Examination of witnesses
Dr Tracey Chantler and Professor Pru Hobson-West.
Q22 The Chair: Good afternoon and welcome to today’s meeting. This is the second oral evidence session as part of the committee’s inquiry into childhood vaccination rates in England. Thank you to Dr Tracey Chantler and Professor Pru Hobson-West for attending. The session is open to the public, it is broadcast, and very soon it will be accessible via the parliamentary website. A verbatim transcript will be taken of the evidence, and it will be published on the parliamentary website for all to see. A few days after the session we will send it to our witnesses in case they have any small corrections to make. In addition to that, if they have any further information to provide to us, that will be very welcome.
It is possible that there will be votes this afternoon; if that happens, I will have to suspend the recording and the meeting for about 15 minutes. Once the majority of members have come back, we will start again. It may take about 15 minutes.
I will ask the witnesses to introduce themselves briefly
Professor Pru Hobson-West: Good afternoon. I am from the University of Nottingham. I am a sociologist of medicine, and my title is professor of science, medicine and society, because basically I study the interrelationship between those three aspects. I have been working on vaccine hesitancy for about 25 years.
Dr Tracey Chantler: I am an associate professor of public health evaluation at the London School of Hygiene and Tropical Medicine. I have a background in nursing, and I have worked overseas in immunisation programmes. Currently, my work is primarily on the intersection between the delivery and demand or uptake of vaccination programmes in the UK, but I have also done some work in Uganda, Kenya, Ethiopia and other parts of the world.
Q23 The Chair: What is the evidence of why childhood vaccination coverage in England has been declining in recent years? What is the relative importance of different factors in influencing childhood vaccination coverage? How is the relative importance of different factors changing over time? When you answer, can you give us an idea of the strength and weakness of any of the evidence that you cite? Perhaps we could start with you, Professor Hobson-West.
Professor Pru Hobson-West: In terms of the evidence base, as you probably heard in the first session last week, it is a combination of issues to do with access—difficulty or perceived difficulty in accessing immunisation services or advice—and aspects of vaccine hesitancy, which is more about parents who may have concerns or questions about immunisation. But it is more than just that; it is about the interrelationship between those two things. If we step back even further, we need to think about how immunisation services are funded, the resource that is allocated to immunisation services, and wider pressures on the NHS: in other words, something to do with the wider context in which immunisation services sit.
In terms of the relative importance of access and hesitancy, it is very difficult to disentangle those two things. I know there is some emerging qualitative evidence that is trying to do that, but it is difficult. I would also be very wary of attempts to try to quantify what the importance of hesitancy versus access is. It would be a mistake if we were to try to look at the relative importance. You also have a follow-up question maybe about the strengths and weaknesses of the evidence, do you not? Shall I carry on with that?
The Chair: Yes, please.
Professor Pru Hobson-West: I am very familiar with the social scientific evidence base around this issue, which speaks to the public health evidence. Overall, there is traditionally too much focus on vaccine hesitancy and a particular side of vaccine hesitancy research, and there has been less attention devoted to more mundane questions of access. When I say mundane, they are very important but more everyday questions of access and how that is seen. We still need more research on the social science side, on the qualitative research side, which focuses on access rather than hesitancy. Some of that work focuses too narrowly.
Dr Tracey Chantler: We also need to take a systems perspective and to look at how immunisation programmes are being commissioned, managed and funded. When we talk about access and hesitancy, we really need people on the ground close to where we have these vaccine inequalities, where we have pockets of lower uptake in certain populations, who understand those populations and can really provide input on how to best reach them.
My colleague Ben—who you will hear from later—and I did a lot of work during the Covid pandemic and previously in Hackney, working closely with community groups who are linked very closely with the public health authority, the ICBs and others. We were able to build on an existing collaboration; an existing group of people who had put this at the forefront. It is really important to involve communities. I know I am veering maybe on to community, but that needs to be central in how we design our health systems.
One concern I have, which we need to really focus on in the next year, is the reorganisation with NHS England coming together with DHSC. It is not necessarily a bad thing. I am not saying that: it could be a strength. My concern is that, if the expertise for commissioning and monitoring vaccination is held at a very high-level footprint, so you are responsible for a very wide area, that makes it very difficult to do the public health insights work you need to do with communities where there is low uptake.
That is where we need to rethink and maybe go back to the past and think about the role of immunisation co-ordinators—I know Helen Donovan also brought them up last week—and think about them as these key clinical or public health specialist roles within local authorities. I do not have the exact answer as to where they would sit, but they would be funded and could monitor the training of those health professionals who are highly valued by parents, and do exactly what we were talking about: place people within the health system who can address parents’ concerns. We have a populace who are much more vaccine-aware now and are asking difficult questions, and we need to be ready. The people who can do that on the ground are the health professionals. If they are not there, you are going to have people turning away and looking for information from elsewhere.
