Childhood vaccination: Access problems in UK began way before covid-19

Health and Social Care Act

Many medical leaders and healthcare professionals link access problems to the 2012 Health and Social Care Act, which abolished primary care trusts in England and fragmented the vaccination programme. In 2019 the National Audit Office released a report saying that when NHS England took responsibility for commissioning vaccine call and recall in 2013 it didn’t set out the requirements of GPs. This led to inconsistency in the way parents were invited and reminded to vaccinate their children. Other problems identified included difficulty accessing healthcare, incomplete data on vaccination uptake, antivaccination messages, and vaccine hesitancy among a small minority of parents.

“I do think that some of the changes to the way immunisation strategies have been delivered over the past 10 years since the Health and Social Care Act have had an impact, because it’s made a lot of those things far more fragmented, and information and support for the healthcare professionals are far less straightforward,” Donovan says. “One example is not having one portal where all of the vaccine immunisation information is kept any more. It’s on lots of different sites. And I think that in itself is confusing for people. We used to have an immunisation website with all of the resources, primarily for professionals but obviously open for the public as well.”

The 2012 act also separated health visiting and the delivery of vaccinations in community settings. “It seems illogical that a health visitor cannot vaccinate a child who is due for their jabs due to commissioning barriers,” says Khan, who—alongside City and Hackney Clinical Commissioning Group’s clinical lead for children and young people, Suki Francis—is leading a project to increase childhood vaccination uptake in Hackney, east London (box 1). “By shifting it to GP delivery, it may have impaired access,” says Khan.

In response to the declining rates the government was due to release a vaccination strategy in spring 2020, though this seems to have been delayed by the pandemic.5 The consultation document noted that the strategy would set out how the government plans to increase uptake of all childhood vaccines to over 95%, including through the enhanced use of local immunisation coordinators and primary care networks, consistent application of call and recall, and improved data services.

However, Helen Bedford, vaccinations lead at the Royal College of Paediatrics and Child Health, says many of the solutions have already been laid out in National Institute for Health and Care Excellence (NICE) guidance first issued back in 2009.6 This says that opening times of clinics should be extended and they should be made child and family friendly. “That means not only timing of vaccination sessions to allow for working parents but also the environment: somewhere to park buggies, space for children, etc,” explains Bedford, who is professor of children’s health at the Great Ormond Street Institute of Child Health.

NICE also recommends that tailored invitations be sent out and that, if appointments are not attended, tailored reminders and recall invitations should be sent, as well as follow-ups through phone calls and text messages. On top of this, parents and young people should be given “tailored information, advice, and support to ensure they know about the recommended routine childhood vaccinations and the benefits and risks.” This should include details of the infections the vaccines prevent, provided in different languages as appropriate.

Space and opportunities for parents and young people to discuss any concerns they might have about vaccines should be provided. “This could either be in person or by telephone and could involve a GP, community paediatrician, health visitor, school nurse or practice nurse,” NICE states.

Home visits to parents who have not responded to reminders, recall invitations, or appointments should be offered, with healthcare professionals able to give vaccinations there and then if consented to. This could especially help groups of people who may not engage with primary care services, such as Travellers and asylum seekers.

Finally, the immunisation status of children and young adults should be checked at every appropriate opportunity, such as during GP, hospital appointments, and emergency visits. “If all these recommendations were implemented across the board, this would be an important start,” says Bedford.

It’s normal to ask questions

Although vaccine hesitancy does not seem to be the main issue, it’s still a concern. “A lot of vaccine hesitancy and low health literacy levels is leading to mistrust of vaccines generally,” says Francis.

But Donovan says she does not like the word hesitancy. “Just because somebody has a question doesn’t mean to say that they are going to refuse the vaccine. It just means that they’ve got a question. We wouldn’t expect to give or advise any treatment and not ask questions. People who are antivax are an issue, particularly when it takes over on social media, but these people are a minority. We need to be really clear that people should ask questions, and we should be ready as healthcare professionals to answer them.”

This is where better training and support for healthcare professionals come in. “I would also say that vaccine programmes are quite complex now,” says Donovan. “We are vaccinating against more and more diseases, which is fantastic. But it does mean to say that the healthcare professionals delivering those programmes need to have constant updates so they can speak knowledgeably and support people to have confidence and accept the vaccines they need—and that can be a challenge.” She explains that vaccinations are primarily a nursing role but that, within nursing education, vaccination training is mainly taught after qualification.

Complacency is also an issue in high income countries, Donovan adds. “We don’t see these vaccine preventable diseases in the way that we once did. So they don’t have the importance in the public eye as perhaps we, as healthcare professionals, think that they should have.”

That is where the current pandemic may present an opportunity for improvement. Francis and Khan say that much of what has happened in response to covid-19 can be applied to childhood immunisations, including community activation and education about vaccines, training staff to have conversations to increase vaccine confidence, and adapting vaccine delivery to fit the needs of patients and the community (such as having weekend and evening clinics and offering home visits.)

As Donovan puts it, this is an opportunity: covid-19 has shown the importance of vaccination and has extended conversations over efficacy, trials, and risk-benefit analysis out to the public. “We could use the information and learnings from the covid vaccine to have a better dialogue with the public about how vaccines work,” she says.