Recommendations

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations and has information about prescribing medicines (including off‑label use) professional guidelines standards and laws (including on consent and mental capacity) and safeguarding.

1.1 A multicomponent approach

1.1.1 Use a multicomponent approach to develop and deliver programmes to increase flu vaccination uptake. Combine interventions recommended in this guideline to influence both demand and supply.

1.1.2 Providers of flu vaccination should work together with other agencies (including intervention developers, commissioners and local stakeholders) to develop programmes to increase vaccination uptake. This could include assigning within organisations a lead team or flu vaccination champion to manage the programmes and be responsible for working across organisations.

See how the committee made recommendations 1.1.1 and 1.1.2.

1.2 Raising awareness

Raising awareness in health and social care staff

These recommendations are for educators, line managers and organisational leads.

1.2.1 Educate health and social care staff, particularly those in contact with eligible groups, about flu vaccination. These could include:

  • Staff working in GP surgeries and community pharmacies.

  • Secondary care staff, for example in clinics for children with chronic conditions or wards such as oncology or antenatal.

  • Social care staff who may have contact with carers and other eligible groups, such as people with learning disabilities. This may include during home visits, individual needs assessments and carers' assessments.

1.2.2 Provide information on the following as part of an education programme on flu vaccination for health and social care staff, particularly those in contact with eligible groups:

  • Who is eligible for free flu vaccination, and where to get it.

  • Benefits of vaccination for people at high risk from flu and its complications. For example, those with immunosuppression, chronic liver disease or neurological disease.

  • Benefits of flu vaccination for health and social care staff.

  • How flu is transmitted.

  • Relevant guidelines and definitions of eligible groups as outlined in Public Health England's Immunisation against infectious disease (known as the 'Green Book').

  • How the flu vaccine is given to children and adults.

  • Evidence supporting the safety and effectiveness of flu vaccination.

1.2.3 Explain to health and social care staff how they can:

  • Identify people who are eligible, for example by using GP records or medicines dispensing records (including how to identify carers who might be eligible; see section 1.6).

  • Make the most of opportunities to raise awareness about and offer flu vaccination to eligible groups. This could include discussing it with:

    • pregnant women during antenatal appointments

    • eligible people booking GP or other clinical appointments

    • eligible people visiting community pharmacies to seek health advice, collect prescriptions or buy over-the-counter medicines.

1.2.4 Health and social care staff who are in direct contact with eligible groups (for example, practice nurses, health visitors, community pharmacists, midwives, specialist nurses and domiciliary care workers) should:

Raising awareness in eligible groups

These recommendations are for providers of flu vaccination.

1.2.5 Raise awareness of free flu vaccination among people who are eligible, as listed in the Green Book and the annual flu letter. Do this at the earliest opportunity before the flu vaccination season starts in September, and ideally by the end of December.

1.2.6 Consider working with statutory and voluntary organisations, including those representing people with relevant medical conditions, to increase awareness of flu vaccination among eligible groups (and their parents or carers, if relevant).

1.2.7 Give people who are eligible (or their parents or carers, if relevant) face-to-face brief advice or a brief intervention on the importance of flu vaccination. Tell them that they can have a free flu vaccination and explain why they are being offered it, using language they can understand and taking into account cultural sensitivities. This includes explaining:

  • How people get flu.

  • How serious flu and its complications can be (make it clear it is not just a bad cold).

  • That flu can affect anyone, but if a person has a long-term health condition the effects of flu can make it worse, even if the condition is well managed and they normally feel well.

  • That flu vaccination is safe.

  • That having a flu vaccination is the single best way of helping to protect against catching or spreading flu.

  • That they should get the vaccination as soon as it becomes available to maximise their protection throughout the flu season.

  • Any myths about flu vaccination: dispel these myths, including the belief that it can give you flu.

  • The need to have a flu vaccination every year.

