Guidance

Flu vaccinations: supporting people with learning disabilities

Updated 25 September 2018

Several studies, including numbers emerging from the current Learning Disabilities Mortality Review (LeDeR) Programme have shown that respiratory problems are a major cause of death of people with learning disabilities. Despite the fact that from 2014 people with learning disabilities were eligible to have a free flu vaccination there has not been an appreciable rise in the numbers receiving this.

What GP surgeries can do

1. GP surgeries should give a clear message that people with learning disabilities, their family carers and paid supporters are entitled to a free flu vaccination.
2. People on the learning disability register should have it recorded in their notes that they “need a flu immunisation” - there is a specific Read code for this.
3. Talk to people at their annual health check about why it is important that they have a flu vaccination.
4. Put reasonable adjustments in place to help people with learning disabilities have flu injections.
5. The person seeing the patient may need to assess the patient’s capacity to decide to have the flu injection. If they do not have capacity for this decision, then this should not be a barrier to the flu injection being given; there would need to be a decision taken by the health professional that this is in their best interests.
6. Consider use of the nasal spray flu vaccine as a reasonable adjustment.

Background

The Confidential Inquiry into the Deaths of People with Learning Disability (CIPOLD) found that respiratory problems were a major cause of death. The CIPOLD report recommended that people with learning disabilities should be identified as a high-risk group for inclusion in seasonal influenza vaccination programmes.

Having reviewed the evidence, Public Health England’s (now UK Health Security Agency) Joint Committee on Vaccination and Immunisation updated their guidance on eligibility for the seasonal immunisation in the summer of 2014 to include specific reference to people with learning disabilities The 2014/15 Public Health England Winter Flu Plan published that year asked GP practices and other immunisation providers to ‘prioritise the improvement of vaccine uptake’ among people with learning disabilities (among other groups). From this point, people with learning disabilities were eligible for the immunisation free of charge.

Data from GPs for the influenza season of 2014/15 showed 41% of people recorded by their GP as having a learning disability were immunised. Uptake varied greatly with age, rising from just above 20% in the youngest adult groups to around 80% in those aged over 65.

In January 2015 Mencap surveyed 100 GP practices in England. They found that 73% said they did not provide free flu vaccinations for people with learning disabilities, as they were not in the clinical risk groups. Many surgeries suggested that anyone with learning disabilities wanting a flu vaccination should go to a pharmacy and pay for it. This lack of awareness of the new guidance was concerning, as it was reflected in the low uptake rates for flu vaccination by younger adults and children with learning disabilities.

As there was some uncertainty about the eligibility of all people with learning disabilities during the 2014/15 winter, a second letter was sent out advising practices about this. This should not have been a factor in subsequent years, but coverage has not been appreciably better except in the youngest age group.

Reasonable adjustments

There is a legal obligation to put reasonable adjustments in place to ensure equal access to healthcare services for people with disabilities. This means that services should be making changes that help people with learning disabilities have a flu vaccination. These might be changes at a service level, for example sending out an easy-read leaflet about why it is important to have a flu vaccination. It might be changes at an individual level, for example offering a longer visit to someone who needs more time.

All organisations that provide NHS or adult social care must now follow the accessible information standard by law. The standard aims to make sure that people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand with support so they can communicate effectively with health and social care services.

Examples of reasonable adjustments

Many people with learning disabilities are anxious about needles but there are a lot of resources and approaches that can help them to tolerate injections or blood tests. There is more detailed advice, as well as good practice case studies, in our report Blood tests for people with learning disabilities: making reasonable adjustments.

This includes guidance on:

• how to help someone to be prepared, for example desensitisation work
• how to support the person to make an informed decision if they have capacity to do so, for example using accessible leaflets and videos
• how to improve their experience, for example the use of topical applications to numb the skin prior to needle insertion
• how safe-holding and sedation can be used if other approaches such as desensitisation have failed and a best interests decision has been taken that this is warranted

Nasal spray vaccine

When someone with learning disabilities who is anxious about needles requires a blood test or an injection there should always be consideration of less invasive alternatives. This would include the use of the nasal spray flu vaccine.

The live intranasal influenza vaccine is given as a single spray squirted up each nostril. This has the advantage of being needle-free and for children it is more effective than the injected flu vaccine. This is not licensed for adults, as there is evidence it may be less effective than the injected inactivated vaccine. However, guidance for healthcare workers says that medical practitioners can choose to use the nasal spray “off-label” and that this can be for “patients with learning difficulties who become seriously distressed with needles”. UK Health Security Agency (UKHSA) has agreed that the national stock of the nasal spray flu can be used for this purpose but it needs to be individually prescribed using a Patient Specific Direction (PSD).