The Chair: It sounds as if you might be a little worried about the reorganisation; that that local leadership is going to disappear.
Dr Tracey Chantler: Yes, I am concerned. There is a need for research in this area. When I first joined the London School as part of the health Protection Research Unit in Vaccines and Immunisation, we did a study where we looked at the effect of the Lansley reforms at the time, 2012, which were then instigated in 2013. We looked at what the benefits were and what the downfall was. Part of the downfall was that they were fragmenting how immunisation services were designed and delivered. At national level that can sometimes mean, even now, that you have three tripartite organisations that have to sign off on the same thing, which is time-consuming. Where we did particularly well in parts in Covid was in the fact that we could speed things up. There were fewer committees, there were fewer issues.[1] That is one, but it needs more research.
I was reading the paper we had written and this has the potential to make things better, because we potentially have just two organisations. However, we must learn the lesson of making sure that we have people on the ground—whether it is at ICB level or in the local public authority—who are responsible for training and for understanding where the pockets of low uptake are in this area, and actually looking at the interventions that might work and evaluating them in real time, perhaps with the support of academic colleagues. We have a lot of highly trained public health specialists in local authorities who could do that work, and I am concerned that that is not going to be present.[2] If we lose that, then decline will continue.
Baroness Browning: Dr Chantler, you said you felt there should be more research in this. For school-age children in a very urban area, you might have one classroom of children who are registered with two or three different GP practices. Is there any research that has looked at what happens if, once children are school-age, you move more to vaccines being given within school, with a letter going to parents in advance to say this is going to happen so parents are not unsighted on it? Is there anything as simplistic as that?
Dr Tracey Chantler: School-age immunisations are currently organised by a school-based service called SAIS: the School Age Immunisation Service. There are teams of nurses who are commissioned to provide exactly those services through schools, and they work closely with the schools. The parents will receive a letter, now more and more electronically, with information that they look at together with their young person.
The young person should also be getting education sessions within the school. That does not always happen because of resource constraints and that is something that colleagues and I have worked on, particularly in populations where there might be more questions about this. We have worked to develop a resource that could really address their issues and that actually has been accredited by the PSHE: the lesson they do in school about personal, social, health and economic education.
Coming back to your question, it happens. If children are not in school, for whatever reason, they can be followed up by their GP and they can have the vaccines there. Where it gets trickier—my colleague Ben can talk more about this—is that sometimes in independent schools and some faith schools, they will not always let the school immunisation teams come in. That is problematic, because actually the offer is for all young people. There is a requirement until they are 16 for parents to provide consent, although in some cases a child or young person of 14 or 15, if they have demonstrated that they understand what the vaccine is for, could give Gillick consent as well.
Baroness Browning: Is there a good take-up of that programme?
Dr Tracey Chantler: I think the school immunisation programme was introduced shortly after HPV vaccines were introduced, so it has been running for 18 years.[3] It works really, really well, generally. There has been a decline in adolescent vaccination—as across all vaccinations—but generally it is a good system because, as long as the parents and young people are getting the information they need beforehand and can make an informed choice about it, they can get the vaccine at school.
Q24 Baroness Cass: Dr Chantler, you mentioned the risk of loss of local leadership with the changes. In last week’s session we were talking about the fact that there was already loss of leadership in 2012 from the vaccine co-ordinator, which was sometimes public health and sometimes a community paediatrician. Is that a double loss? We have already lost some leadership so, from your previous research, what leadership is left locally that we are going to lose further?
Dr Tracey Chantler: I would not say it is necessarily a further loss. There are people working in public health and working in the ICBs and other areas who are very knowledgeable about vaccination. Helen Donovan was talking about how in the past—pre 2012—you had somebody within the PCT, which had a smaller footprint, who was responsible for training. It could also be the person you would call up and who would know where the issues are. You could say, “I have a problem, I don’t know which vaccine I should give because the schedule’s changed”, or, “I have a child who’s come from a different country and I need advice”. Some of that has really gone missing.
The risk we also have now is that, with the cuts in the ICBs, we have people moving to other places because they already knew last year that they were potentially going to lose their job. Therefore, that institutional memory is lost. That was very much a feature after the Lansley reform: people just suddenly dispersed. It took two years for people to regroup and find each other. There was this sense of, “Whoa, actually you’ve been working there for the last two years. I wish we had known that before, we could have been doing stuff together”. It is that kind of thing.
