In under five months, all front-line staff who work in registered health and social care settings in England will have to be fully vaccinated against Covid, unless exempt. Whether this is the right policy decision is hotly debated and, given it distils down to ethical judgements and some speculation on the impact, will continue to be.
Unpicking such arguments sits within the sphere of expertise of bioethicists and others. So our focus lies in a related question: given the policy, what can be done to mitigate the downsides? Certainly, given the scale of the backlog, the size of the workforce affected (including some 1.8 million working in health care) and pre-existing staff shortages, it is imperative the NHS and social care make efforts to reduce the expected negative impact on staff retention, recruitment or wellbeing.
That no meaningful NHS workforce plan for England has been forthcoming only underlines the importance of managing the effect on staff carefully. Failing to be mindful of this during the implementation is likely to undermine the very purpose of the policy: to safeguard patients. To that end, we have developed five tests to inform the effective implementation of the policy.
Vaccination levels for NHS staff
Before exploring these implementation tests, it is worth restating where England stands on health care staff vaccinations. As of 7 November, an estimated 90% of NHS trust health care workers had received their second dose. After adjusting for differences in age and sex, this is higher than we might expect if vaccination levels were similar to those of the general population (84%), although these comparisons need to be treated with caution as the population and staffing numbers come from different data sources.
Much has been made of the variation within this national figure. However, the regional differences in hospital staff vaccination levels reflect those of the regional population, as shown in the chart below. This appears true at the hospital level too. London has the lowest population vaccine coverage and, as of 31 October, also accounted for 16 of the 20 NHS trusts with the lowest rates.
We should know by now – particularly given the experience of the last 20 months – that we can benefit greatly, and avoid needless mistakes, by learning from the past and elsewhere. In this respect, it is important to note that making vaccines a requirement of deployment in health care is nothing new and so lessons on how to implement it already exist.
Reportedly the first medical centre to require vaccines was Virginia Mason in the USA back in 2004. They appear to have had success and learnt lessons from compulsory influenza and, more recently, coronavirus vaccinations.
And some countries have trialled – with varying degrees of success and challenges – requiring Covid vaccinations for health care staff for some months, including in Italy where it’s been compulsory since March this year. The experiences of these nations will point to opportunities as well as unintended consequences that can inform implementation in the NHS. In the UK, there has been long-standing guidance that health care staff doing certain exposure-prone procedures must have had the Hepatitis B vaccine.
There are also lessons from other sectors. In particular, a compulsory Covid vaccinations policy for staff working in care homes in England was announced in July. As shown in the chart above, rates across social care staff vary between settings, although the data – which do not neatly align with the staff groups covered by the policy – pre-date the deadline for second doses (11 November) by a few days. So while there may be some emerging lessons, including the importance of offering advice, the full story is as yet unclear.
The consequences of this policy on the workforce may be considerable. The Department’s own impact assessment estimates that 126,000 of the health and social care workforce subject to the new regulations are expected to remain unvaccinated. However, they accept there is a high degree of uncertainty around this estimate, with their own calculations suggesting it could be around 50,000 higher or lower.
Encouraging vaccine take-up and reducing hesitancy will inevitably reduce the risk that this policy materially harms the sustainability of the workforce. There are established strategies to do this, including through use of targeted communications, improving access to vaccines and increasing opportunities to discuss concerns.
In addition, we have developed five tests that the Department and its arm’s-length bodies must demonstrate as part of ensuring an effective implementation of the policy, namely having:
- a clear grasp of the number of staff who have not taken the vaccine, including by staff group, protected characteristics, type of contract, and geography.
- a comprehensive understanding of why staff have not taken up vaccines – including medical exemptions and whether shortcomings in either access to, or information about, vaccines has been a factor – and removal of barriers where feasible.
- a targeted, evidence-based communications strategy to disseminate the benefits of comprehensive vaccination across front-line staff, including an appraisal of alternative and additional strategies to safeguard staff and patients such as through using Covid tests.
- an understanding of the likely effect on retention and morale, based on experience from other countries and sectors, and an accompanying strategy to manage the effects, including a realistic workforce plan for filling posts for staff moving or leaving because of the vaccine requirement.
- a clear view on, and plan to address, the regulatory, financial and legal implications at national and employer levels – including a clear articulation of where responsibilities sit and how the policy is applied including any exemptions – given, for example, the likely challenge to the policy from some and the enforcement issues that raises.
The debate highlights a long-standing failure, namely that the NHS has only a partial understanding of the motivations and wellbeing of its staff. In the long term, there needs to be a more forensic understanding of the reasons for joining and leaving the NHS and the motivation of staff to participate. However, in the short term, given the policy has been decided, the implementation needs to be done intelligently, with the wellbeing of staff and patients depending on it.
Palmer W (2021) “How to minimise the negative consequences of compulsory vaccines for NHS staff?”, Nuffield Trust comment.