3Vaccine uptake
39.The NHS flu vaccination programme offers vaccination against flu to eligible groups in the UK:
- Two and three-year olds are offered vaccination through General Practice and a school-based programme for all children up to at least nine years old.41
- All eligible individuals under sixty-five and all over sixty-five year olds are offered vaccination through their GP or community pharmacy.
Maximising vaccine uptake is listed as one of the strategic aims in the Department of Health and Social Care’s annual flu plan, including raising uptake in the lowest performing areas.42
40.Flu vaccine uptake in the 2017/18 season was similar or higher than in previous seasons in all eligible groups in England. The table below summarises vaccine uptake in all groups between the 2015/16 and 2017/18 seasons, as well as the uptake and the vaccine uptake ambition:
Vaccine uptake in eligible groups in England (Public Health England 2018)43
|
2017/18 |
2016/17 |
2015/16 |
Uptake ambition 2018/19 |
|
|
Patients aged 65 years or older |
72.6% |
70.5% |
71.0% |
75% |
|
Patients aged six months to 65 years in risk groups (excluding pregnant women without other risks factors) |
48.9% |
48.6% |
45.1% |
55% |
|
Pregnant women |
47.2% |
44.9% |
42.3% |
55% |
|
Health care workers |
68.7% |
63.2% |
50.6% |
75% |
|
Children aged two years old (including those in risk groups) |
42.8% |
38.9% |
35.4% |
48–65% |
|
Children aged three years old (including those in risk groups) |
44.2% |
41.5% |
37.7% |
|
|
Children aged four years old (including those in risk groups) |
62.6% |
33.9% |
30.0% |
41.However, there was some significant geographical variation in vaccine uptake among children vaccinated as part of the school-based programme, the Wessex area achieved the highest uptake with 70.7%, whereas London only reached 47.8%.44 Variation was less in other groups, for those over 65, vaccine uptake “ ranged from 66.9% (London) to 75.5% (Cheshire and Merseyside).” In the 18–64 eligible groups, uptake ranged from 45.4% (London) to 52.4% (Greater Manchester).45
42.Professor Cosford highlighted the contributing factors to the variation in the school-based programme. These included religious objections46 and reduced uptake in inner city populations.47 Professor Pollard highlighted media reports that claimed that the vaccination did not work and the effect that had on individuals offered the vaccination.48
43.Public Health England produces a wide range of materials promoting flu vaccination to all eligible groups prior to and during the flu vaccination season. This includes leaflets and posters for parents setting out the benefits of the flu vaccination, as well as advice for healthcare professionals. GPs may also send personalised invitations and reminders to eligible patients before the start of the flu season.49 In August 2018, the National Institute for Health and Care Excellence published guidance for commissioners, healthcare workers and others on increasing the uptake of flu vaccination in all eligible groups.50
44.Other actions to increase uptake, especially in GP practices, were highlighted by Professor Cosford, including:
general practitioners [putting] on special clinics on Saturday mornings to get to their specific at-risk groups, or use asthma and antenatal clinics, or whatever, to encourage vaccination. All that is working very hard, and of course there are incentive schemes in the system as well to help improve uptake.51
45.We heard that vaccine uptake rates were increasing year-on-year but there remains high geographical and demographic variation in uptake in some groups. We are reassured to hear about communication campaigns and other actions being taken to improve vaccine uptake in eligible groups. We recommend that the Government ensures that research into better understanding of the causes of unacceptable variation in vaccine uptake takes place. We call on the Government to continue to look at what actions work to increase flu uptake. Further, we call on the Government to invest in campaigns that are proven to be successful.
