Childhood Vaccinations Committee 

Corrected oral evidence

Monday 9 March 2026

2 pm

Watch the meeting

Members present: Baroness Walmsley (The Chair); Baroness Andrews; Baroness Browning; Baroness Cass; Lord Dholakia; Baroness Freeman of Steventon; Baroness Neuberger; Baroness Nye; Lord Randall of Uxbridge; Baroness Ritchie of Downpatrick.

Evidence Session No. 1              Heard in Public              Questions 1 – 21

Witnesses

I: Dr Helen Stewart, Officer for Health Improvement, Royal College of Paediatrics and Child Health (RCPCH); Helen Donovan, Chair, Self-Care Forum, and independent nurse consultant; Dr Alexandra Creavin, National Institute for Health and Care Research Clinical Lecturer, University of Bristol, and Public Health Registrar, South West Deanery.

USE OF THE TRANSCRIPT

1. This is a corrected transcript of evidence taken in public and webcast on www.parliamentlive.tv.
   

Examination of witnesses

Dr Helen Stewart, Helen Donovan and Dr Alexandra Creavin.

Q1                The Chair: Good afternoon and welcome to today’s meeting, which is the first oral evidence session as part of the committee’s inquiry into childhood vaccination rates in England. I would like to thank Dr Helen Stewart, Helen Donovan and Dr Alexandra Creavin, who are attending. The first two witnesses are joining us in the room, and Dr Creavin is online. This session is open to the public, will be broadcast live and is subsequently accessible via the parliamentary website. We will be taking a verbatim transcript of the evidence, which will be published on the parliamentary website. A few days after this session, our witnesses will be sent a copy of the transcript so that they can check it for accuracy. It would be very helpful if you could advise us of any small corrections as quickly as possible after you receive that. If, after this evidence session, any of the three of you wishes to clarify or amplify any points made during your evidence or have anything additional that you think would be helpful to us, please submit supplementary written evidence to us. I need to warn you that there may be Divisions in the House this afternoon. If that is the case, I will pause the recording and we will resume in 15 minutes.

I think we are all ready to start with the questions. As usual, as Chair, I will ask the first question. Why is childhood vaccination important, what impact does it have, and what are the benefits and the costs of routine childhood vaccination programmes in England? Helen Donovan, would you like to start? Introduce yourself briefly before you reply.

Helen Donovan: Thank you. I am Helen Donovan. I am a registered nurse with over 40 years of experience, and over 30 years of experience in vaccination. I worked in vaccination—sometimes, I think, for longer than I should have done—and as a practice nurse, a health visitor and an immunisation co-ordinator; I was at the Royal College of Nursing; and I am also now the chair of a charity for self-care. I work independently, mostly around education and training.

In answer to the question, I think the evidence is absolutely clear that vaccination is so important for saving lives and preventing deaths and ill health. The latest NHS data suggests that we have prevented over 5,000 deaths through the pre-school vaccination in England alone, and even more hospital stays, obviously. When we look worldwide, there was a study published in 2024, which I always quote when I am teaching because I just think it is so impressive: 154 million deaths prevented in 50 years. This is the evidence on saving lives and morbidity of illness, and, of course, those children then go on to live productive lives. I am not sure how you quantify that, in reality.

Obviously, on the cost, we need to invest in this, because it is about investing in our children and their lives. I could talk about individual vaccines. We have recently implemented the RSV vaccine for maternal and for older people, and there is very clear evidence almost immediately of the impact of those vaccines. We could talk about measles and the MMR—I am sure we will come on to them—and things such as the hepatitis B vaccine and the cost implications and the saving of morbidity for that.

I am going to let my colleagues come in as well, because I think it is just so important that we do not forget this really clear evidence about how important these vaccines are.

Dr Helen Stewart: Hi, I am Dr Helen Stewart—another Helen; there are many of us in vaccinations—and I am the officer for health improvement at the Royal College of Paediatrics and Child Health. Anything related to improving child health comes under my remit, which includes vaccinations and health inequalities. I am also a clinician: I am a consultant in paediatric emergency medicine in Sheffield, and I have worked there for 13 years now and as a consultant since 2019.

I would echo everything that Helen has said. We know that vaccines have saved millions and millions of lives across the world. In this country alone, they have saved thousands and thousands of lives. They are an unquestionable benefit to society, and they allow children to grow up healthy and safe and become productive members of society.

I can add my clinical perspective to the evidence that has already been talked about. I have seen children die every year from flu and RSV, and I have seen children come to the emergency department and go to intensive care units with measles and chicken pox. It is incredibly frustrating, from a healthcare professional perspective, to see a child so unwell from something that could potentially have been prevented. I think it is impossible to quantify the benefits of vaccination to us as a society.

The Chair: Thank you. Vaccination programmes obviously cost quite a lot, but am I right in assuming that you think the cost is outweighed by the benefits?

Dr Helen Stewart: Yes—how do you put a cost on the lives that it is saving? There is also the cost of the morbidity that comes with these vaccine-preventable diseases. Before polio was virtually eradicated in this country, the costs of the disability caused by polio were huge. I speak to parents who have come from countries where polio is still present, and they are extremely keen to get their vaccines, because they have seen the impact it has on their relatives. There are huge costs that we are not having to pay because of the vaccination programme.

The Chair: Thank you very much. Could we have your perspective, Dr Creavin? Please introduce yourself briefly. Oh, dear—we are not getting any sound from you, I am afraid. Can the technicians do anything about that? Are you muted at your end? Are you hearing us? Nod if you are. We are not hearing you. That is a shame, because, a few minutes ago, we did. Is there anything the technicians can do, or shall we move to the next question while you sort it out? Okay. I am very sorry, Dr Creavin. We are trying to sort that out for you, but we will come back to you. The second question is from Baroness Nye.

Q2                Baroness Nye: Hello. Just to put it on record, I have no interest to declare for this committee. What is the evidence on childhood vaccination coverage in England, what are the disparities in coverage, and how are coverage and disparities changing over time?

Dr Helen Stewart: I will start. On the coverage changing over time, it is decreasing, unfortunately: vaccination rates are falling across all four nations in the UK, particularly in England, actually. That is also the case when you delve deeper into the evidence. If you look at children living in difficult economic circumstances, rates are falling even more. That is the same for certain ethnic minorities. The evidence is showing a really concerning picture at the moment on vaccine coverage. In absolute numbers, the evidence base is fairly good. We do not collect data routinely on the rates in different ethnicities and socioeconomic circumstances; that would be a really useful point to add to the data collection.

Helen Donovan: One of the things to add to this is that I think it is fair to say we have seen the disparities in uptake of vaccination go up and down over the years. I certainly remember working with Traveller communities and other marginalised communities way back in the 1990s and having similar pockets of inequity. I think Helen is absolutely right. We now have data on ethnicity for the RSV and pertussis vaccines in pregnancy, which shows a very clear reduction with ethnic diversity, but that does not follow through for all the vaccine programmes. That would be quite useful to have.

The underlying principles that we look at as to the reasons were looked at by the WHO back in 2014. Whether you think of it as a 3C model or a 5C model[1]—I am sure you have heard about these things.  Public context and, communication, what people have seen and heard and convenience—is something that some people do not think about. But if you are a parent trying to get an appointment and you are working and your child is well, so it is not an urgent thing and you are not going to A&E, you need it to be easy.

Complacency, most parents, certainly in this country, have not seen these diseases, so people think, “Why worry about it?”. They hear something on the news or see something on social media or hear the school gate talk—it used to be called the “school gate mafia” when I was a health visitor—and people think, “Maybe I won’t bother”. All those factors come into it and, if you are marginalised anyway, those issues become even more prevalent. Those are the things that we need to look at. It is very much local populations that we need to look at. That is where I would say that the people delivering the services—very often the nurses—need to be given the time to understand their population. The evidence is out there, but the disparities are very much down to local population needs.

