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A multicomponent approach

  • 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 
  • 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 

Raising awareness

Raising awareness in health and social care staff

  • These recommendations are for educators, line managers and organisational leads 
  • 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 
  • 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 
  • 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) 
    • 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 
  • 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 
  • 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 
  • 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) 
  • 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 
  • 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 
  • Give people information about the location and opening hours of relevant flu vaccination services, including out-of-hours services and community pharmacies 
  • Include information on flu vaccination with other health-related messages and existing health-promotion or vaccination programmes for people in eligible groups 

Offering vaccination

  • These recommendations are for providers of flu vaccination services 
  • 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 
  • 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 
  • 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 
  • Consider outreach opportunities for underserved groups in line with local practice and patient group directions arrangements
  • 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 
  • 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 

Increasing uptake among eligible groups in primary care

  • Inform and invite children and adults in eligible groups for flu vaccination during face-to-face interactions, whenever the opportunity arises 
  • Advise parents of all children aged 2 and 3 years who are covered by the universal vaccination programme,[A] 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 
  • 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 Raising awareness, above)
  • 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’) 
  • 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 
  • Consider using peer-led approaches for inviting people in underserved groups who are eligible for flu vaccination 

Patient records

  • 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) 

Audit, monitoring and feedback

  • 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 
  • 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 
  • 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 
  • 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 

Flu vaccination in carers

  • 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 
  • 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

[A] 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

© NICE 2018. Flu vaccination: increasing uptake. Available from: www.nice.org.uk/NG103. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

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