Professor Pru Hobson-West: Also, we have not yet seen the full impact if healthcare professionals or those in more senior do not know quite where to go for the information, or—as has just been said—there is a loss of institutional memory. It actually might be building in terms of public and parents. There will be a knock-on impact. This is a slightly different question, but where parents would need to go for more information is also unclear, given how complex the system is, as has just been described.
Baroness Cass: Baroness Wyld and I spent an inordinate amount of time before the start of the committee doing just what you told us not to: asking whether this is more about access or hesitancy. Are you saying do not do that because between those who say, “Over my dead body is my child going to have a vaccine”, and those who say, “I need to get this vaccine at any cost”, there is such a spectrum of how people feel about it that access can tip somebody who may do it into somebody who may not do it? Is it that spectrum?
Professor Pru Hobson-West: Unfortunately, there are layers of complexity to it. If you are thinking about an individual person making a decision, they may have questions that they do not feel are being answered. If it is then difficult to make the appointment, or if they cancel the appointment and it is difficult to rebook, that might tip the person into then having a non-vaccinated or under-vaccinated child.
Even if we do not take an individual perspective and we look more at the public or community level, it is unwise to try to disentangle those things. We also need to be very careful when we are talking about topics such as ethnicity and making what may sound like sweeping statements about certain communities. That can further potentially alienate parents and other groups. It does not always follow a linear or straightforward pattern.
Q25 Baroness Nye: Dr Chantler has started down the road of my question, so perhaps Professor Hobson-West can go first. Have the Government, NHS England and UKHSA identified the right approach to tackling the causes of the decline in childhood vaccination coverage? If not, what should they do instead?
Professor Pru Hobson-West: Yes. Some recommendations in the recent report by the Royal College of Paediatrics and Child Health, and in the NHS vaccination strategy, are actually very sensible. They would align quite closely with some results from this huge evidence base we now have in the social sciences around vaccination hesitancy in particular. I am sure you will hear from some authors about how both those reports talk about the different priorities; they are quite sensible.
I would be concerned if we were to try to enhance accessibility but then did not also focus on data records and the reliability of vaccine data. That would be a huge problem. It is difficult to put these things in order of importance, but we need to try to improve the front door to vaccination services and look at offering vaccination services in more places. The NHS strategy talks about potentially using supermarkets, communities and libraries, and learning lessons from Covid on that. That is fantastic, but if we diversify who can deliver a vaccination and the spaces where they can take place, we need to be even more careful with the data vaccination record. It is just not joined up at the moment. We would need even more focus on that.
Baroness Nye: Would you say that the data lever is paramount? If you were going to grade any of those interventions, would you say the data being shared is really important?
Professor Pru Hobson-West: Yes. It is difficult to put those in order but, based on evidence on the public’s and parents’ decision-making and how they understand communication messages, the concern is that we have mixed messages at the moment. On the one hand, the message is, “Vaccination is incredibly important. This is a really important decision for you, your child, your family, elders in the community and the nation. This is an important health intervention”.
On the other hand, we do not have joined-up vaccination records, so somebody may not know whether they have received a vaccination. There is no joined-up data. If you have a private vaccination in a pharmacy, that is not then linked with your NHS record. On the one hand we are saying, “This is a really important health intervention”, but then we are saying, “We don’t know whether you or your child actually received the vaccination”. My concern is that there is a real mismatch in the communication message we are trying to give about vaccination.
Dr Tracey Chantler: Yes, I would agree that it is really important. It is hard. You are asking whether that should be the top priority; it is one priority. There have been some good advances recently with a system called RAVS, which was used during Covid but they are now trying to spread out. I am not a data person, so I cannot remember exactly what RAVS stands for, but I can look it up in a moment. They are trying to expand that. There is a lot of good work going on.
One of the issues is also that they can be using different systems for collecting data at the primary care level and other levels. That is complicated. I know some of you have a background in medicine, and it makes it really difficult, with the coding, the sorting and who is sending out the recall reminders: is it from the child health information systems or is it from the GP? There is a lot of thinking that needs to go on about how to join that up better. In essence, it is a population-level health programme. It should be something we can do quite well.
I am coming back a bit to what I said about this large footprint and small footprint. In some things, we need a large footprint with joined-up data, working together, integrating. Where we need the smaller footprint is really the communities that need that intervention, or that reach into them to increase uptake, whether it is to do an educational intervention or to work with health visitors to reach those under-ones where there is a vaccine delay. That is where we need that. The data just needs to be much more integrated nationally.
