in their population, as contrasted with practices A, D, E and H, with very low ethnic diversity. Of note, these figures do not account for migration status or use of English as a secondary language, which are important factors in health services access. The proportion of children aged 0 to 4 years old was relatively close to the England average, ranging from 3.3% in practice A to 7.7% in practice J, with higher proportions of younger children in the urban practices. The proportions of older people however varied more widely, from 10.4% in practice B and 11-12% in the London practices (G and J) to above 30% in the affluent rural practices D and A. In all but two practices (C and J), achievement of QOF points was higher than the England average, in some cases by quite some margin, with five practices scoring above 98% (A, B, D, E, H). This suggests that these practices are relatively well performing in terms of meeting targets. While the ‘friends and family test’ has been criticised as lacking validity (Manacorda et al., 2017), it is a routinely reported statistic pertaining to patients’ perception of health service quality that can provide an immediate and high-level comparison. Every

113 practice scores higher than average on the proportion of patients recommending the practice to friends and family, except F, which scores very low (56.6%).

To compare coverage, I have extracted results from Unify2 for DTP-IPV-Hib three doses by 12 and 24 months, MMR1 by 24 months and MMR2 by 5 years. To compare to ImmForm data I have

extracted the equivalent MMR2 by 5 years statistic, although this was not available for practice H. For adult vaccinations, only PPV coverage was available in an annual, comparable format from ImmForm and so this has been included as a proxy for adult vaccination coverage. Practices D and E have high coverage of both childhood and adult vaccines. Practice C has quite high childhood, although lower than average MMR2, and high adult coverage. Practice A has very high childhood, but average adult coverage, and B has average childhood and adult. Practice F has high 12 months coverage, but lower 5-year coverage and very low adult coverage (56.1%). Practice H, which is the large rural practice, has low childhood and low adult coverage. The two London practices (G and J) have very low childhood coverage (particularly G) and very low adult coverage (particularly J).

Overall the sample contains a selection of GP practices in a wide range of geographic and socio- economic contexts. However, there are some limitations to this sample. There are no very small practices included, nor any very large practices, and, overall, the practices appear to be relatively highly performing in terms of non-vaccination indicators. However, they do present a range of vaccine coverage profiles.

114 England Average A B C D E F G H J Region - East Midlands East of England Yorks & Humber

South West East Midlands

East of England

North East & Central London

South East South London

Urban/Rural status (a)

- Mainly rural Urban, city & town

Urban, city & town

Mainly rural Urban, city & town Largely rural Major conurbation Largely rural Major conurbation List size (b) 7,000 4,600 6,600 7,000 8,100 12,600 13,800 14,000 16,000 20,000 Demography Deprivation decile (b) - 8 2 1 8 10 7 4 6 4 Minority ethnic groups (%) (b) - 1.6 6.2 12.0 1.3 1.8 3.4 30.3 2.1 41.4 Aged 0-4 years (%) (b) 5.7 3.3 7.3 5.7 4.4 4.6 5.0 5.0 5.4 7.7 Aged 65+ years (%) (b) 17.3 31.6 10.4 13.6 30.4 23.6 21.5 11.3 18.9 11.8 Quality Indicators QOF Achievement (%) (b) 95.6 99.6 98.2 94.5 98.9 99.3 96.2 95.7 99.6 93.7 Patients recommending practice (%) (b) 77.4 95.3 78.4 81.4 89.3 84.4 56.6 87.8 83.1 85.9

Childhood Vaccination Coverage DTP-IPV-Hib 3 doses by 12 months (%) (c) 93.4 98.9 96.0 97.3 96.0 98.9 98.7 78.7 90.6 91.2 DTP-IPV-Hib 3 at 24 months (%) (c) 95.1 100.0 95.8 100.0 97.5 100.0 98.1 91.4 90.8 94.6 MMR 1 by 24 months (%) (c) 91.6 100.0 97.9 98.6 93.7 97.2 97.5 78.1 85.5 86.9

115 MMR 2 by 5 years (%) (c) 87.6 94.4 94.2 95.5 98.3 94.4 93.1 69.6 85.1 88.4 MMR 2 by 5 years (%) (d) 83.4 100.0 92.7 93.0 98.8 96.8 93.8 79.7 - 74.5

Adult Vaccination Coverage PPV (%)

2017-2018, 70- 74 (d)

70.2 79.0 71.3 81.9 83.3 88.7 56.1 64.4 65.6 42.9

Data sources: (a) 2011 Rural-Urban Classification of Local Authorities (https://www.gov.uk/government/statistics/2011-rural-urban-classification-of-local-authority-and- other-higher-level-geographies-for-statistical-purposes);(DEFRA, 2017) (b) National General Practice Profiles; for deprivation 1 is most deprived decile, and 10 is least deprived (https://fingertips.phe.org.uk/profile/general-practice);(PHE, 2017c) (c) derived from UNIFY 2 data 2016-2017, which are experimental management data and have lower reliability;(NHS Digital, 2017b) (d) derived from Immform data 2016-2017. QOF = Quality Outcome Framework; DTP-IPB-Hib 3 = Diphtheria, tetanus, pertussis, polio & haemophilus influenzae group b, 3rd _{dose; MMR = measles, mumps and rubella vaccine; PPV: pneumococcal polysaccharide vaccine.}

116 The information about each included practice in Table 6 has been summarised to create an adjective list to describe the overall characteristics of the practice and assist with the qualitative analysis, and is presented in Table 7. Aside from list size and urban/rural status, if a characteristic is not mentioned, it is close to the England average.

Practice Characteristics

A Small, rural, affluent, low diversity, few children, many older people, high childhood coverage.

B Average, urban, deprived, many children and high childhood coverage.

C Average, urban, deprived, high diversity, high childhood and adult coverage.

D Average, rural, affluent, low diversity, many older people, high childhood and adult coverage.

E Large, mixed urban/rural, affluent, low diversity, many older people, high childhood and adult coverage.

F Large, rural, low patient recommendation, high childhood coverage, very low adult coverage.

G Large, London, very high diversity, few older people, very low childhood and low adult coverage.

H Large, rural, low childhood and low adult coverage.

J Very large, London, very high diversity, many children, few older people, low childhood and very low adult coverage.

Table 7: descriptors of characteristics associated with each included practice.

The first recruited practice was used as a pilot of the methods as described in section 5.5.1. The pilot practice was the smallest of all the recruited practices, with a list size of 2,700. It was in a suburban area in the East of England region, with low deprivation, low ethnic diversity and high coverage of vaccinations. There was one GP employed and one practice nurse undertook all the vaccinations. This made it slightly different from the other practices, however it did enable me to undertake an in-depth review of the methods with the relevant staff and receive feedback on the tools.