Healthcare workers
46.NHS organisations are expected to offer flu vaccination to all healthcare workers with direct patient contact.52 The Flu Plan for England states that immunisation against flu should be part of the NHS organisation’s policy for the prevention of infectious diseases.53 This is not an NHS programme but an occupational health responsibility for NHS organisations. Under the Health and Social Care Act 2008 and related regulations, both health and social care settings have obligations to provide effective prevention and control of infection.54
47.The Care Quality Commission is responsible for the monitoring and inspection of health and social care services in order to make sure they meet quality and safety standards. As part of this work, it looks at how a provider meets its obligations in relation to “assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated.”55,56 Department of Health and Social Care guidance, issued in 2015, on meeting these obligations states that occupational health services include “arrangements for provision of influenza vaccination for healthcare workers where appropriate”.57
48.Professional bodies, such as the General Medical Council58 and the Royal College of Nursing,59 also require healthcare professionals to ensure that they are immunised against common infectious diseases. Resources to support and advise on the provision of the flu vaccination to healthcare workers is provided by the Flu Fighter annual communications campaign run by NHS Employers.60
49.Witnesses agreed that it was a professional duty and obligation for healthcare workers to ensure that they were vaccinated to protect themselves and their patients from flu. Professor Cosford set out why vaccination was important for this group:
It protects them, it reduces sickness absence, so it helps the NHS to operate through the winter, but, importantly, because 30% to 50% of cases of flu, as we understand it, are subclinical, there is a risk, even when you are not showing clinical symptoms of flu, of passing that on to patients. Therefore, from where I sit, it is a patient protection issue.61
50.There is mandatory collection of data on flu vaccine uptake amongst frontline healthcare workers.62 NHS Hospital Trusts, GP Practices and independent sector healthcare providers must submit data to their local NHS England teams. NHS payments are made to NHS organisations based on the vaccine uptake achieved and data submitted to NHS England.63
51.Vaccination rates in healthcare workers were the highest ever in the 2017/18 season at over 68% compared to 63% in the 2016/17 season.64 However, we heard from that significant variation remained with poorly performing trusts only achieving 30–40% uptake.65
A mandated vaccination programme for healthcare workers
52.The Chief Medical Officer, Professor Dame Sally Davies and the former medical director of NHS England, Bruce Keogh, have called for discussion on whether there should be a mandatory flu vaccination for healthcare workers.66 However, most of our witnesses were not in favour of a move to a mandated programme for healthcare worker vaccination at present. Professor Powis said that he thought that introducing a mandated system would “not [ … ] be a simple thing to do operationally”. He said that there was more that could be done before this should be introduced, such as making it easier for staff to get vaccinated and introducing local incentive schemes.67
53.Professor Cosford argued that the position should be that all healthcare workers should be vaccinated unless there were contraindications, and said that there should be further discussion on whether vaccination should be mandatory in this group:
I would want to have a clear discussion with professional leaders about it, because, equally, we have a long tradition in this country of vaccination without mandation, and we get very high rates as a result. The psychological and cultural aspects of a move to mandation are important. We could end up with some groups of people being even more suspicious of vaccination than they are already, which could be counterproductive. It is a complicated area. It is a brilliant issue to discuss and we must get to a better place on it.68
54.In September 2018, as the flu vaccination season was starting again, there have been further calls from senior NHS figures regarding the importance of healthcare worker vaccination against flu. In early September, clinical leaders from NHS England and NHS Improvement sent a letter to all hospital trusts stressing the importance of flu vaccination for healthcare workers.69 This set out an ambition for 100% of healthcare workers with direct patient contact to be vaccinated and asked trusts to provide information on how they aimed to achieve this. The letter advised that trusts should ensure that ‘high risk’ clinical environments, such as haematology, oncology and special care baby units had 100% staff vaccination uptakes as soon as possible.70 It advised that trusts should consider changing the staff in certain clinical departments to maintain the safety of the service. The Royal College of General Practitioners has also called on all those working in the NHS to ensure that they have been vaccinated against flu this season.71
55.Despite the 2017/18 season having the highest flu vaccination uptake ever in healthcare workers, significant variation remains. Some hospital trusts only achieved 30 to 40% uptake, whereas others achieved over 90%. All hospital trusts should give the same level of priority to vaccination programmes for staff. We recommend that the Care Quality Commission should continue to assess how well trusts have performed this role and take action where fundamental standards relating to infection prevention and control have not been met.
56.It is a professional duty for healthcare workers in hospitals to be vaccinated each year. We welcome recent advice to hospital trusts from NHS England and NHS Improvement on healthcare worker vaccination. The Government should undertake and conclude a review by the end of February 2019 to establish whether flu vaccination should be mandatory for certain categories of healthcare workers.
Social Care workers
57.We heard that the case for vaccination in staff working in social care settings was just as strong if not stronger than those working in hospitals.72 As noted above, there is an established system for all healthcare providers to submit information on healthcare worker flu vaccination uptake to NHS England. However, Professor Cosford told us that routine information on social care worker vaccination rates was not collected because of the “complexity of care homes”.73 However, in Northern Ireland, for example, health and social care is integrated and data is collected by the Public Health Agency on social care worker vaccine uptake.