I also agree that the NHS vaccination strategy is good. It is very long. The bit that is complicated within the NHS strategy is point six or seven, where it talks about the commissioning and changing in the two years. I know there are a lot of questions about why we are not seeing a reverse and decline. How can we see a reverse and decline if nobody is quite sure where their job is going to be tomorrow, or who is going to be responsible for what? I understand that reform can be necessary and really important, but you have to build on your strengths. It is hard for people doing this work to know where they stand if in the midst of a strategy you are also saying, “Well we’re not quite sure. The ICBs are going to start commissioning vaccinations in 2026, but then in 2027 you’re going to have to decide on slimming down”. That was a weakness in that strategy.
Like any strategy, it needs to be reviewed regularly. You should have a look every two years. I agree with Pru, it is great to think that we can offer vaccines everywhere, but is that really realistic? That might have worked really well during the pandemic, but we need to have some solid points of delivery that work with some communities. I have some questions about spreading too thinly: instead of just really strengthening the primary care delivery, thinking about other health professionals who could be involved, and giving opportunistic vaccination for older populations in hospital appointments or in clinics. I know we are talking more about children here, but we can be creative in that sense. That would be my point.
Q26 Baroness Freeman of Steventon: My question actually follows on very well from what we were just talking about. I want to start talking about barriers and accessibility, understanding of course that they cannot be separated from everything else. I wonder if you can talk about what you think the main barriers to childhood vaccinations are, and the best ways to overcome them.
Professor Pru Hobson-West: As with anything, there are simple things and complicated things. We need to make vaccination appointments easier to book and more convenient to attend, but also easier to cancel. I know that sounds counterintuitive potentially, but according to all the evidence, parents are under a lot of pressure as to whether they do or do not accept vaccination. As I was saying at the beginning, the vaccination decision is part of a broader set of decisions that parents are making about their children. Life gets in the way, particularly if you have complicated home situations. The idea that if you cancel an appointment you will be able to rebook it is important.
I happened to take my cat to the vet for a vaccination last week. It was much easier to book, cancel and rebook. The vaccination card was almost more straightforward than my own children’s ones. Vaccine hesitancy is a huge issue in veterinary medicine, which I know is another topic, but it just shows how deep-seated some areas are.
So, yes, make the appointments easier to book, closer to community sites, with the caveat that has just been said of consultation with the stronger data points. If you were to make it more convenient and easier to book in more locations, you would want to feel that there was a lot of joined-up thinking in those records. As I said before, there is a danger if it is perceived that those records are not joined up.
Dr Tracey Chantler: I want to touch on the accessibility. Going back a little—I will answer the question, do not worry—to when you were talking earlier about divorcing hesitancy from accessibility: we cannot do that. One of our PhD students and one of my colleagues, Helen Bedford, presented some of her work as part of an academic meeting here. She did a longitudinal cohort study with 20 or 24 parents, interviewing them during that first year of their journey.
What was very clear from that was that for some, there were real accessibility issues in terms of booking appointments. For others, it was that they encountered rudeness. They were quite taken aback by that, having been well looked after during maternity, but then they encountered rudeness when they were five minutes late for an appointment. We all know and understand how stretched primary care and other places are, but that turned somebody away from it. I do not think that mother actually went ahead and had the MMR vaccine later. Those things are really important, and that is part of training. That is part of having enough staff locally as well. Those are some key issues.
Also, currently the vaccination appointments in primary care are 10 minutes for a practice nurse. Maybe they would have received some information from their midwife or health visitor, but they may not have had the opportunity to ask a question from a health professional. That nurse may not have time to actually answer all those questions in those 10 minutes. We might also say that the first visit needs to be 20 minutes, but of course that is a GP contract issue. You also have the question there of whether we can make sure that nurses can have 20 minutes with the first vaccination visit. Those are some things.
Other barriers are for some specialised programmes, such as BCG vaccination, which is given separately and often outside GP surgeries. Someone who needed their child to be vaccinated for BCG—either a family member had tuberculosis in the past, or they came from a country where the prevalence was sufficiently high—was having to trek across London on a bus with a child of 28 days to get to a place to have the vaccine. That is one quite extreme example, but it is like that. Again, it is quite difficult to think that through and then think about offering those vaccinations closer to home, or possibly in the maternity setting. They have moved the BCG vaccine to after 28 days because of SCID screening, but it is those types of things. Again, these are more the service-related things.
Of course, there is then misinformation. We cannot deny the fact that you do not need to look too deeply to find out or hear things from your friends or family. Those things also need to be addressed. As health professionals and academics, we need to be aware of those and be able to debunk them, and be prepared.
Baroness Freeman of Steventon: You mentioned that the consent forms at schools were a barrier. Do those work quite well, or are there better ways to structure that system of giving consent?
