David Salisbury described the successful program that the United Kingdom has implemented to achieve immunization rates of at least 90 percent for children of all ages and for all vaccines. By 1990, the Department of Health had initiated action on three fronts: (1) provider practices, (2) administrative policies, and (3) public education.

• Provider practices. Three major steps were taken to encourage providers to immunize as many children as possible. First, the immunization guidelines were revised and distributed to all providers, regardless of specialty. The revised guidelines sanction a minimal set of valid contraindications to immunization. Second, an extensive provider education program introduced the new guidelines and a revised immunization schedule. Third, the Department of Health adopted a new system to pay providers for administering immunizations. Instead of small payments for each immunization, providers receive quarterly lump-sum payments if they meet an overall level of immunization for the children in their practice. Specifically, they receive a minimum payment for immunization rates of at least 70 percent and a larger additional payment if their immunization rates are 90 percent or higher. The new payment scheme makes immunizations a higher priority than in the past and promotes timely reporting on the immunizations that have been administered. Coverage rates are based on all children in a provider's practice who were due for immunizations during the quarter, including any for whom immunization was contraindicated. This policy removes any incentive to attribute missed immunizations to invalid contraindications.

• Administrative policies. The program made several administrative changes. National health promotion and disease prevention goals were established, including achieving immunization rates of 90 percent. The national goals provided the targets for the new provider payment system. The immunization schedule was standardized and compressed, which increases the chance that children will have completed their immunizations if their families move. Each health district was required to appoint an immunization coordinator who is responsible for the delivery of immunization services in that district. These coordinators work with the providers in their districts and must answer to the Department of Health at the national level. Health districts were also encouraged to improve their computer-based information systems, which are an important factor in the success of the program. Each child is registered at birth, and the system generates notices to primary care providers when newborns are added to their practice. The information system helps in scheduling appointments and identifies children who have not received immunizations. Individual providers and the staff of the health district monitor the system to ensure that it accurately reflects the children in a providers practice (e.g., children who have moved are taken off of a provider 's list).