14
Examination of witnesses
Dr Dan Hungerford and Dr Ben Kasstan-Dabush.
Q31 The Chair: Welcome back to today’s meeting. This is the third oral evidence session as part of the committee’s inquiry into childhood vaccination rates in England. I thank Dr Dan Hungerford and Dr Ben Kasstan-Dabush for attending this afternoon. The session is open to the public; it is being broadcast and will subsequently be accessible on the parliamentary website. There will be a transcript of the evidence, which will be published on the parliamentary website.
I will ask our witnesses to introduce themselves briefly when I ask the first question, but I need to warn them that, as we reach the end of the afternoon, it will get more and more likely that the session will be interrupted by a Division in the Chamber. If that should happen, I will have to pause the recording and then, after about 15 minutes, start it again when members have had an opportunity to go and vote.
The first question this afternoon focuses on the disparities in childhood vaccination coverage. What are the main disparities in childhood vaccination coverage in England, and how are these disparities changing over time, if they are changing?
Dr Dan Hungerford: Thank you for inviting us today. I am based at the University of Liverpool. I am a non-clinical infectious disease epidemiologist. Most of my research is focused on real-world evaluations of vaccines and trying to maximise the impact of vaccines for those who need them most. I have worked across what used to be Public Health England and the Health Protection Agency, but I have been in academia for the past 12 years. Some of my work is overseas in Malawi, Ethiopia and Kenya.
We should probably start off by setting the scene a little. On the inequalities in infections, we see £6 billion of secondary care costs due to infection in the UK. We also see that infectious disease hospital admissions are not distributed evenly. Essentially, we see twice as many in the most deprived populations as we do in the least deprived. With that as a setting, it is no surprise that we see such large inequalities and inequity against a backdrop of unfair, unjust and avoidable differences across society.
What we have seen in the past four or five years is a widening in the inequity of vaccine uptake. We conducted a nice piece of work, published in the BMJ, which showed that the gap in vaccine uptake between the richest and the poorest—the most deprived and least deprived—was widening. It had widened substantially, particularly for vaccines such as MMR2.
In that context, though, there have always been inequalities. When you look back at the measles’ outbreak in 2012, there were inequalities in vaccine uptake; it is just that the gap has gotten so much wider in the UK in recent years. We find that the populations that need vaccines the most are not receiving them. When we introduce vaccines, you have the best benefit if you can get them to those who need them most. You should spend your resource where the risk is highest, but we do a very poor job of that in some respects. The higher-level uptake across the population does not look too bad but, when you dig into the detail, there is a problem. In terms of setting the scene, that is where we are with vaccine inequalities and the widening of those inequalities.
Dr Ben Kasstan-Dabush: Thank you for the invitation to join you. I am a Lecturer of Global Health Policy at the University of Edinburgh and an Assistant Professor of Global Health and Development at the London School of Hygiene & Tropical Medicine. I also hold an honorary contract at Public Health Scotland, but I speak explicitly in an academic capacity today.
I wholeheartedly agree with what Dan has just laid out. The evidence is that disparities are consistent, persistent and widening over time. There is a strong overlap in differences between those areas of greater deprivation and diverse communities. There is, again, a disproportionate risk. We certainly saw that in the nationwide measles’ outbreak in Birmingham, where the vast majority of cases were in children from the most deprived areas and among people from Black African backgrounds; they had significantly more infection cases than the children of white British groups.
I would add that this becomes persistent across the life-course. It is an issue of not only vaccine uptake but timely uptake: when vaccines are received at the point they are recommended, and the gap thereafter. We see this in the under-fives cohort, and it continues into the school-age cohort then into the adult cohort. This widening of the gap between children from a Black Caribbean background as compared to a white British background continues. We know, for example, that the uptake of the influenza vaccination is much lower among pregnant women from Black Caribbean backgrounds, adults who are living with long-term conditions and adults in the 65-plus cohort. It continues across the life-course.
Q32 Baroness Hodgson of Abinger: Thank you both very much; that was an interesting introduction. Studies in Norway have shown that, where you have had a GP for a length of time, people are less likely to go to hospital and less likely to die. In this country, there has been a move away from the GP who knows their patient; now, people have a lesser relationship. Do you think that this has had an effect on the uptake of vaccinations?
Dr Ben Kasstan-Dabush: That relationship between you and your local healthcare provider is important, but there have been broader structural changes since 2012. We heard from the previous panel about the system-wide reforms but, obviously, that happened in the context of austerity. One victim of austerity was Sure Start children’s centres, which had an impact on preventing hospitalisation among children and adolescents. There is an issue in primary care, but it is about the broader way in which we integrate our services for young people and the impact and benefit that that can have over the course of their lives.