Dr Tracey Chantler: That is a really interesting question, because in some parts of the world, there is opt-out. The parents would be aware that vaccination is part of the school schedule and would be given information at different points and told, but you would not need a signature. We did some research on the consent forms around them getting lost in students’ book bags or wherever, or never turning up at home. That is partly why they have gone electronic, but the electronic can actually stop the young person getting any information about it, because it goes straight to mum or dad, they sign it, and the young person is suddenly called into a room to have a vaccine.
Whether they are a complete barrier is a good question. It is still nice to ask, to make sure that everybody is happy to have the vaccine. Consent forms need to be simple; they do not need to go into huge detail. Obviously with some, such as HPV vaccination, it is very low-risk. You do not need too much detail because they have to be able to trust you, the person doing it, as a health professional as well. I would still argue for consent forms but keeping it pragmatic.
Q27 Baroness Cass: Just as an aside on the vet parallel, when my cat was in intensive care, my local vet—whom I trusted—had immediate access to all the results from that morning. They could talk to me about withdrawing treatment, even when the cat was somewhere else; we could only dream of our GPs having that connectivity in the NHS.
Anyway, what I wanted to ask about is how we sustain public trust. What are the main barriers to sustaining public trust, and what might we do to overcome these? Obviously, that is a multilevel question. I realise you have 20 years of experience to answer this from, but could you distil your knowledge for us?
Professor Pru Hobson-West: Yes, I will be as concise as I can. Of course, trust is absolutely at the heart of this whole issue that we are talking about. We need to promote trust in healthcare professionals, in the individual relationships there. Again, it probably sounds counterintuitive, but healthcare professionals need to feel able to acknowledge uncertainties when there are uncertainties. It is difficult because the evidence shows that parents want healthcare professionals who feel confident and have access to information. However, on this topic and others, there is also a strong evidence base that acknowledging uncertainty, or the limits of our knowledge about certain subjects, can actually go a long way to promoting public trust. I would be quite confident in the assertion that healthcare professionals need to feel able to do that, which I know is challenging.
Also, since Covid we talk about the black box of vaccination. The black box was opened and there was greater understanding of the different pharmaceutical companies that were producing the different vaccines. That box has not fully closed and may not close. To promote trust, we may need to be a little more open or provide more information about who is producing the vaccinations, because that has changed post Covid.
In terms of the barriers, again, it is really tricky. I would say this as a sociologist, but language is absolutely key. We need to be very, very careful with terms such as “anti vaccination”. I would absolutely avoid terms such as that, because that can cause a further erosion of trust for some communities. On that, we also need to be really careful with arguments such as, “The public have forgotten the seriousness of diseases”. This argument is used a lot, and I understand why it is made. It is factually correct that many of us do not have experience of seeing polio cases and so on, but if we think about the Covid experience, where everybody absolutely could see the impact of the disease, there were lots of people who still did not want the Covid jab. There were some healthcare professionals who were also sceptical about the benefits. We need to be very careful with some language we use. To imply that it is because we have forgotten, or we have a lack of knowledge, can further exacerbate problems of trust in some communities.
The training of healthcare professionals has already been mentioned. They obviously get training on vaccination, but what sort of training on hesitancy? How up to date is that training? I know other universities do this too, but I have been involved in developing an online tool for healthcare professionals on the topic of hesitancy.[4] This is to try to provide a space for them to think about and reflect on their own relationships with vaccination as a topic, not what they need to do when they are confronted with parents.
Finally, there is lots of discussion around whether the public or parents trust healthcare professionals. We can also flip that the other way around and ask, do healthcare professionals trust parents? There is much less research on that side. It was alluded to before, but stereotypes in this area are rife around vaccination. Do some parents have negative experiences talking to healthcare professionals about vaccination but also about any other topic? Trust is a two-way relationship; it is not just one-way. We need to be really careful to see this as a two-way relationship in how we talk about this issue and how we make recommendations.
Baroness Cass: On what you say about acknowledging uncertainty, it is probably easier to do that the more senior you are. Some people giving vaccinations may be more junior, so it might be harder for them.
Professor Pru Hobson-West: Yes, that is a really good point. That goes back to training. Again, is the training mainly for secondary care? How much focus do we have on nurses who will go into primary care and become practice nurses? Yes, acknowledging uncertainty is easier said than done.
Dr Tracey Chantler: We also have to think a little bigger when we talk about trust. Immunisation is delivered within the health system, and there have been quite a lot of health inequalities. I am being careful with my words at the moment. There are some populations who have expressed greater mistrust of vaccinations, those from particular ethnicities potentially, but some ethnicities have also experienced the worst maternal health outcomes. They receive the worst maternity care.