Family carers and paid supporters

People with learning disabilities are less likely to get the flu if the people around them have also been vaccinated. Family carers can get a free flu vaccination as well as health and social care workers. This will help to protect them and reduce the risk of spreading the flu to the people they support. NHS England has issued a letter to social care organisations confirming that health and social care staff are entitled to a free flu vaccination.

Resources

The 3 following lists contain all the information and resources we have found in relation to supporting people with learning disabilities to have flu vaccinations.

List 1 lists guidance and policy about the current national flu immunisation programme.

List 2 lists websites and resources that may be of use to professionals/family members and carers who want more information and resources.

List 3 lists the easy-read resources and films we have found. This is where you can find information to use with people with learning disabilities.

Some resources may be available from more than one site, but we have only given one link. We have only included resources that are free to download, although some of the websites may also include resources you can buy.

List 1: Policy and guidance about the national flu immunisation programme

1. The national flu immunisation programme 2018/19. Detailed information about the 2018/19 national flu immunisation programme (UKHSA, DH and NHS England)
2. The National Childhood Flu Immunisation Programme 2018/19: Information for healthcare practitioners. Guidance for healthcare workers on the childhood flu immunisation programme for 2018/19. This includes advice on immunisation of adults with learning disabilities and those with needle phobia (see page 23) (UKHSA)
3. Letter to social care organisations. This confirms that NHS seasonal flu vaccination will continue in 2018/19 and will be extended to include health and care staff in the voluntary managed hospice sector that offer direct patient/client care as well as social care workers.
4. Community Pharmacy Seasonal Influenza Vaccine Service. This webpage has a service specification and supporting patient group direction for the Community Pharmacy Seasonal Influenza Vaccine Service for the 2018/19 flu season.
5. Patient Group and Patient Specific Directions. This webpage has advice on the use of Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) in general practice. There are links to further resources and the full guidance can be downloaded (BMA)

List 2: Resources about flu immunisations for use by professionals/family members and carers

1. Protecting children and young people with learning disabilities against flu. A one-page information sheet aimed at parents about the flu vaccination (NHS England)
2. Head teacher letter. A letter to head teachers in special schools about promoting flu vaccinations (NHS England)
3. Parent letter. A letter to parents of children in special schools promoting flu vaccinations (NHS England)
4. National flu programme training slide set for healthcare professionals 2018 to 2019. This slide pack has been developed for trainers and leaders of the national flu programme (UKHSA)
5. Patient Specific Direction. A template to use for a Patient Specific Direction (a written instruction from a doctor or other independent prescriber for a medicine to be supplied or administered to a named patient) (Wessex Local Medical Committees)
6. Flu vaccination: invitation letter template for at risk patients and their carers. A template for GPs to invite patients at risk of flu, due to a medical condition or age, and their carers to have their annual flu vaccine (UKHSA)
7. Preparation for health professional to be able to assess Mental Capacity to Consent to the Seasonal Flu Injection. This supports carers or relatives to make sure they take steps in advance to help the person with learning disabilities understand easy-read information about the flu vaccination. It prompts people to think about any reasonable adjustments that may be needed and to contact the surgery to arrange these (Hertfordshire County Council Community Learning Disability Service – Health Liaison Team)

List 3: Easy-read and accessible resources about the flu injection

1. People with learning disabilities and the flu injection. Easy-read information with information for people with learning disabilities, their family carers and paid supporters (NDTi)
2. Easy-read flu injection letter. An easy-read letter explaining about the flu vaccination and inviting someone to come to their GP surgery to have one (Hertfordshire County Council Community Learning Disability Service – Health Liaison Team)
3. Flu vaccination. An easy-read leaflet about having the flu vaccination (Cheshire & Wirral Partnership Trust NHS)
4. All about flu and how to stop getting it. An easy-read leaflet telling people what flu is and how to get a flu vaccination (UKHSA)
5. All about flu and how to stop getting it. An easy-read leaflet for children about flu is and about having the nasal spray (UKHSA)
6. Flu jab information: Guide for Pharmacists. Easy-read information about who is eligible for a free flu vaccination. Designed to use in pharmacies (Hertfordshire County Council Community Learning Disability Service – Health Liaison Team)
7. The flu jab for people with learning disabilities.

A short film about someone with learning disabilities having their flu vaccination (NHS England)