The Chair: Thank you. Can we try Dr Creavin again? I think we may have secured the sound.

Dr Alexandra Creavin: Can you hear me now?

The Chair: Yes, we can. Hooray. By the way, Dr Creavin, if you would like to go back to the first question as well and answer that, by all means do. Sorry about that.

Dr Alexandra Creavin: No, I am sorry. I did not hear all of the previous responses, so if I repeat anything from the second question, please excuse me. I am Dr Alexandra Creavin. I am a clinical lecturer in public health at the University of Bristol. I research vaccine uptake, particularly among underserved communities. I am also a registered doctor, an acting consultant in public health at the UK Health Security Agency and co-chair of the Vaccination Special Interest Group.[2]

I agree with the points raised in the first question in relation to the importance and impact of vaccines. It is easy to forget that in the past, and for most of history, around half of children died before they were 15. Some of that was accidents and other reasons, but a large part of that was infectious diseases, especially when compounded by malnutrition. The path of our lives has been hugely changed by vaccination. In the past, most parents would experience a child death, which we do not see in the same way now.

The huge impact it has on healthcare was also mentioned—hospitalisations and infection control workload—and I will just touch briefly on costs. There was a study in 2016 to 2017 of the amounts that GP practices were paid relating to vaccines. I think it was £227 million, which is a large amount of money, and it needs to be cost-effective. That is why we have the JCVI, to show that the vaccinations we choose to provide are cost-effective, and effective as well.

My first experience of understanding how important vaccines are was when I was a medical student doing a paediatric rotation and I met a little boy in the orthopaedic clinic who was three and had survived meningitis. He was a double amputee with two false legs, and he also had a false arm. The fact that we now have a vaccination for meningitis B, which is what he had, is transformative in terms of what children might experience if they have had that vaccination.

A final point on that is that not everyone who is protected by vaccination are the people who have had vaccination. A large driver for having good coverage of vaccines is to protect those who are vaccinated but also those who are too young or vulnerable to be vaccinated—for example, under ones with MMR who cannot be protected. That is also a benefit of the programme.

Baroness Nye: How reliable do you think the UKHSA’s local coverage figures are, and what are the biggest gaps in evidence or data quality?

Dr Alexandra Creavin: That is a very good point. There are challenges with the data. In Bristol, during the measles outbreak in Birmingham, a lot of work was done locally to look at the data we had and we found that quite a few people had been vaccinated who were not recorded as being vaccinated—particularly adults and people who were not born in the UK who may have had a vaccination through a different programme. Work was done specifically to support GP practices to update records by contacting patients individually and finding out who was vaccinated. We found hundreds of people who had been vaccinated who we thought had not been. That is an important area.

There are challenges with the data. Quite a lot of work is happening. It depends on which infection and which dataset. Not all data sets speak to each other. If you want to find out which populations, for example, have a low vaccination rate, you are relying on having that data completed as well. We do not have very good language data or ethnicity data. A lot of work has happened in those areas as well. But trying to draw conclusions is difficult when you do not have the full picture. Things are much better, though, than they were only a short time ago. It is an improving area, but certainly having good data is really important for understanding who is not vaccinated and who could benefit from more information and support.

The Chair: Thank you. Before I come to Baroness Andrews and Baroness Cass, who have supplementary questions, do our other witnesses have anything to add about the strength of the evidence base?

Helen Donovan: I echo what Alexandra has just said. But one of the key drivers that we need to really push forward is to have this interlinking and cross communication between the different data sets. A lot of work has happened over the last few years about vaccines being given in, say, maternity or in pharmacy, and what happens is that that data does not necessarily come back to the GP practice. Ideally, we need to push for that, because then it is there within one record for that particular patient and it gets fed in.

Alexandra is absolutely right: the problem has been that the systems do not talk to each other. Picking up where people have been vaccinated and we do not have data has been going on again. I remember doing that when I was an immunisation co-ordinator in north London. It is an ongoing problem and one of the things we have to remember is that we might get it sorted out in the short term but we need to keep it on. So, after the cohort we sort out today, we then need to think about the cohort tomorrow et cetera. It is an ongoing process that we need to really keep our finger on.

Dr Helen Stewart: I also echo everything that has been said. Helen mentioned the importance of systems that talk to each other. I would add systems that are accessible for parents, because one of the difficulties I have every day is that I can ask a family, “Is your child fully vaccinated?” and the parents are often not 100% sure. They think that they are, but they are not sure, and there is no easy way to check without going through a GP practice, which can be very difficult to access.

As someone working in secondary care in a hospital, I cannot see my patients’ vaccination records, so I cannot check myself. I might have a child who presents with an injury that needs a tetanus booster, or they might need a hepatitis B vaccination, and I cannot see what their status is. Until very recently, I also could not register that I had given that vaccination; I had to write a letter to the GP and they had to put it on the system. There are all kinds of holes in that process. We now have a way through that, but it is very recent. There is a lot of work to be done on the data we have and how we record it and share it. I know that using the NHS number as a single unique identifier has been talked about recently, and I think that that would really help for data continuity and linking up those data sets.

The Chair: So you can now give the vaccination and it will be registered. But is there any danger in giving it again?

Dr Helen Stewart: No, there is not a danger at all in giving it again; it is just unpleasant for the child. But that is specific to my trust. I know that in other trusts they would not be able to register that they had given it. It is a feature of our system that we have been able to put in place. So it is a local rather than national solution.

Q3                Baroness Andrews:​ Thank you, Chair. Can I follow that up? I have two other specific questions. Who is responsible for ensuring, as quickly as possible, that paediatricians have access to this data, not just in your trust but across the patch? Is anyone making this their particular responsibility?

Dr Helen Stewart:​ Not that I am aware of. I think everybody has to look locally to what IT system they have purchased and that they use and to how they talk to each other.

Baroness Andrews:​ So it is as specific as that? You have to fend for yourselves and find the data?

Dr Helen Stewart:​ Within the region. Within our trust, we use a particular system that we have chosen as a trust; it does not speak to the community system.

Baroness Andrews:​ So it is a postcode lottery perhaps? If that is not too banal.

Dr Helen Stewart:​ Potentially.

Q4                ​​Baroness Andrews:​ My other question is on your job title. In the Office for Health Improvement, within the Royal College of Paediatrics and Child Health, to what extent is vaccination seen as an area where there really needs to be improvement? Is it a specific part of a strategy for health improvement? Is it a high priority? Or is it one of the many things that you would describe as needing improvement?

Dr Helen Stewart:​ I would say that it is one of our biggest priorities at the college at the moment and has been for a couple of years. It is a really big issue for a lot of paediatricians, because they are seeing children every day. I have a lot of children presenting to the emergency department with flu and RSV, a lot of whom are not vaccinated, so it is a huge priority. So much so that, last year, we created a commission on access to vaccinations to try to really understand why vaccination rates were falling. I am sure that you saw in the news that a young person unfortunately died of measles last year in England. That just made it ever more important for us to look into it and try to understand.

Baroness Andrews: ​That is really helpful. Dr Creavin, what is the vaccination special interest group? What is its task and mission? Does that bear down on closing this gap on access to, and take up of, childhood vaccination?