1.2.8 Explain to parents or carers that the nasal spray (not injection) is recommended for eligible children from the age of 2 years. Explain that the injection will be offered instead of the nasal spray only if:

  • the child is in a clinical risk group and

  • the child cannot have the nasal spray for medical reasons (for example, if it is contraindicated because they or a close family member is severely immunocompromised), or they choose not to because of their religious beliefs; see NHS Choices for more information.

1.2.9 Give people information about the location and opening hours of relevant flu vaccination services, including out-of-hours services and community pharmacies.

1.2.10 Include information on flu vaccination with other health-related messages and existing health-promotion or vaccination programmes for people in eligible groups.

See how the committee made recommendations 1.2.1 to 1.2.10.

1.3 Offering vaccination

These recommendations are for providers of flu vaccination services.

1.3.1 Use every opportunity throughout the flu vaccination season to identify people in eligible groups and offer them the flu vaccination. This could include when:

  • People register in general practice.

  • Women have a newly confirmed pregnancy.

  • People are newly diagnosed with a condition that may place them in a clinical risk group, or have a BMI of 40 or over.

  • People attend outpatient and antenatal clinics or drug and alcohol services.

  • People (including children aged 6 months to 17 years) who are in a clinical risk group attend routine GP or outpatient clinic appointments, or for other vaccination services.

  • People visit community pharmacies for health advice, a Medicines Use Review or a New Medicine Service, or to collect prescriptions (check whether the person taking the medicine or their carer is eligible, while taking into account confidentiality).

  • People in clinical risk groups are staying in hospital.

  • People who are eligible are having home visits for healthcare.

1.3.2 Establish and use links with statutory and voluntary organisations that work with carers, looked-after children and young people or other groups, to identify eligible people who have not been vaccinated. These could include drug and alcohol services, and organisations working with Traveller communities or people who are homeless.

1.3.3 Provide multiple opportunities and routes for eligible people to have their flu vaccination at a time and location convenient to them. This could include at community pharmacies, GP surgeries or clinics they attend regularly for a chronic condition.

1.3.4 Consider outreach opportunities for underserved groups in line with local practice and patient group directions arrangements (see NICE's guideline on patient group directions).

1.3.5 Consider providing evening and weekend services in primary care, including community pharmacy, to deliver flu vaccination to people who may find it difficult to attend at other times.

1.3.6 Use clinical systems to identify eligible groups and work out supply requirements, planning for a higher uptake than the previous year. Ensure enough flu vaccine is available to meet local needs.

See how the committee made recommendations 1.3.1 to 1.3.6.

1.4 Increasing uptake among eligible groups in primary and secondary care

Primary care

1.4.1 Inform and invite children and adults in eligible groups for flu vaccination during face-to-face interactions, whenever the opportunity arises.

1.4.2 Advise parents of all children aged 2 and 3 years who are covered by the universal vaccination programme[1], and children aged 6 months and over who are in a clinical risk group, about the benefits of flu vaccination. Do this whenever the opportunity arises, for example when they attend routine appointments or for other vaccination programmes.

1.4.3 When inviting people for flu vaccination:

  • Ensure the invitation comes from a healthcare practitioner that they know, such as a practice nurse, midwife, doctor, pharmacist or health visitor.

  • Tailor it to the person's situation, for example link it to their pregnancy or clinical risk factors.

  • Include information about the risks of not being vaccinated.

  • Include educational messages to help overcome barriers to accepting the offer of a vaccination (see section 1.2).

1.4.4 Use written reminders (including text messages, letters and email), phone calls from staff or an auto dialler, social media, or a combination of methods, to contact people in eligible groups whose immunisations are due ('call') or overdue ('recall').

1.4.5 For invitations and reminders using digital media:

  • link to further information on trusted websites (see NHS Choices) and enable the person to ask for further information

  • provide a prompt (for example, a hyperlink) so the person can make an appointment online

  • encourage people to find out more during face-to-face interactions, such as with their health visitor or pharmacist.