Dr Dan Hungerford: Ben is probably leading into your next question a bit. This is a wider problem than just vaccination. When we look at the inequalities children are facing, it is not just vaccinations. We look at the increase in child obesity and infant mortality. It is not just a vaccine problem. It would be simple to look at access and hesitancy as the problem, but those cuts have hit preventative public health services. They have been decimated by almost 50% over the course of austerity, and those cuts were greatest in the most deprived areas; they were almost fourfold there. All of those combined factors are happening at the same time.
We have just conducted a study looking at how child poverty has changed over time. It has shown that child poverty relates to those drops in MMR uptake. About 20% to 33% of the decline in MMR uptake can potentially be attributable to child poverty. Think about it practically: if you live in poverty, your ability to access services is far more difficult because of the psychosocial or financial pressures in getting a GP appointment—and, even then, in having the tools to arrive at that appointment. Even if you trust your GP, can you get there? Does it fit with the fact that you might have to take time off work? All of these factors are more complex than they used to be. Having a trusted individual is always beneficial—we have already heard evidence that having community GPs whom you trust and who are embedded in local communities is key—but our ability to access them has changed. It is very difficult in our busy and often pressured lives.
Q33 Baroness Wyld: Dr Hungerford, correct me if I am wrong, but I think you said that you had identified a specific issue around MMR2. I wonder whether you have any more insight into why that is the case? Presumably, it is people who want their children to be vaccinated, because they have had their first lot. Is something specific in the system acting as a blocker?
Dr Dan Hungerford: MMR1 is currently given at around 13 months of age—just after infancy—but MMR2 has historically been at three years and four months. That is a big gap in time away from infancy, where you are routinely in that preventive healthcare environment as a parent and a family. The children are not quite at school yet, so there is a gap in the contact points with the health system at that point. If you have had MMR1, you have shown that you would like your family to have vaccines, so one would think that you would transition to MMR2. There are clearly barriers in terms of that second dose at three years and four months.
One comment you made earlier was about the chickenpox vaccine coming in with MMR. The second dose of MMR has been brought forward to 18 months. Part of the reasoning is that they believe that it will increase uptake, because they are bringing it closer in line with the early and booster doses of vaccination, when there is more contact with healthcare so it is in that routine for parents and families. However, there needs to be a robust evaluation of that change to make sure that it improves uptake. Has adding chickenpox into that vaccine had a positive impact on improving uptake? Are any other changes going on? That is an important change to monitor.
Baroness Wyld: Do you think that bringing it in earlier in the child’s life will make a difference? I do not want to put words in your mouth, but there is a fragility in the system where it stops being joined up.
Dr Dan Hungerford: There is fragility in the system. Parents and family members go back to work. Obviously, as the child ages, other aspects of life come in further down the line. We need to evaluate that; that is part of the intention in bringing MMR2 forward.
Q34 Baroness Cass: You have already started on my question about why there are disparities and how the drivers are changing over time. I do not know whether you can answer this—I did not get a clear answer when we discussed it last week—but how much you can dis-impact poverty from the ethnic mix of the population? If you control for socioeconomic status, how does that impact the relative rates for different communities? Finally, given what we have heard about data, how confident are you in your evidence?
Dr Dan Hungerford: I will start with what I have already touched on, which is the analysis of childhood poverty that we did. There are issues with the data around ethnicity. That is a massive problem, particularly granularly, so making any assumptions around the data at a population level is very difficult. However, the association between inequalities and vaccine uptake broadly is robust. The vaccine uptake data has perhaps not been particularly timely, but, if you look at it over a long period of time, it is very robust. We have a good history of inequalities’ research in the UK, whether quantitatively or qualitatively. We are confident that austerity cuts and child poverty have a massive impact on child health, including vaccination uptake.
On the details of the intersection between socioeconomic status, ethnicity and particular communities, you need localised community insights to supplement them. If you look at NHS data, ethnicity data is missing for 18% to 32% of occasions, depending on which part of health system you look at. That is a big challenge, not just for vaccination. We need to look at the community insights work on top of the high-level, overall trends, and we need to trust communities to deliver that information.
Dr Ben Kasstan-Dabush: May I briefly add to that? It is complicated when it comes to ethnicity, because there are some communities where we do not have an accurate understanding of coverage. We know they are under-vaccinated because they are disproportionately affected by outbreaks, but we do not know about uptake. They could be Orthodox Jewish Haredi, Roma, Gypsy or Traveller. Then there is the “other” category, which is a catch-all mystery to many of us. Who are they? Does that reflect the reticence of a healthcare worker in having that conversation and asking how they would like to be coded then putting them there? It conceals much more than it indicates. With Orthodox Jewish people, again, we do not know which part they fall into. This has material consequences for how you allocate resources for your targeted outreach.