Dr Alexandra Creavin:​ That is a new group that has been set up. I am not representing it today, but it is newly established in response to the concern over the vaccination rates in the country. It has not got a remit to improve vaccination; it is supposed to be a place to bring together people within public health who are either working in vaccination or have an interest in vaccination or are researching those topics. The aim is to have those people be at least able to speak to each other. One of the main focuses initially will be around training for people who are delivering, or who are involved in, the vaccination pathway. We will probably come to this, but it is quite a fragmented system, and it may become even more so with NHS changes and reforms. The idea is to try to have a place where people can come together to find out information and share ideas and resources.

Baroness Andrews:​ What will you do with the information and ideas? Who will you want to talk with to get action?

Dr Alexandra Creavin:​ It will depend on the area. When it comes to training, that is currently the responsibility of the Health Security Agency. There are some elements that are the responsibility of NHS England, and there are other areas that may be devolved to ICBs. There are also regional leads, and obviously GPs, who are running practices and providing vaccination and school-age immunisation services. There are lots of parties, and there is not necessarily an easy way of communicating across all of those. There is not a sort of pyramid system or anything; it is quite fragmented. One of our aims is to be a more united voice within that, at least for public health.

Baroness Andrews:​ You have just demonstrated the fragmentary nature of the problem, have you not? You have to tell different people. You might be able to address the other data issues—the fragmentation of data as well as agency. Do you have a priority for the next six months, or a series of priorities that we might look to see in development?

Dr Alexandra Creavin:​ It has been set up only since last month, so the priorities are being determined at the moment.

Q5                Baroness Cass:​ I am Hilary Cass. I do not have any conflicts to declare in relation to this, apart from having been a practising paediatrician and sharing your pain, both from the hospital end—seeing the morbidity—and from the community side. Just briefly, when I was in the community, my opposite number trained in Delhi. They were almost reduced to tears of frustration because, at home, their families would walk 200 miles from the villages, carrying their children to get them vaccinated, and we could not get uptake in Stoke Newington.

My question may have been rendered irrelevant in the face of what you have said about the patchiness of the data, but if we look at falling rates of uptake and compare different ethnic groups, is the rate of decline greater in some ethnic groups? They are all declining, but is there a significant difference in the rate of decline in some ethnic groups? The second question is, if you look at similar levels of deprivation and then look at different ethnic groups within that, does that give us any clue to the kind of relative weighting of deprivation versus ethnic factors? Does that make sense?

Helen Donovan: One of the challenges is, as you have said, we do not really have that level of granularity with the data, but whenever you look at any of the uptake data you can see that deprivation is a significant factor. Whether ethnicity comes into that or not is difficult to determine, because we do not have that ethnicity data throughout, but certainly from a London perspective, one of the things that adds into that is the churn of population, and I suspect that that is the same with other big urban areas. You have people moving around all the time, so actually knowing your denominator is a really big challenge.

That comes back to one of the points that I think Alexandra was making about getting children’s previous vaccine data recorded, because parents do not always have that information. We have this thing called the Red Book in this country. I know that you have knowledge of the Red Book, but other colleagues may not. All parents will have this for their child, but that may well not always be easily accessible. So that is another factor that goes in with it.

There is an argument for having a national drive, but you need to then be able to look at the data at a local level to see what the challenges are within your local population, whether that is because of a particular ethnic group or because of a particular challenge with getting appointments in that locality—whatever it is. There needs to be a strategy. Yes, the training and delivery is set by the UKHSA, but how that is then delivered is very much up to local systems. That is not always given the importance that it should be given, so staff do not always get the training and confidence to do what they need to do at a local level.

The Chair:​ I see that Dr Creavin has been nodding.

Dr Alexandra Creavin:​ Yes, I agree, and I definitely agree with the point that local data is really important, because it does vary across the country as to which groups it might be important to focus on. There is a very clear socioeconomic gradient, and that was actually exacerbated after the Covid lockdowns, where it became more pointed. There are several ethnic minority groups that have lower uptake; there are also ethnic minority groups that have higher uptake than white British populations. Those have sometimes been commented on as perhaps case studies where we can look at what the reasons behind those differences might be.

There are also smaller groups—for example, children with complex medical needs, where parents might have concerns about their individual needs, or they may need many hospital appointments and have complex challenges. There are also those with refugee status, so it might not be ethnicity; it might be about the country of origin and their ability to take part in the vaccination system here. There are geographical differences too. London consistently reports lower rates—that may relate to what was just said about people movement—but there may also be other factors in that.

In Bristol, we have looked locally at our population and found that there was a huge gap among, at the time, 17 to 30 year-olds—who would be 20 to 33 now. That was partly because of the timing of Wakefield and those reports. There are lots of people in that group, in various populations, who we have on our radar now. There are people who did not even realise they were not vaccinated and so do not know that they are at risk. In fact, we had one person in our research team who found out they were not vaccinated as a result of us doing the study. It is varied: locally, different cities might have different findings, and it depends whether it is city or coastal as well.

The Chair: Thank you. Baroness Freeman also has an interest in data.

Q6                Baroness Freeman of Steventon: Yes, I was going to ask—actually, it follows on very well from that—if there are any groups that you know of where the vaccination rates are perhaps increasing, or at least not decreasing, and what those are and what we might learn from them.

Dr Helen Stewart: If I could just add on what Baroness Cass asked on socioeconomic deprivation and ethnic minorities, there is some complexity there, because the areas of socioeconomic deprivation often map onto areas where there are high numbers of people from minority ethnic communities. It is quite complex and quite tricky to understand. There need to be multifaceted, targeted approaches to cover all those factors, rather than just one or the other.

On doing well, we know that, for instance, there are some areas within England where rates are not falling in the same way as other places. South Tyneside tends to perform very well; it is not entirely clear why, and it is definitely something to be studied. There are some ethnic minority groups that have very high rates of vaccination coverage as well. Every community and area is different and needs to be looked at by the locality on an individual basis, I think.

Baroness Freeman of Steventon: Which ethnic groups had higher coverage?

Dr Helen Stewart: My understanding is that East Asian groups particularly tend to have very high rates of vaccination coverage, as an example.

Helen Donovan: It is often vaccine specific as well. Sometimes, there are particular concerns for some vaccines. I was going to say that we saw that, with the Covid vaccine, the Bangladeshi community started off with a very low uptake in Tower Hamlets, then a lot of work was done to target them with particular strategies and the uptake went up. With some of the ethnicity data, the Chinese population is showing very high uptake, but it seems quite vaccine specific; that may well be because of the quality of the data that we have as well. I think it goes back to being able to understand the local needs and local drivers, because it often comes down to particular community challenges and things that are being talked about within that community, and the staff having that knowledge about their local community.

The Chair: Dr Creavin, have you anything to add to that particular point? Any good news in Bristol?

Dr Alexandra Creavin: No, I agree. I would say that there is no good news that rates are rising; across the board, rates are falling, but they may be falling less than we were projecting. Certainly, a lot of work has happened in Bristol since seeing the Birmingham outbreak. We were able to plan ahead a little, seeing that up the motorway, and have that benefit. We have a lot of work in particular communities locally where we have seen improved uptake as a result. I would not say it is rising uptake compared with the historical trends; it is more that it has rescued the uptake.

The Chair: Thank you. We will now move on to the next question, from Baroness Ritchie.

Q7                Baroness Ritchie of Downpatrick: Thank you, Chair. I have no particular interest in this regard to declare, just an abiding interest in the vaccination programme. You are very welcome today. What are the consequences of the decline in childhood vaccination coverage and the disparities in coverage? Obviously, we have seen an outbreak of measles in Enfield. Is there a correlation with a downturn in vaccinations? What would be the impact of that on public health and the incidence of disease? The second part of my question is this: in your experience as practitioners, how aware are the parents and the general public about the possible consequences of a child not being vaccinated? I will go to Helen Donovan first.