We have to think about Windrush and bigger things such as that when we are talking about trust in institutions. Our health service is one of our institutions, and if there are certain populations who are not trusting for other reasons of discrimination or inequalities, that trickles down. I am not going to go into too much depth, but we have to bear that in mind, particularly when we know that in some populations there are particular issues to address. It is important to bear that in mind.
One thing that can work really well is to actually have close connections with particular groups who can work with local public health authorities. During the Covid pandemic, there were several faith forums across London. There was also a particular group that was promoting health and issues for black people in London. These things are also really important to think about with trust, actually opening that up.
The Chair: This is obviously a really interesting subject for this committee because I have three people who want to come in on supplementary questions. Can I just point out to everybody that we have less than 20 minutes left and two more questions to do? Short questions and short answers, please.
Q28 Baroness Hodgson of Abinger: I have to declare my interest: I am the chair of ISCAS, which is the Independent Sector Complaints Adjudication Service. Trust is a very big issue. Professor Hobson-West, do you think that the professionals have really been open with the public? If one takes Covid, do you think we have been given enough information about the adverse effects of some Covid vaccines? Do you think that there was enough research done on morbidity in relation to having had vaccines quite recently?
To my thinking, there was a vague, “We’re not going to give younger women this particular vaccine,” but it was never really openly talked about. To my way of thinking, we never really heard the whole story from the professionals. I know there is an inquiry going on, but I just wonder what you feel as a sociologist about being open from the medical side. My personal experience of the health professionals is that when things go wrong they clam up.
Professor Pru Hobson-West: Thank you for that question. During the pandemic, in an emergency situation, there were particular challenges maybe around—if that is what you are referring to—some information about side-effects, risks, and risk profiles of particular vaccines or vaccine recipients. Obviously, that was in a pandemic situation and there were particular pressures. However, I would say more broadly that maybe we need to get better at acknowledging uncertainty and the limits of knowledge, as I said.
There is the issue of the Vaccine Damage Payment Scheme, for example. Are healthcare professionals aware of that scheme? Would they know to direct questions around that scheme? I know that is a topic for another committee perhaps: “This is something that the state is asking you to do, not just for the benefit of your family but for the benefit of the community”. That is why we have a state-run system of support for when there are injuries as a result of vaccination. In the past we have possibly not been open about the existence of that scheme, for example.
Going back to what I said before, maybe now there is more understanding of the role of the different producers of vaccination. The childhood vaccination schedule is quite complex. If you are not a healthcare professional, if you are a parent trying to navigate it, it is quite complex. There are lots of combinations of vaccination, for good reasons, but we need to be able to then answer the questions around who has produced that jab, what the regulation was around the production of that jab and the testing, and so on. As I said before, acknowledging uncertainty is easier said than done, but the evidence is pretty strong on this and other topics that it helps.
The Chair: I still have three people. I have Lord Dholakia, Baroness Wyld and Baroness Freeman. Can I ask just one panellist to answer each of these next three supplementary questions? That will help us with time.
Lord Dholakia: You hit the nail right on the head when you talked about public trust. Do we use the same tactics in dealing with the general population about lack of involvement of young people in vaccination as we would do in relation to a diverse community who are settled in about 60 to 65 areas in this country? We have doctors, teachers, qualified people in those particular areas. Are we using them?
The last time I worked at the Commission for Racial Equality, I counted 1,400 ethnic minority organisations in this country. How often do we use these people in terms of passing a message that must be described quite differently from how it would be with the general population? How do we use temples, mosques and gurdwaras in bringing these people into this sort of discussion? This is the way to take things forward: a separate strategy for separate communities in a way they would understand the issue.
Dr Tracey Chantler: There has been a recognition of this importance. It was also the basis of some work we did with Dr Leonora Weil in London during the pandemic. They were setting up a Jewish health forum, a Muslim health forum, and a forum for Black Londoners, which I do not have the exact name of right now, to address inequalities in vaccination related to Covid and other things such as primary care. What is key in this engagement is recognising that so many of our health staff are from ethnic minority backgrounds or different backgrounds, who are often much better placed to speak to particular concerns in an underserved group. Either they know their language, or they know the nuances of the culture or why they may want to delay a particular vaccine, or they understand what the community message is in the background.
Again, this is a bit of a plug for an immunisation co-ordinator. There are some immunisation co-ordinators who are also in primary care networks, particularly employed to work with some populations to come alongside and find out what the issues are, and know where the local organisations are that they need to go and do a talk at, or get their GP to come along and talk to. There is a recognition of that. There has been quite a lot of work on different faith groups and engagement in public health.