1.4.6 Consider using peer-led approaches for inviting people in underserved groups who are eligible for flu vaccination.

Secondary care

1.4.7 Consider providing flu vaccination during routine appointments in specialist clinics to people who are at high risk from flu and its complications. For example, people with immunosuppression, chronic liver or neurological disease, and pregnant women.

1.4.8 When the opportunity arises, for example when people attend routine hospital appointments, identify anyone in a clinical risk group who has not been vaccinated and offer them a flu vaccination. Ensure this is in line with any local patient group directions or enhanced service arrangements that have been agreed with commissioners (see NICE's guideline on patient group directions).

1.4.9 When offering people the flu vaccination:

  • Make the offer face-to-face, if possible.

  • Use positive messages to encourage people to have the vaccination. For example, for a pregnant woman the message could be that the flu vaccination gives 'two for one' protection to both her and her baby before and after the birth.

  • Tailor information to the person's situation, for example their pregnancy or clinical risk factors. Include the risks of not being vaccinated.

  • Ensure information is simple, easy to read (if written) and provides a consistent message about flu and flu vaccination.

  • Ensure a healthcare practitioner they know (for example, a midwife or a consultant from an outpatient clinic they attend) offers the vaccination.

  • Make it easy for the person to get the vaccination, for example by offering and administering it during the same visit.

Patient records

1.4.10 Include prompts about people's eligibility for flu vaccination in electronic patient records or in medical notes (for example, by putting reminder stickers in antenatal notes).

See how the committee made recommendations 1.4.1 to 1.4.10.

1.5 Audit, monitoring and feedback

1.5.1 Healthcare providers should keep patient records up to date and accurate to help identify people who have not been vaccinated and are eligible for flu vaccination that season.

1.5.2 Providers of flu vaccination should record uptake rates. For example, keep records of the following:

  • reason for eligibility

  • numbers of people called and recalled

  • vaccination setting (for example GP, community pharmacy, antenatal clinic, outpatient clinic)

  • people who declined vaccination and why, by eligible group.

1.5.3 Commissioners and providers should agree approaches for sharing information with general practices about flu vaccination given outside a person's own GP surgery (for example, by a school nurse or in a diabetes outpatient clinic). Aim for timely, accurate and consistent recording of vaccination status in health records to ensure all vaccinations are included in uptake data, and to avoid wasting resources by inviting people to attend appointments unnecessarily or duplicating vaccination.

1.5.4 Use audit and monitoring systems to give providers of flu vaccination regular feedback on organisational progress towards targets throughout the immunisation season. Also use them to review past activity and impact on uptake to help plan and prioritise for the next season.

Organisational incentives

1.5.5 Commissioners should raise awareness among healthcare staff and providers of flu vaccination about enhanced services payments and provider payments linked to flu vaccination. Also keep them informed and up to date about other financial incentives linked to flu vaccination. This includes those offered in the general practice Quality and Outcomes Framework (QOF), or the Commissioning for Quality and Innovation (CQUIN) system in secondary care.

1.5.6 Commissioners should ensure that providers of flu vaccination know that submission of information on flu vaccination directly affects any linked organisational incentive payments.

1.5.7 Commissioners should highlight the need for audit, monitoring and feedback of flu vaccinations given as part of an incentives programme. Link agreed Read codes or CQUIN indicators to incentives and include the required code or indicator.

1.5.8 Organisations responsible for agreeing quality indicators in incentives programmes (such as QOF) should be aware that revising target conditions may encourage providers to meet targets for flu vaccination across all clinical risk groups.

See how the committee made recommendations 1.5.1 to 1.5.8.

1.6 Flu vaccination in carers

1.6.1 When considering increasing flu vaccination uptake in carers who are not otherwise eligible, use clinical judgement. Base decisions to offer vaccination on whether the carer looks after someone whose wellbeing may be at risk, needing hospital or other formal care, if the carer had flu.