Helen Donovan: Thank you. Essentially, it is about those who have not had the vaccines—I think Alexandra picked up on this as well—because of their age. We do not give the MMR vaccine to children under the age of one because we cannot guarantee that it will work effectively, so those children are particularly at risk of measles. If there is measles out in the community, they are going to catch it, because measles is so infectious. It is the loss of herd immunity; it is community immunity that we are losing. Of course, there are also those children with underlying complex health needs, who cannot have particular vaccines for certain reasons. That is the broad area.

In coming to your second question, many parents are quite well informed, but, unfortunately, there are also a lot of parents who are not so well informed. I guess one of the challenges that we always have with vaccination is it being a victim of its own success: if you have not seen polio or measles, then, is it something we really need to worry about, or are these diseases that children will get, where it is just one of those things?

There are also the consequences of those diseases. Measles does not just cause challenges for measles; it is about its late effects and the way our immune system can then respond. You get this thing called immune amnesia with measles, so children are then susceptible to a whole host of other infections for two or three years, sometimes five years, after a measles infection. That is not really well understood, and it is quite a difficult thing to explain to parents.[3]

There is an underlying, I suppose, acceptance that these are horrible diseases, but I suspect that most parents these days really do not know what that means in reality, because they have not seen it—unless you are coming from other parts of the world. As both Helen and Alexandra have said, if you have parents who come from other parts of the world, they will be very keen to tell you how important protecting against these vaccine-preventable diseases is. But for parents in this country, I suspect it is not seen as quite so important.

Baroness Ritchie of Downpatrick: Is that because of a historical reason—that they are no longer living in a period where incidents of that type of disease are prevalent?

Helen Donovan: Absolutely, yes.

Baroness Ritchie of Downpatrick: Have we got any data on the breakdown of parents who fully embrace it and understand the issues of not vaccinating, or of the other group who do not embrace it?

Helen Donovan: There is a lot of qualitative data looking at the reasons why people do not vaccinate. It often comes down to particular groups, and it is often very vaccine specific. As I said at the beginning, the reasons often come down to confidence in the system and in the vaccines but also confidence—or complacency, if you like—about whether these diseases are really something that they should worry about. A lot of these things often overlap if it then becomes too challenging for them to get appointments. We need to look at a multi-pronged attack and a multi-pronged approach to how we improve the vaccine uptake.

Dr Helen Stewart: I would echo that we are seeing the consequences: we are seeing more measles; we have seen children die; we are seeing children get admitted to hospital. Those are the consequences of the decline, unfortunately. Measles is usually the first to raise its head because it is the most infectious of the diseases that we vaccinate against, so it is the first thing that we see, and it means that we need to start worrying about the other conditions as well.

In my experience, I would say there is a loss of collective memory about these conditions and how unwell they can make people. I have had families that pick and choose. They might say that they have had the meningitis vaccine because they know that that is serious, but they want to wait for the others or are not sure about them. Each family is making their choices on an individual basis about what they are aware of.

I would also include healthcare professionals in that group as well, though: unfortunately, there are quite a lot of healthcare professionals who do not have any training in vaccinations. There are studies to suggest that, if a healthcare professional is confident and knowledgeable on vaccines, they are more likely to have the vaccines themselves and to recommend vaccines to their patients. I think there are a lot of healthcare professionals who are resistant to some vaccines. In our report, one parent reported that they had been told by a midwife, when they would gone for their RSV vaccination, not to have the vaccination because it was a new one. She had literally gone to the appointment to have it and was told not to have it by the healthcare professional there. There is also some work to do around making sure that healthcare professionals are all well educated and well trained, and that they are given the time and the resources so that they can all speak with the same voice. We know healthcare professionals are a really respected voice of information about vaccines. People really trust them; I should say “us”. It actually carries an awful lot of weight if people go to their GP and they are really confident in the benefits of vaccination. They hold a lot of sway with families, so there is a whole big piece of work there.

Baroness Ritchie of Downpatrick: What preparations are currently being carried out by the various bodies involved in the vaccination programme, with a view to training professionals about its importance?

Dr Helen Stewart: UKHSA is working on some educational materials now to be able to roll out to healthcare professionals. There is also a nationally available training package for how to talk about vaccines. However, it is not mandatory, and obviously there are a lot of things that healthcare professionals have to do, so they need the time and resources to be able to sit down and actually do the training and have it facilitated for them. But there is stuff out there.

Dr Alexandra Creavin: I will come back to that question, which is important. I will just start with the first part about the consequences. I agree with everything that has been said. I was just going to add that there is a lot of pressure on emergency departments and GPs when there is an outbreak of infection, especially when it is something very infectious like measles. Just sitting in the waiting room, people are going to be infecting other people, and you are infectious for four days before you have the rash. Trying to contain things—seeing people outside—is very complicated.

There is also a lot of work involved in outbreak control, which often is not really very visible within the NHS—contact tracing if there is an infectious disease, urgent clinics for vaccination and so on. There are lots of consequences for that work as well for the health system and not just for individuals and for those who are not protected by the vaccine.

There is quite a helpful table that was looking at what the impact is in terms of lives saved. Before the vaccine came out for diphtheria, there were just under 3,000 cases a year of diphtheria. The population was smaller then, but we are looking at around that number of people having diphtheria. There are similar counts given for different other diseases—meningitis, 224, for example. These are real numbers of people that are not dying because of infections.

What do people know about the severity of infections? This is such a key area. I completely agree with the reasons people have given about the loss of memory across the country. That is true for healthcare workers as well. It used to be that, if you saw your GP, they would have a memory of seeing people with measles. Now of course that will be true again, but it was not true for a while. An attitudinal survey is done every year by the Health Security Agency that asks parents about this question. There has been a slight improvement. They are asked if they view, for example, measles as very serious and it has gone up from 41% to 48%, though still fewer than half of people report considering measles very serious. You can see there is work to be done there.

Having said that, we do work with particular groups, and one of them is with our Gypsy, Roma and Traveller community in Bristol. Actually, some of those parents feel stuck because they are very worried about measles—it is really hammered into that community—but they are also really frightened of the vaccine. These are parents who are trying to do the best for their children, but they feel caught between a rock and a hard place. We also do focus groups with students, and we did a focus group recently with medical students who all said they did not perceive measles to be serious. These are obviously doctors of the future, so there is definitely work to be done on both sides.

At the Health Security Agency at the moment, we are writing a framework for an action plan for training. That is because there are lots of challenges around training. The vaccination programme is far larger and more complicated than it was only a short number of years ago. The knowledge we are expecting healthcare workers to retain is much more. The range of professionals who are delivering vaccines—either administering them directly into arms or part of the pathway—is much higher, even down to teachers being part of the pathway in schools, where vaccines are being done there. There are pharmacists and health visitors. It used to be really quite a small group—school-age nurses and nursing teams in primary care. The range of people that need training is much bigger. The diversity of the population and what questions they might want to have answers to is broader, and not everyone is equipped to answer those questions. There are many other reasons why it has got more complicated.

At the moment, we do feel that there needs to be quite a big change in how we do training, to make sure we can assure ourselves that people not only are meeting the minimum standards which are published by UKHSA, but are actually getting the sufficient training that they need to do a really excellent job of supporting people to make a decision for themselves about vaccination. That is recognised as a piece of work that really needs doing.

The Chair: Thank you. I have got a lot of supplementary questions on this particular topic. I have got Lord Randall, Baroness Neuberger, Lord Dholakia, Baroness Andrews and Baroness Cass, in that order. Lord Randall? We have to keep the answers as short as possible, because we do need to make progress.