It is part of community engagement and outreach, which is a key part of the NHS England immunisation strategy, but there is going to be limited funding. We have to be real on this. Are you going to spend money on promoting partnerships at that level; are you going to spend money on commissioning pharmacies to give vaccines; or are you going to spend money on strengthening primary care? That is where it is important. I absolutely agree, there needs to be that community participation. It is probably a local public health authority responsibility, with the ICBs and that local connection.
Baroness Wyld: I just need to declare my registered interest as a non-exec board member at Ofsted. I wanted to pick up the point about the complexity of the childhood vaccination schedule and how health professionals then communicate with parents. If you take what I think is the latest change on adding chickenpox to the MMR, do you know how much planning went into the on-the-ground communications around that, and helping those who are delivering the vaccine to explain that to parents and to answer any questions? How soon does the planning start and how thorough is it, in your view? I do not mind who answers.
Professor Pru Hobson-West: I do not know enough about the timing of the research, but there would have been research done and communication materials tested for a change in the schedule to be rolled out. Even so, my guess is that it would have been experienced as complex if you were adding another vaccine to the mix, even if there was strong evidence about the need for it.
We also forget that people are making decisions in a family context. If you have had a child, or children of different ages, and then suddenly—or it is perceived as suddenly—the recommendations change, what does that mean for your other child? Why did you not know that before? Is this a new piece of research? What happens in other countries? You can imagine the pathway of questions that a parent may have. As was said before, how long is the appointment where somebody might be able to ask those questions to understand?
The Chair: This is obviously a really important issue. Now for the last supplementary on this question, then we really must move on.
Baroness Freeman of Steventon: Yes, sorry, but it is important. I would like to ask if you know of any research around trust and the attitudes of medical health professionals in the vaccination schedule.
The Chair: Does either of you have any information on that?
Dr Tracey Chantler: The childhood vaccination schedule? There has been quite a—
Baroness Freeman of Steventon: I am just thinking that we have heard of attitudes from those who are giving a vaccination that they themselves do not have confidence in it. That can obviously have an effect on people who are turning up for appointments or considering appointments. I wondered if there was any research that had been done that would quantify or at least give us some insights into that.
Dr Tracey Chantler: Actually, that helps me touch on a point from the previous one. UKHSA runs surveys regularly with parents and adolescents, and it is going to be doing it with older adults soon. It has also done a survey with health visitors and midwives around their confidence in communicating about vaccines. It is still analysing some of that data, but it will be published soon.
It might be worth following up with someone called Dr Helen Campbell and with Louise Letley, who run that tracker survey work. Linked to that, that work feeds directly into the development of publications. There is a big publications group within UKHSA, led by somebody called Cherstyn Hurley, that also does some of that co-development research that you are asking about in terms of the information materials that were developed for the MMRV.
The Chair: We have those names. Excellent.
Professor Pru Hobson-West: May I just add one sentence to that? It is a really important question. I would say the evidence base is probably strongest on Covid. There is more research—more qualitative and quantitative research—done on attitudes of healthcare professionals towards the Covid vaccination. Maybe we could encourage a broadening of that to look at other vaccines.
I was involved in some work interviewing healthcare professionals in Nottingham, who were not necessarily hesitant but they expressed doubts about who was responsible for what. They were not sure where the boundaries were between health visitors, their own role and the hospital. They expressed doubts around the layers of responsibility.
The Chair: We are doubtful about that at the moment, but I hope by the end of the year it will be a lot clearer.
Q29 Baroness Neuberger: We are doubtful about this one too. Thank you, it is really helpful. Dr Chantler, you have answered some of this, but what would you regard as the best ways to strengthen national and local responsibility and accountability for childhood vaccination? You have already hinted at immunisation co-ordinators. We are seeing ICBs having to shed staff at the same time as they are given responsibility—I should declare an interest: I am on an ICB for the next two weeks—and we have seen NHSE losing staff at a rate of knots. How would you do it?
Dr Tracey Chantler: How would I do it? It has to be quite proactive and I hope it will start now. I have been reading the recent publication where it talks about how once it has decided who is going to be this new OPIC—this Office for Pan-Integrated Care Board Commissioning—it is going to move some senior staff from the screening and immunisation teams in there. But you really have to maintain people who have that long-term experience in those positions, because commissioning vaccination, monitoring vaccination, and that horrible term “performance management”—but it can be a very proactive and supportive performance management—need to be central.