58.Professor Cosford revealed that ad hoc surveys of care homes by PHE showed “huge variability, with the best [uptake] at around 25%”.74 Public Health England later explained that due to the low number of respondents to this survey, the results should be treated with caution. As such the results have not been published.75
59.In October 2017, NHS England announced that it would add care home workers to the eligible groups for NHS flu vaccination through GP practices and community pharmacies.76 This has continued for the 2018/19 season.77 However, NHS England stressed that this scheme was intended to “complement, not replace, any established occupational health schemes that employers have in place to offer the flu vaccination to their workforce”.78
60.We believe it is as much a professional duty for staff working in social care to be vaccinated as it is for frontline healthcare workers. We were surprised that no effective system of monitoring uptake of flu vaccination rates amongst staff working in social care settings has been established in England. While we accept there may be challenges in relation to information collection, we recommend that the Government should review this and determine how vaccination uptake data can be collected from care homes. An effective system of data collection should be established by the 2019/20 flu season. In its role regulating within the social care sector, the Care Quality Commission should take action where poor immunisation rates (or poor recording of uptake) could impact on standards of infection prevention and control. There should be an expectation of full coverage amongst staff working with individuals who are most at risk from serious illness from flu.
61.We were shocked by survey results from Public Health England which showed that the best flu vaccination uptake in social care settings was around 25%. The poor response rate was also disappointing. We welcome the extension of the NHS programme to frontline social care workers. We call on the Government to look at ways in which uptake among social care staff could be improved and establish the same principle as now exists in the NHS—the aim of 100% coverage.
41 In Scotland and Northern Ireland children up to the age of eleven are offered the school based vaccination.
42 Public Health England, Annual flu programme, accessed 16 October 2018
43 Public Health England, The national flu immunisation programme 2018/19 slideset, accessed 16 October 2018
44 Public Health England, Surveillance of influenza and other respiratory viruses in the UK: Winter 2017 to 2018, May 2018
45 Public Health England, Seasonal influenza vaccine uptake in GP patients: winter season 2017 to 2018, Final data for 1 September 2017 to 31 January 2018, May 2018
46 For example, some religious groups have concerns in relation to the porcine gelatine within the nasal spray flu vaccine.
49 Public Health England, Annual flu programme, accessed 16 October 2018
50 NICE, Flu vaccination: increasing uptake, August 2018
52 Public Health England, Annual flu programme, accessed 16 October 2018
53 Public Health England, Annual flu programme, accessed 16 October 2018
56 Care Quality Commission, Regulation 12: Safe care and treatment, accessed 16 October 2018
57 Department of Health, The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance, July 2015
58 General Medical Council, Good medical practice, 2014
59 Nursing and Midwifery Council, The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates, 2015
60 NHS Employers, Flu Fighter, accessed 16 October 2018
62 Public Health England, Seasonal Influenza Frontline Healthcare Workers Vaccine Uptake Survey 2018/19 Guidance ImmForm User Guide for Survey Data Providers, September 2018
63 Public Health England, Seasonal Influenza Frontline Healthcare Workers Vaccine Uptake Survey 2018/19 Guidance ImmForm User Guide for Survey Data Providers, September 2018
64 Public Health England, Seasonal influenza vaccine uptake in healthcare workers (HCWs) in England: winter season 2017 to 2018 Final data for 1 September 2017 to 28 February 2018, May 2018
66 The Telegraph, Mandatory flu jabs for all NHS workers must be considered in wake of crisis, medical director says, 7 January 2018
69 Letter dated 7 September 2018 from NHS England and others to Chief Executives of NHS Trusts and Foundation Trusts regarding Health care worker flu vaccination
70 Ibid.
71 RCGP, RCGP encourages all primary care professionals to get their flu jab this winter, 7 September 2018
76 NHS England, NHS leaders unveil action to boost flu vaccination and manage winter pressures, 11 October 2017
77 NHS England, Extension of NHS seasonal influenza vaccination, 10 September 2018
78 NHS England, Extension of NHS seasonal influenza vaccination, 10 September 2018
Published: 18 October 2018