Q8                Lord Randall of Uxbridge: It is actually a point of clarification. I think, Helen Donovan, you said that you cannot give MMR to children under one year old. Is there a vaccine for measles on its own for children under one?

Helen Donovan: The reason that we do not give it to children under the age of a year is quite complex. It is to do with the fact that they may well still have maternal antibodies circulating, which may well inhibit the vaccine virus replicating. You can actually give the vaccine in an outbreak to children from six months of age, but we would still then give the routine vaccine. The reason I brought that up is because babies under the age of a year, who will not routinely get the vaccine, will be potentially at risk in an area where there is an outbreak. It is quite complex but that is what I was getting at. It is the herd immunity that we are looking for with any vaccine—well, with most vaccine programmes.

Q9                Baroness Neuberger: I am really sorry, but I have got to declare rather a lot of interests, because it is the first time we have had an official public evidence session. I chair University College London Hospitals and the Whittington Hospital. I am a member of the North Central London ICB and I hold honorary fellowships at the Faculty of Public Health, the Royal College of Physicians and the Royal College of GPs. I apologise for all of that, but it is relevant because you were talking about the reluctance of staff and the question about staff training, and I am only too aware about all the statutory and mandatory training that our staff have to do. There is a wish, I think, to reduce the amount of it. As an NHS chair, I have to do loads of it. Would it not be more sensible to have mandatory training for health professionals in this area than some of the training that we do, first? Secondly, you began to talk about this, but how would you tackle the very obvious reluctance of quite a lot of health professionals to have vaccination themselves? We see that both with flu and with Covid, because we get that reported to our board every year. I find it inexplicable, really. It is really awful in central London.

Dr Helen Stewart: It is really challenging. I have had some very tense conversations with some of the nursing staff in our department. Everyone is susceptible to the same influences from the news and social media and the same concerns among each community, despite seeing all the children come in with flu every year. It is a real challenge. There is no good evidence behind a particular way of changing those minds. But there is room for really good education on and training on each vaccine—on understanding how the immune system works, and the risks and benefits of each vaccine. Particularly in an emergency department, we do not necessarily get seen as part of the vaccination workforce, but it is really important to make every contact count.

Particularly for people from disadvantaged backgrounds, often if they cannot access a GP appointment in the same way then we are the place that they come. While there is an argument for making it mandatory, that is probably not relevant for all staff groups, so that is quite tricky. There are some who will not have an opportunity to have those conversations. It is a tricky balance in not overburdening people but getting them the right information, and I am not sure we have achieved that yet.

Lord Dholakia: Earlier you talked about the low uptake in the Bangladeshi and Chinese communities.

Helen Donovan: I said it was higher.

Lord Dholakia: It became higher later on, but I am talking about before that.

Helen Donovan: During Covid, yes.

Lord Dholakia: Did you look at the international dimension—whether the factors that applied here applied elsewhere, in third-world countries?

Helen Donovan: That was certainly looked at for Covid. As we know, with the Covid vaccine particularly, there were a lot of, shall we say, wider politics at play in terms of trust between countries.

There is a danger of focusing too much on Covid vaccines. The childhood programme is very different. To pick up on something that Helen was just saying, it is about recognising the benefit of these wider diseases. The Covid vaccine served its purpose but, in terms of the benefit of the wider vaccine programme, we now need to do a lot of work. To pick up on what Baroness Neuberger was just saying, it is about instilling confidence in the wider vaccine programme.

I echo what you were saying about making things mandatory. I was working at the Royal College of Nursing during Covid, and there was anger from the adult social care staff about mandatory vaccination. It was not really to do with having the vaccine; it was more about being made to do something, and that switches the dilemma. A mandatory vaccine might seem like an opportunity, but I suspect it is probably not.

The problem that you may be getting at is that all vaccine programmes are different. Obviously there is an international element, and what is happening in people’s country of origin plays a part. In my experience, people from Bangladesh and India often have a high respect for vaccines and want to have vaccines in general, but that is not always the case with all ethnic groups, and we need to recognise that.

The Chair: We have two more supplementaries on this question before we move on. I ask that one witness answers each of these in the interest of making progress.

Baroness Andrews: Something else that you might feel we should have written evidence on is the learnings from Covid and what you learned  about the best way to identify and deliver. Maybe it would be best to have something written from the witnesses.

The Chair: Indeed, the Covid inquiry has not concluded yet, and we will certainly be looking at that. Perhaps that is a reasonable response to that question, or is there other learning that any of you feel that we already have?

Helen Donovan: I would be very cautious about the fact that the childhood vaccine programme is very different from the Covid vaccine. The delivery mechanisms that we employed for Covid were by definition very different from the ones we need for children’s vaccines.

Q10            Baroness Cass: A week or two ago, Baroness Browning was much more worried about training than I was. I think that is because I am a fossil. Back when I was doing this, we had a senior community paediatrician who was responsible for training in the patch, and everyone went to them and there was less scepticism. Clearly it is very different now. If you look at training, you could have it run nationally or locally, but it seems to me that you need someone in a local patch who people have confidence to go to. That seemed to get lost around the 2012 reforms. Is there anyone locally now who is a go-to person who has that responsibility for a patch?

Dr Helen Stewart: No. We were talking about the loss of the immunisation co-ordinators in different areas—a clinical person who was responsible for overseeing vaccination programmes and training in their region—and unfortunately that has gone. That is something that it would be really helpful to bring back.

Dr Alexandra Creavin: I agree. There is definitely merit in reintroducing that; there is not a good understanding of who should be training and to what degree.

On the Covid question, there are quite a few lessons to be learned. I completely agree that the two programmes are not the same. I would say there are two angles. One is that a lot of good was done during Covid to build relationships with communities, and that could be learned from. On the contrasting side, a lot of damage was done in terms of openness about vaccine side-effects or people feeling pushed into having vaccines that they did not feel people knew a lot about, and that has done a lot of damage to relationships as well. Both those angles, positive and negative, could be looked at.

Q11            Baroness Neuberger: You will be relieved, because we are running late, that you have covered some of this. You have covered a lot of the evidence on why childhood vaccination coverage has declined in recent years and why there are disparities in coverage, but I draw your attention to the point that has just been made about the whole health system leadership, commissioning and funding, and it all being a bit chaotic—I speak as someone who is involved in it—and whether you think the changes since 2012 and the ongoing changes are making a difference even now, and what you would see as a way through that might help.

Dr Helen Stewart: Vaccination rates have been falling since 2012, so it is possible that the new organisation had some impact. I do not think the routes of responsibility are particularly clear at the moment. I know it was announced this morning that the takeover by the ICBs is being delayed, which will cause a bit of confusion about how it is all going to work.

On the wider question about evidence on vaccination coverage and why it is falling, a lot of the report that we released last year was about what was reported back to us by parents about accessing appointments, how easy it is to access an appointment, how difficult it was to find someone to put their questions to, understanding what was available in their local area and where was an easy place to get their questions answered. Parents themselves did not really seem to bring up misinformation as such when we were talking to them; a lot of it was about knowing who they could go to and finding the time when you are busy and you are working. People from deprived backgrounds in particular have a lot more barriers to accessing healthcare than those in in wealthier areas; that translates into vaccination access as well, and a lot of the same difficulties come up. There is a lot that the system can look at and work on to improve things.

Baroness Neuberger: To pick up on the pressures, particularly in poorer areas and for poorer groups, do you think some of that is due to poor access to GPs, or could schools do more? Where do you think some of this lies?