Baroness Cass: I can see that. It is presumably quite difficult, if you are targeting multiple approaches, also to work out which ones are effective.
Q35 Baroness Nye: You both started off by saying that disparities in inequalities have been widening over a long time. Do you think that the Government, NHS England and UKHSA have identified the right approach to tackling the causes of the decline in childhood vaccination coverage? If not, what should they be doing instead? One of the other witnesses said that the strategy from 2023 should be reviewed. Do you think that it is due a review?
Dr Dan Hungerford: Some of the points made earlier were very good. Generally, the stuff in the NHS immunisation policy and the UKHSA immunisation equity policy is sensible and aligns with the things we are saying here. They should be reviewed more regularly but big organisational change is planned; reviewing those documents while it takes place will be a real challenge. I would not like to say whether it should be done before or after the organisational change.
The other aspect of what I have touched on so far is that they are a bit too narrow. We are not talking about the social determinants of health in any of those policies; they do not talk about child poverty. Aspects of them are not looking at the wider drivers. The danger is that you set yourself up to fail a bit because, if the social determinants and drivers are causing a lot of these access problems, an immunisation policy can only go so far. Acknowledging that in the first place would be a good start. Evidence that has come from health visitors interacting with parents has identified that poverty is a potential barrier to immunisation.
Dr Ben Kasstan-Dabush: When we look at the three actors together, there are some clear indicators of strengths, but there are also some clear limitations in tackling the causes. My concern is that, when you look at those strengths and limitations together, it tells us that we do not have a coherent, integrated public health agenda and strategy to deal with the problem.
If we look at some of the strengths, at the minute, we have a pilot programme to reintegrate vaccination into the work of health visitors, possibly with targeted work around catch-up. That is a strength; taking that away was a consequence of 2012. We have investment in the Best Start Family Hubs, which should be in every local authority. They will not have the same scope of work that Sure Start had once upon a time, but they are a step of progress towards offering vaccination as part of a broader commitment to a child and a family’s health and well-being. Ending the extremely cruel two-child benefit cap, strengthening the income security of the poorest families and allowing them to manage the trade-offs they make will, I hope, allow prevention and vaccination to take the upper hand. Changes to the GP contract will, I hope, allow GP surgeries to be incentivised to increase uptake. What we saw before was that those surgeries—particularly our partners in Hackney serving large under-vaccinated communities—felt these targets were totally unattainable.
There are these great strengths. However, as we heard from the first panel, expecting ICBs to slash their headcounts by up to 50% will have huge consequences. I am yet to see any impact assessment on what that will mean for the immunisation system. When we look at these approaches together, I do not see a lot of coherence, and that really troubles me.
Dr Dan Hungerford: It is really positive to see the health visitor programme, but thinking that a £2 million pilot will have a big impact is overly optimistic. You potentially risk not detecting the benefit of such a programme because of such a low investment in the pilot. Lots of good things are being proposed, but it is about whether the level of investment is right. As Ben said, incentivising GPs needs to be evaluated because, on the face of it, it is a really sensible move.
Dr Ben Kasstan-Dabush: Also, with that limited piggy bank for health visitors, how sustainable will this ever be? What we should ultimately be striving for is sustained, equitable increase in vaccination coverage. That is absolutely the right point to make, Dan.
Baroness Cass: Going back to what Dr Chantler said in the first session, I was just reflecting that there must be a sweet spot between how many avenues you pick for hubs, health visitors, GP incentives and so on versus spreading things too thin, which is what you have implied. Where is it? If you have too many initiatives, do parents lose track of where they should go, and do you not have enough people in each of those pockets of activity?
Dr Ben Kasstan-Dabush: That is absolutely a fair concern. The burden of vaccine programme delivery—vaccines in arms—should always be on primary care and your GP surgery. However, there is a broader supporting role that health visitors, Best Start centres and even the secondary care system can have: offering a trusted touchpoint to have that conversation. As we heard in the previous panel from Dr Chantler, your practice nurse cannot do that in a 10-minute consultation at the point when someone is ready for vaccines in arms. Building that pathway through other avenues can be crucial, but it goes back to the same problem of having a competent and confident group of healthcare workers who can do that.
Q36 Baroness Freeman of Steventon: You have already touched a little on the accessibility of services. Can you give us a bit more detail about the accessibility of the core offer for all children—that is, infants and school-age ones? What are the barriers for different communities, and how could we best overcome those?