1.6.2 Providers of flu vaccination, including primary care staff and nurses working in the community (such as district nurses, specialist nurses and those working in rehabilitation) could consider:

  • Identifying and offering eligible carers a flu vaccination as the opportunity arises. For example, this could be offered during a home visit when the person they look after is being vaccinated.

  • Informing the carer about other local vaccination services if a patient group direction or enhanced service arrangement has not been agreed with primary care commissioners (see NICE's guideline on patient group directions).

See how the committee made recommendations 1.6.1 and 1.6.2.

1.7 Employers of health and social care staff

Employers of health and social care staff are responsible for providing occupational flu vaccinations. This includes: NHS organisations, independent contractors, local authorities, and private and voluntary sector employers of social care staff. Immunisation should be provided by occupational health services, infection prevention and control teams, or using arrangements with private healthcare providers.

1.7.1 Provide flu vaccination to all front-line health and social care staff who have direct contact with patients or clients. This includes employees who provide community-based care services to people in their own homes, or who care for people in residential care homes or other long-stay care facilities (see the Green Book).

1.7.2 Use audit and monitoring systems to review previous strategies and flu vaccination uptake rates among eligible staff and to plan what methods to use to increase uptake and manage the supply for the next flu season. Start planning each year when the annual flu letter for the forthcoming season is published.

1.7.3 Consider the following as part of a multicomponent approach to increasing uptake of flu vaccination among front-line health and social care staff:

  • A full participation vaccination strategy, with nationally agreed opt out criteria (A full participation strategy is one in which a range of approaches are used to maximise uptake and in which the expectation is that all front-line staff should be vaccinated. The full participation approach includes agreed mechanisms enabling staff to opt out if they wish.)

  • Assigning dedicated staff (for example, a flu vaccination champion or a team with responsibility for implementing a communication strategy) to increase awareness and uptake.

  • Using local broadcast media and social media.

  • Getting and publicising support from high-profile organisational leaders or staff representatives.

  • Providing information about the effectiveness and safety of the flu vaccine.

  • Using staff incentives that fit with the organisation's culture and the values of its employees.

  • Training peers to vaccinate their co‑workers, or to encourage uptake and challenge barriers, such as myths that the flu vaccine can give you flu.

  • Using prompts and reminders in various printed and digital formats. Include information about on- or off‑site vaccination locations and times.

  • Using systems linked to named staff records to monitor uptake and to target prompts and reminders.

1.7.4 Consider promoting flu vaccination to front-line health and social care staff as a way to:

1.7.5 Consider:

  • Extending on‑site vaccination clinic hours to fit in with staff work patterns.

  • Using outreach or mobile services to offer flu vaccination in areas and at times where large numbers of staff congregate, such as staff canteens or during shift changeovers.

  • Publicising information about mobile flu vaccination services.

  • Offering opportunities for off‑site and out-of-hours access, for example, by providing vouchers for flu vaccination at a community pharmacy.

1.7.6 Publicise flu vaccine uptake rates and the comparative performance of individual departments or sites within the organisation or locality. This could be done within the context of national targets such as CQUIN.

1.7.7 Develop the flu vaccination strategy in conjunction with staff representatives. Consider an anonymous survey of reasons for opting out, which could be used to inform future flu vaccination programmes.

1.7.8 Agree approaches for information sharing if off‑site access to flu vaccination is offered to allow timely, accurate and consistent recording of people's vaccination status.

See how the committee made recommendations 1.7.1 to 1.7.8.

Terms used in this guideline

This section defines terms that have been used in a specific way for this guideline. For general definitions, please see the glossary.

Carers

People who receive a carer's allowance or who are the informal 'main carer' of an older or disabled person whose welfare may be at risk if the carer falls ill. This definition is in line with the Green Book, which recommends offering the flu vaccination on the basis of clinical judgement, regardless of whether the person receives a carer's allowance.