Dr Helen Stewart: I think it is access to the healthcare system. For instance, our health visitor service in Sheffield has started doing drop-in clinics in schools, so after school they can just walk in and get some catch-up vaccinations. It is things like that, going to where people are so they do not have to pay for a bus. I work in a city centre hospital and we have a Q-Park. It is not cheap, and we have people saying they cannot come to appointments because they cannot afford to. It is going to be the same for people trying to get a vaccination appointment as well. Can they afford the bus? Can they afford to take a day off work? A colleague has done a lot of work talking to families, and they had real issues. They would call up for an appointment and they were told the appointments were not released yet; then they would call on the day they were released but all the appointments had gone and they had to wait for another day. It means call after call after call, just to get what should be a straightforward, easy process. There are a lot of these issues that need ironing out.

Baroness Neuberger: And particularly for the older children, not the very small ones, do you think the schools could do more?

Dr Helen Stewart: We did a youth forum discussion with some really interesting young people, and they were asking for more education in schools. They asked because they said, first, they want to know; and secondly, they are parents of the future, so they want to have the information so that they can make the decisions for themselves. There is definitely space for some education in schools, and also some support from schools in facilitating appointments and making it easy. Obviously, we lost the Sure Start centres, which were a great community place that people could go for things like that. Schools could potentially have a role in replacing that facility.

Baroness Neuberger: Do you think you could give us some data on your youth forum? It might be very useful.

Dr Helen Stewart: It is all in the report so we can get it to you; we can send you the report.

Q12            The Chair: Can I just come back to the people who have questions but perhaps do not feel they have got an opportunity to ask them? Some of the people not turning up is simply because they are not sure and they have not had a chance of asking. Everybody gets a call or a recall to a clinic, as long as we know where they are and that they are eligible. At the same time when people receive an appointment to go to a clinic, would it make sense if they were given information about how they can get answers to their questions, if they have them, before they turn up or do not turn up and waste an appointment? Would something like that help?

Helen Donovan: Absolutely, and there is really good evidence that it helps, for those people who do not respond to those initial appointments, having a nurse phone you up and then being able to give you the information. We talk these days as if health visitors vaccinating is a new thing. I am afraid I have been around for so long that I was a health visitor who vaccinated all around the time with the MMR in the early 2000s, and I would phone families and have a conversation—sometimes for just five or 10 minutes—and the number of people who would then say to me, “I wish somebody had said this” was really telling. We should have the confidence to be able to pick up the phone and say, “I see you have not had your appointment. Do you want to have a chat about it? Make an appointment”, et cetera.

The flip side of that goes back to the staff knowing where to go for queries. The district co-ordinator, the immunisation co-ordinator—those posts went. I was in one of those posts in north London, I am afraid; it went. The challenge then is: where do you go to get the information? I still do a lot of training and education, and sometimes the nurses come to me, because they know me, asking very detailed clinical questions. It is not my job to do it because I do not know the families and I am not there, but they have nowhere else to go. It is really important for the public to have someone but the staff themselves need a co-ordinator, because these are complex programmes.

Going back to the question of training, you can have training, but you need to then keep that up because these programmes change at least every year. Who do you go to get that information? It is that model. You have the national and then you have the district co-ordinators and the local co-ordinators being able to deliver the training, and the staff know that that is the person that they can access. It is really important.

The Chair: I know those catch-up programmes are very effective, but they do cost money and not every area has the money for them, does it? What I was thinking about was some system of people being able to ask questions before they have missed an appointment—when they first get the appointment. Anyway, perhaps we will look into that. Baroness Freeman and Baroness Nye have supplementary questions.

Q13            Baroness Freeman of Steventon: Thank you. Mine is quite a short one, and I must declare an interest in that I am involved in making decision aids for the NHS. I wondered whether you have any decision aids around vaccination, because these things that we are talking about are exactly what we used to do, which would be to collate information that lots of people would have questions about and then put it all into one document, that could be in a waiting room or whatever, that gives people all of the answers to the pros and the cons and the side-effects—all of the information that a lot of people are asking for.

Helen Donovan: There are some really good resources. The UKHSA produces them, increasingly in a range of different languages and in different formats. There is video, British Sign Language and all sorts of things, and they are all free. Unfortunately, a lot of the staff delivering the programmes do not know how to access them. I know that the teams at UKHSA are doing a lot of work at the moment to make this more available, but that could be more widely disseminated.

Q14            Baroness Nye: I think we all agree that it is not vaccine hesitancy; there are a whole number of access barriers that are the cause of this decline. Is there one specific thing in your opinion that, if it were addressed, would start to reverse that decline?

Dr Helen Stewart: Oh, that is mean. I would struggle to put my finger on one thing. It is such a complex issue and it is so multifaceted. For instance, there are resources out there but we know that, for someone to change their minds, they need to receive the information quite a few times. Actually having a decision aid there as well could be really helpful. We know that the public debate around vaccinations has become very toxic—quite aggressive. For parents, there is a real fear of asking the questions, and that would be helpful to get over. They do not feel that they have a trusted relationship with a healthcare professional whom they know, because you do not necessarily see the same GP every time. You might only see your health visitor four or five times, and then you might not have felt like you have built a relationship with them, and they are really overstretched. Having more time and resources for healthcare professionals to build those relationships and be available to answer those questions and allay any fears that a family might have would be really helpful.

The Chair: We are going to have to speed up, I am afraid, because we have four more questions, but we have one more supplementary on this from Baroness Andrews.

Q15            Baroness Andrews: Very briefly, I am following from the last question. Would you suggest that the committee recommend restoration of the co-ordinating role that you say had been lost in 2012? Given that the responsibility has been transferred to the ICBs—there is a question coming on the ICBs—would you suggest that that could be placed within an ICB or do you think, in fact, it stands outside the structure?

Helen Donovan: The challenge with ICBs is that they are quite big, and it needs to be possibly more localised than that. It could probably sit as part of the ICB, but there needs to be that local knowledge and ability to liaise.

The Chair: What about the director of public health?

Dr Helen Stewart: Within the director of public health office, do you mean?  That would give them more regional knowledge.

Baroness Andrews: You definitely would recommend that that post be restored?

Helen Donovan: I definitely would.

Dr Helen Stewart: Yes, it would be really useful.

The Chair: Let us move on to the next question and Baroness Browning.

Q16            Baroness Browning: I should declare that I am an officer of the all-party groups for health and also for autism, and the vice-president of the National Autistic Society. My question is, and it really follows on from what we have just been discussing: who is responsible and accountable for reversing the decline in childhood vaccination coverage and reducing disparities? How clear are the lines of responsibility and accountability? I am asking you that question and at the same time feeling that, in the answers you have given so far this afternoon, we have heard that there are problems with the data, there are problems with training, and there are problems with accessing staff resources. Let me just put it like this. If somebody asks you to draw an organogram tomorrow of exactly how the structure works and who or what is responsible, do you think you could do it? If not, who should be drawing up this organogram?

Helen Donovan: I feel that we have answered this, so does Alexandra want to answer it?

Baroness Browning: Dr Creavin, have a go.

Dr Alexandra Creavin: I agree. I do not think we could draw that organogram. I am going to speak as a public health professional now. It is a public health role, and we used to have a stronger public health voice, and that is within the whole team—public health, medical, the consultant, public health nursing. A lot of that structure has been lost, partly with the move from public health into different spaces; it has slipped to the side somehow, or is shared with screening, which has become much bigger. So yes, it needs a lot of work.

Helen Donovan: The challenge is that, when you try to reorganise these things, some of the elements that are needed to bring it together get dropped. The Section 7A arrangements for the national programme did not incorporate a requirement for training, so the responsibilities get very muddied. My role as an immunisation co-ordinator at the time sat within the public health directorate; I was employed as a public health nurse within that directorate. I agree with Dr Creavin that it should sit within public health, but then the directorate also needs to have oversight and the responsibility for that oversight, yet at the moment it does not. That would need to change as well.