The thing that I am a bit concerned about is that, when they are commissioned, people are not necessarily being visited. Not visited as in, “We’re going to visit you and give you an X tick if you have not done A, B or C”, but visited to make sure you have been properly trained and you have everything you need to deliver this service well. A lot of the commissioning happens in an office space. If they do not reach their targets, there is a question, but there is not any going out and seeing what is happening on the ground. That is where you need those more local leaders—immunisation co-ordinators and district immunisation co-ordinators—who are trained and can do that.
Baroness Neuberger: One of the barriers at the moment is the lack of local responsibility and accountability. There is plenty of responsibility higher up the chain.
Dr Tracey Chantler: I know they work really, really hard. You know that they are piloting different ways of looking at the health visitors one, and then there is a community pharmacy one. I am involved in an evaluation with the community pharmacy one and I was slightly concerned. The commissioning had happened both in the screening and immunisation teams and in the ICBs, where they have a group of dentistry, ophthalmology, and pharmacy, who were involved in setting up the commissioning.
This is a community pharmacy for RSV in the over-75s, so it is a different age group. The main thing was, can a community pharmacy help address vaccine inequalities? Will they be able to reach the communities where they are not taking the vaccine up? But there was no follow-up to see if they are doing that. What are they doing? Do they have the materials? Do they have outreach to do that? Nobody goes and visits. Nobody goes and sees. There might be some training checks. Again, I have not seen the in-depth detail, but I am concerned that there is no longer that person who can go over and look. It is time-consuming but, for a good service, it is essential.
Professor Pru Hobson-West: I do not have anything to add to what we would call that person and where they would sit. That is a really difficult question. As has been said, there are other people spending a lot of time thinking about these issues. From a public point of view, even if it is complex, we need to find a way to explain the pathway of responsibility. Whatever the system is, we need a way of communicating that simply. That would be what I would say about responsibility at the local level.
The Chair: If our witnesses do not mind, can we go on five minutes extra, please? Yes, good. We have one more question. You will find it really easy to answer this one.
Q30 Baroness Wyld: At the end of our inquiry, we will make recommendations to the Government about how to tackle what we all agree is such a hugely important issue in terms of reversing the decline in vaccination coverage and reducing the disparities that we have touched on. What would you prioritise?
Professor Pru Hobson-West: First, the Royal College of Paediatrics and Child Health report that I mentioned at the start talks about the need to shift focus from hesitancy to access. It sounds very simple, but it is difficult to do in practice. That is what we should prioritise with limited time and limited resources. Secondly, we should ensure that that follows through into the academic work and the evidence base around this. I would suggest we need more in-depth, qualitative work, looking at the interaction between hesitancy and access. Going back to what I said before, there has been too much focus on certain aspects of hesitancy for historical reasons, particularly in the UK, thinking about the legacy of MMR.
Finally, this has been touched on, but we should definitely protect and prioritise the length of the vaccination appointment. I was involved in a project at the University of Nottingham, and it is quite rare to carry out observation of vaccine appointments. We found that there is a lot that goes on in those 10 minutes. It is not just putting the jab in the arm; there is a lot that is discussed around child health in general, thinking about future priorities and future vaccinations as the child gets older. There is a lot that goes on in those 10 minutes. I worry that, with the increasing pressures in the NHS, there may be pressure to restrict the length of the appointment. The priority would be to maintain that length of appointment, particularly the first appointment, as we have discussed.
Dr Tracey Chantler: It will be no surprise that I will say it is important to have a local authority-level person who is responsible for training and support, and for looking at where the pockets of vaccine inequalities are in their area. They need to work carefully. I agree on the importance of doing academic research, but it is also important for public health. Some staff in public health, if they were given the funding and the resources, could do some of that work together with academics and make that difference in that real-world research: there is a lot of good practice out there, but it is not actually shared widely. There is an importance for that as well.
Going back to data, even though it is not my speciality, there needs to be a much wider, integrated, national, better data system. It is obviously tricky with protective characteristics, but it would be helpful for health professionals, particularly for those looking at inequalities, to know a little more about what the groups are who have a lower uptake. Obviously, that can be sensitive though.
Then there is funding: money. We need to protect the money. I know this is a big question, but currently in the grant that public health gets, it has set money for drugs and set money for smoking cessation. There is no set funding for vaccination or other things. Actually, it is so important to—
The Chair: Are you saying ring-fenced money, then?
Dr Tracey Chantler: Yes, the ring-fenced money it has. We just need to prioritise our children’s health. As we all know, vaccinations are one of those interventions that has improved quality of life.
The Chair: That is a very good point on which to end our session. Thank you both very much indeed. You have given us a great deal of really important information. Please do not forget, if there is anything further you want to add, do please write to us. With that I would like to close this session.