Clinical risk groups

People who have a medical condition that means they are more likely to develop potentially serious complications from flu. People in these groups are eligible for free flu vaccination and are specified in the Green Book and the annual flu letter. At the time of publication of this guideline, the groups are:

  • chronic respiratory disease, such as asthma (requiring use of inhaled or systemic steroids, or with previous exacerbations needing hospital admission), chronic obstructive pulmonary disease, or bronchiectasis

  • chronic heart disease

  • chronic kidney disease (stage 3 or above)

  • chronic liver disease

  • chronic neurological disease such as Parkinson's disease, motor neurone disease, or a learning disability

  • diabetes

  • a weakened immune system caused by disease (such as HIV/AIDS) or treatment (such as chemotherapy or high-dose corticosteroids)

  • asplenia or conditions that can lead to dysfunction of the spleen, such as sickle cell disease or coeliac disease

  • morbid obesity (adults with a BMI of 40 or over).

Eligible groups

People who are eligible for free flu vaccination in the NHS, as outlined in the Green Book. For the purpose of this guideline, the specific eligible groups considered were:

  • children and adults aged 6 months to 64 years in a clinical risk group (as listed in the annual flu letter)

  • pregnant women

  • people in receipt of a carer's allowance

  • people who are the main informal carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill.

In addition, flu vaccination with live attenuated intranasal vaccine (LAIV) is recommended for all children aged 2 to 17 years who are not in a clinical risk group. This programme is being implemented in a phased roll-out, starting with the youngest first. At the time of publication (August 2018), the universal vaccination programme is available for children aged 2 to 9 years (up to school year 5). Preschool children (aged 2 and 3 years) should be vaccinated in general practice. Older children (from reception age) are being vaccinated by local healthcare teams working with schools. Once the programme has been rolled out to all primary-school-aged children, it will be reviewed to assess whether to continue the extension into secondary schools. Decisions about further roll-out to include older year groups will be notified in the annual flu letter.

Full participation vaccination strategy

A full participation strategy is one in which a range of approaches are used to maximise uptake and in which the expectation is that all front‑line staff should be vaccinated. The full participation approach includes agreed mechanisms enabling staff to opt out if they wish.

Multicomponent approach

A set of multiple interventions implemented together to increase flu vaccination uptake. These target both demand (for example, increasing awareness of eligibility and the reasons why vaccination is beneficial) and supply (for example, creating more opportunities for vaccination, such as increasing the offer by professionals).

Peer-led approaches

Approaches to reach underserved groups in which people with lived experience (for example, people who have been homeless, or who are from particular cultural backgrounds) work alongside health and social care professionals to provide information that is accessible and appropriate to the target group, acting as local 'flu champions' to promote awareness and uptake among their peers.

Providers of flu vaccination

Staff who are allowed to administer the flu vaccination, or affiliated staff (for example general practice staff who log patient demographics and could therefore see who satisfies Green Book criteria).

Statutory organisations

Organisations with legal responsibility at a national or local level for the provision, commissioning, regulation or improvement and oversight of government-funded health and care services.

Underserved groups

This term is used in this guideline to mean adults and children from any background who are 'underserved' if their social circumstances, language, culture or lifestyle (or those of their parents or carers) make it difficult to:

  • recognise they are eligible for flu vaccination (for example, they have an undiagnosed clinical condition)

  • access health services

  • attend healthcare appointments.

The groups classified as underserved in this guideline are:

  • people who are homeless or sleep rough

  • people who misuse substances

  • asylum seekers

  • Gypsy, Traveller and Roma people

  • people with learning disabilities

  • young people leaving long-term care.



[1] At the time of publication (August 2018), the universal vaccination programme is available for children aged 2 to 9 years (up to school year 5). Preschool children (aged 2 and 3 years) should be given the nasal flu vaccine in general practice. Older children (from reception age) are usually given the nasal vaccine by local healthcare teams working with schools. Decisions about further roll-out to include older year groups will be notified in the annual flu letter.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)