Dr Helen Stewart: To me, it is probably more about clarity—being extremely clear who is responsible for each element, and that knowledge being available to everyone, rather than specifically who.

Q17            Lord Randall of Uxbridge: I have no declaration of any interests relevant to this inquiry. Do you think the Government, in what I think was the 2023 NHS vaccination strategy, identified the right priorities for improving childhood vaccination coverage and reducing disparities? Are you able to say what the strengths and weaknesses are of this approach by the Government?

Dr Helen Stewart: The Government’s strategy had a lot of the right thoughts. Their findings were similar to what our own commission found last year, with a focus on workforce, improving access and reducing inequalities. Some of the things coming out of that are going to be really interesting, such as the health visitor pilots and using community champions with local knowledge. Again, it needs more clarity on responsibility, and investment and time to implement are what are really needed.

Helen Donovan: I echo that. The strategy itself was fine. The question is: how we are going to deliver that without the real emphasis and the onus and more time allocated to be able to deliver it?

Lord Randall of Uxbridge: And what about the ambition to get pharmacies involved? Is that something you would be in favour of, or not? Or would you have to think about it a bit more?

Dr Helen Stewart: It would be interesting to see a pilot and see what the evidence was behind its use. They are often well-placed in communities, and we find that families are going to them more and more with low-level health problems, so that is definitely worth exploring.

Dr Alexandra Creavin: There is a systemic review of the use of community pharmacies to deliver vaccinations on a seasonal basis, and there is a current study happening in RSV. At the moment, the systematic review does not find that there is a benefit in improving inequalities or uptake. It would be important to make sure what the evidence was. It is obviously a different programme, so I am not saying that it would apply in that case as well, but it is easy to just bring more people in and think that will solve the problem, so it is important to make sure that the evidence is behind that.

Helen Donovan: We need to be careful about just saying, “We need more areas”. We need to skill up the people who are already doing it. Particularly for children’s vaccines, I am not sure how the logistics of taking a child to a pharmacy, if they need to have three or four injections, would work. I am not saying it would not work. We have good delivery mechanisms, but we need to put the money and resource there.

The Chair: Would they have a role for catch-up programmes—not the basic bare bones of it, but catch-up?

Helen Donovan: Potentially, yes.

Lord Randall of Uxbridge: Do you have any evidence from schools that there are not so many school nurses? These are just my own thoughts on it, but that is an issue as well.

Helen Donovan: Absolutely. School nursing very rarely delivers vaccination these days; it is done by school-age immunisation teams. That is another challenge, because when you speak to school nurses you find that they could often deliver vaccines as part of a wider package of care, going in and talking to people about their mental health and sexual health, alongside giving vaccination. Again, this is about separating out different functions, and it does not necessarily lead to overall good delivery. I work with a lot of school-age immunisation teams and they do a wonderful job, but often there is this challenge. I say you need to give it back to the nurses to do and they can manage it, as long as they are given the training, the education, the resource and the kudos to do it, because it is a complicated programme.

The Chair: But, since a lot of school nurses have two or three schools to look after, is that practical?

Helen Donovan: Exactly. Sometimes two or three would be quite nice; since they often have a lot more than that.

Baroness Nye: If you go to community pharmacies or schools, do not you get back to the data collection problem? If they are not all talking to each other, you do not have the data as to who has been vaccinated when.

Helen Donovan: Absolutely. The systems need to talk to each other. There needs to be one unique identifier and ideally it needs to go back to the patient’s record, whether that is with the NHS or sits within the GP data, and then to be extracted nationally. We did that for Covid, and we should be able to do it for the other vaccine programmes.

Baroness Nye: What is stopping that—the fact that everyone is fragmented and trusts are doing their own thing?

Helen Donovan: Yes, I think so.

The Chair: That message is coming over loud and clear.

Q18            Baroness Andrews: I have no interests to declare either. I think you have answered much of this question, so maybe we can dig down slightly deeper. The main question was about the main barriers to the effective delivery of policy to improve coverage. What is the best way? You have addressed that in different ways, not least in your response to Baroness Nye’s question about the one thing you might be able to do. Helen started off by reminding us of the WHO—the three Cs, context, communication and convenience. You talked a lot about communication, especially about the health professionals, and the drop of 43% in health visitors, and the real difficulty of building trust when nobody knows who is responsible. So we have covered a lot of that. We have covered a lot of the convenience issues too, because you have given a lot of description about how difficult some parents in some communities find it. Could you say a couple of things that you have not yet said about any of those—either the communication points or the convenience points? To pick up on what Helen just said about upskilling people, what is the range of people who need to be upskilled? Who are the critical groups that we might start with if there was going to be a national programme? Well, there is, as you reminded us.

Helen Donovan: I argue that, as the majority of vaccines for the childhood programme are delivered in primary care by general practice nurses, we need more registered nurses working in general practice. They need to be given not only the skills in the national programme but the time to develop them and the confidence to have those conversations.

We talk a lot about the communication style. I would say it is core nursing. You listen to people and use motivational interviewing-type approaches. You are listening to what someone is saying and then you are working with them—what matters to you, what is important. But when you do not have confidence in your own knowledge, those sorts of skills become quite difficult, so we need to have enough registered nurses working in primary care to be able to do the job that they are being asked to.

They need to have not just the core education but the opportunity to have continual CPD because the programmes change all the time, and the time within that to be able to know their particular populations. I often say to nurses when I am teaching in primary care, “You know your population better than anyone”, but if they have 10 minutes for each appointment and clinic after clinic then they do not ever have the opportunity to really delve down. When I was health visiting—this was a long time ago—I used to have a list, which was all on paper in those days, and I would phone people. They said, “Oh, I’m really sorry, we went swimming”, or, “Oh, no, I’ve had other things going on”. It is about those convenience factors that Helen has talked about. If we had enough nurses who were passionate about it and had the knowledge and skills underneath it, that would really help to drive uptake at a local level and then be filtered across.

Baroness Andrews: Can I follow that up? At the moment, GPs are tasked with reaching their population and they are given incentive payments to do that, and we have the new quality and outcomes framework incentive scheme to improve incentives and so on. How would that relate to your proposition that the nurses are the real block here?

Helen Donovan: I guess the thing is, when you are talking about GPs, that the GP contract then applies to all the staff working in general practice. However, I caveat by coming back to the local co-ordinator, that local point of contact. The GP may well be employing the nurses but they might not have the necessary level of expertise and skills, so the nurses need to have somewhere where they can be the leaders in that space. It is about looking at primary care rather than a GP practice. It is about looking at it as primary care and general practice more.

Baroness Andrews: This is a stupid question, but could you increase the incentives for GPs in a way that would enable them to employ more practice nurses with a specific role to pursue the vaccination programme?

Helen Donovan: You probably could. It is almost there within the contract. The contract involves having a local lead, but it does not specify exactly the level of skill for that lead. I suspect that Dr Creavin is more familiar with the GP contract as it is at the moment so I will ask her to step in, but I think you could do more.

Dr Alexandra Creavin: I completely agree. You could definitely do more. There are big challenges with the old contract and the new plans for the contract in the way that the funding is done. Currently, my understanding is that GPs do the work—by “GPs” I mean the GP practice, so often that means the practice nurses—and then they hope they will get paid for it. The system needs to be that there is enough reliability in the way that it is paid that you can invest in the staff having that time. At the moment, if you said to practices, “You have to give nurses more than 10 minutes to have conversations with patients”, that would never happen, but it is what is needed. That is not required for everyone; lots of people will go in and have their vaccine, and they are completely happy with how things are. Most people do that, and it is really important not to forget that. However, where there are pockets, particularly where vaccine uptake is as low as 40%, you really need time to have those conversations. Where uptake is higher, you only need to have those conversations when they are necessary. I completely agree that making sure that the funding works so it is practical for practices is really important.

The Chair: Thank you. That is very helpful.

Q19            Lord Dholakia: One of our tasks is to examine the decline in childhood vaccinations and make recommendations to the Government to reverse that trend. In your view, what should the inquiry seek to achieve? If at all possible, if you have further ideas that you wish to send us in writing, you can certainly do so.

Helen Donovan: The one thing that I have not mentioned is the NICE guidance, which was first developed in 2009 and focused particularly on under-19s. It is now relevant for all vaccines. What we really need to be recommending is delivery of the NICE guidance, because a lot of the things we have been talking about are embedded within that, and there is a good evidence base for it. It was updated in 2022 so it is probably due for a refresh, but the core principles within the NICE guidance have not really changed, all the things that we have been talking about—data skilling of staff, having enough staff and having the confidence of the public. So something to recommend would be enabling the system to deliver what is in the NICE guidance.

Dr Helen Stewart: From the college’s perspective, we would love to see support for the recommendations from our report, a lot of which we have talked about today. It is about improving access to appointments, improving the data systems around that and improving the information available to patients and staff.

Something that we have not mentioned is having a repository of good practice. We have talked a lot about local approaches and there are pockets of amazing things happening, and if that message could be shared more widely for people to take ideas from and implement locally then that would be fantastic.

Dr Alexandra Creavin: I agree with both of those and the other areas that we have covered today. We have not touched on seeking evidence for areas that are proving to still be a barrier to vaccination. Someone mentioned that they were from the autism group, and that still comes up among some of our populations as a hot topic, along with speech and language development, and immune overload concerns from having multiple vaccines at once; if anything, we are seeing those growing in some of our populations. There is also a risk of those becoming really politicised. We should seek opportunities to have a good evidence base for what the actual causes are of those things, separate from vaccination. We should promote a way of having open, accurate and honest cross-party conversations about vaccines that show that a vaccine choice does not have to be a political choice. That is potentially a growing area.

Another area is where initiatives are done locally with communities. First, they need to be shown to be effective and cost-effective. Secondly, if they are, they need sustainable funding. A problem that we have had in Bristol is that a huge amount of money—well, I say huge, although it was small in the grand scheme of things—was funnelled into some community initiatives, and some worked and some maybe did not, but then that money just went and new money has gone into a different set of initiatives, so all that knowledge and relationship-building has been lost. It would be helpful to have better evaluation of things that are done in times of outbreaks so that we can then see what works and what does not and how we can then sustainably fund relationships, because it breaks apart trust when things come and go frequently and then they work less and less as they get taken away and are unreliable.

Lastly, we need to keep getting information from the groups with the lowest uptake but with open dialogues so that people can be honest about what their concerns are and not feel that they are going to be belittled or diminished. We need to have honest conversations. What are people’s worries, and can we address them? Can we answer them easily? Can we then train healthcare professionals to support them to give their informed consent?

Q20            The Chair: I am sure you are all aware of what is coming from the United States on this subject recently. Do you think there is a danger that the public might be influenced by what we are hearing about the change of policies on vaccinations in the United States? Do you have concerns about that? Is there anything that we can do to protect our systems from that?

Dr Helen Stewart: It is definitely a concern. I have not seen that happen yet in clinical practice. I have always had families concerned about the link between autism and MMR and that does not seem to have increased recently, but it is a small world now and information spreads quickly, so it is definitely something that we need to be aware of and plan for. What we know is that it is one of the most-researched issues and there is no link. So we have that evidence, but if we could keep spreading that message, that would be really helpful.

The Chair: That is one of the points being made, is it not? The other one is measles.

Helen Donovan: The other thing that is coming is the confusion about the schedule in America—the reduction in the number of vaccines. That adds to the questions about whether we are giving too many vaccines. We need to be aware of what is being said, and the onus needs to be on healthcare professionals to have that background knowledge. There are people who say, “Well, they’ve stopped doing that in America”, and we need to be aware of that.

However, we need to be proud of the fact that our programmes are governed by the independent JCVI. We need to explain to the staff that we have that governance around it, and that they should have confidence that our vaccine programmes have that scrutiny that goes with it and that they are available to everyone.

The Chair: We will be hearing from them. Dr Creavin, have you any concerns or any suggestions about how we can protect our system?

Dr Alexandra Creavin: Those questions are already in our system, so to suggest that it is coming from America would probably be wrong. People here have already had those concerns for a long time. The way that we respond is probably likely to be more of a risk than what is actually said. I really want to avoid it being a political choice. You could support any political party but you could still think it was a good decision to have your vaccines. The most important thing is that we give people information and do not suggest that we are going to hide information from them so that they make the decision we want them to make.

Helen mentioned that we have a lot of information about autism. That is true, but I wonder whether patients feel they have access to that or would know where to go to get it reliably, and whether they would come across lots of inaccurate information in the process, so I wonder whether making that information more widely available, but not linking it to vaccines, could be helpful.

Lastly, sometimes the term “misinformation” can be really unhelpful, because one person’s misinformation is another person’s finally getting to the truth. We should be clear, as the other Helen mentioned, about what the evidence base is for the information we give and why we believe it is accurate, and then let people make their own choice. It is just not helpful for us to suggest that one piece of information is more important than another. We can just give people the evidence. Some people do not want that—they just want the minimum information and are happy to make a decision on that—but others want much more detail, and if we can supply that then that will be helpful.

The Chair: It sounds as if strengthening and improving our own system is the best protection. I have a final question from Baroness Ritchie.

Q21            Baroness Ritchie of Downpatrick: Helen Donovan, you mentioned the JCVI. Would it be helpful if we built into the assessments the impact on society and the economy when the assessment was being carried out of a particular vaccine? I am thinking of childhood vaccinations. I am not putting you on the spot; if you want to reflect and come back to us in writing, then please do.

Helen Donovan: As I understand it, the JCVI has to look at the wider cost implications. It has to look at the efficacy of the vaccine but also the impact on the burden of disease. For the latest vaccine that we have introduced, which is against varicella, a lot of that was about the wider societal burden—people having to take time off work and children having to take time off school. So, as I understand it, the JCVI has to look at that wider factor already in order to make its decision. Sometimes that has been a criticism because it has taken a long time to introduce vaccines that other countries have introduced much quicker than we have, but I say again that we should be proud of the scrutiny that it gets to do. Whether it could do more, I do not know.

Baroness Ritchie of Downpatrick: I was thinking, Chair, of the issue of the benefit of vaccinations to our economy and to our society.

Helen Donovan: As I say, those things are looked at in terms of the wider economy. I suppose the long-term impact—where a child lives until their 60s because they have not been subjected to some of the diseases that 60 years ago they may well have been exposed to—is a longer piece of evidence to look at, and maybe that is something for the JCVI.

I thought of one other thing when Alexandra was talking. We talk a lot about vaccine hesitancy as if it is a negative thing but we need to be very careful because, when you talk to the public, you find that they do not think they are being hesitant. They have questions, and it is quite right that they do. This goes back to having the skill as a healthcare professional to be able to address that; again, it is about the language. When we use the phrase “vaccine hesitancy”, we use it in its broadest sense, as defined by the WHO, but when the public hear it they think, “I’m not really hesitant. I just have questions”. We need to be careful about that.

The Chair: Thank you. I thank all three of you for answering all our questions. You have been patient with all our supplementary questions, and the information you have given us is very valuable. With that, I call the public session to a close.