Dr Dan Hungerford: I talk about statistics a lot in my daily life but, for this question, it is useful to give a lived-experience example. The school-based programme for influenza in children is potentially being delivered in one or two days in a school. Often, vulnerable children—in and out of school—may have reduced timetables. In this case, a reduced timetable meant that they missed the vaccination days. A parent went to their GP practice to ask for the school-based immunisation team either to deliver it or to have it delivered through the GP. They were told, “We can deliver it here”, which is a good thing, “but not until January”. This was in the beginning of December; their first available appointment was in January. This is someone actively seeking the delivery of a vaccine. Imagine if you layer on the fact that people have different views on vaccination and may need additional information. That is not an accessible environment.
The Chair: No, it is not. Do you have anything to add to that, Dr Kasstan-Dabush?
Dr Ben Kasstan-Dabush: When it comes to the core offer for under-fives in general practice, we probably need to look at the variation. We know that NICE—the National Institute for Health and Care Excellence—has produced guidelines. In operational reality, the Quality and Outcomes Framework, or QOF, will guide decision-making because that is the financial incentive.
That then raises lots of questions around optimal call and recall, and invitation and re-invitation, processes in different areas. To give you an example, I have been leading a study looking at vaccine timeliness in three GP surgeries in different parts of the country that serve linked Orthodox Jewish communities. The variation in how those three surgeries operate is absolutely wild, ranging from some really good examples that are tailored to the place to others that are not. The application of best practice guidance in reality can be compromised by, for example, flexibility on appointment times. When you get out your magnifying glass and look at how they operate, that window of after-school appointments is really constrained for some surgeries, which creates problems for catch-up opportunities as well.
It is also about understanding the different ways in which non-vaccination gets escalated. When do non-responses, for example, get flagged for follow-up and by whom? How does it work in reality? Is it by a nurse? Are they able to engage with the depth of questions? That is in primary care.
The school-age immunisation service is a slightly different landscape. When we look at the under-fives vaccination programme, there has been a downward trend since that 2012-13 period, pre-dating the pandemic. When we really get into the school-age programmes, they have been more profoundly impacted by the Covid-19 pandemic, and coverage recovery has been slower. There are different issues, and the barriers to that school-age population vary by vaccine programme and area.
In theory, this should be a really equitable and convenient pathway—it means that parents do not have to take time out of work and their children can be vaccinated in school—but there are operational problems. Schools can be reluctant to share data, for example. They may feel that they are going against GDPR permissions but they are legally permitted to do so. Another problem is obstruction to the invitation process. You heard from Dr Chantler that, in some cases, young adolescents self-consent through Gillick competence, but schools might worry about litigation from parents.
We looked at north-east London, where there is a group of mostly independent faith schools that do not permit any access to immunisation teams whatever. That is shocking. How can it be accepted that there is this gap in the system? What then becomes more concerning to me is how the system follows these kids. How are they referred to primary care to ensure that vaccination is received? Unfortunately, they just fall into a gap. That should not be happening.
Our school-age immunisation services are commissioned to do a check and an offer of MMR vaccination. That is a check on the child’s status: have they received both doses? If not, offer it. I am not sure that that is happening in practice; again, there is variation. Some might check and offer, some might check and refer, and some might just check—or not. A good look at the system is needed to make sure that the cogs are working together to ensure that every child is kept in the system and not lost through the system’s gaps.
Q37 Baroness Browning: We have heard through the GP contract that the increase in the money GPs would have to spend on vaccination is likely to be a good thing. We have also heard of disparities between GP practices in how they go about their business in the follow-up and recall. What guarantee is there that the increase will make a change in practical terms? Is there a guarantee that that very scarce health service money will result in more vaccines being taken up?
Dr Ben Kasstan-Dabush: That is a good question. It will give some GP surgeries a more equitable chance at the funding and recognise the good work that they do to increase uptake. It is difficult to say that there will be a guarantee, but it is an opportunity to have the financial support to reinvest in the way in which they operate.[1]
Baroness Browning: If we know which GP practices do not follow best practice, or do not follow it because there are mitigating circumstances in terms of the patient profile they predominantly have to look after, what is going to change to make sure that they do not just get extra money but know what to do and are incentivised to do what is necessary to get an increase in uptake?
Dr Ben Kasstan-Dabush: That is another good question. My understanding is that the incentive is for sustaining that uptake, so the work would have to be done.[2] It is also a question of service management. Providers who are commissioned to deliver vaccination also need a degree of service management to make sure that that contract is being fulfilled. What support processes are offered when vaccine coverage might not be where it should be? There is the incentive, but it should not negate service management from commissioners.
Baroness Browning: Does it worry you that we have a system—I know that it has been in place for a long time and is not just vaccines—where, particularly in general practice, additional money is paid to enable or encourage GPs to do things, yet there is a multitude of other disciplines that they must follow without additional money? Does it worry you that vaccines are sitting in this pot?
Dr Ben Kasstan-Dabush: Look at these grey hairs and wrinkles—of course it worries me.
Dr Dan Hungerford: I am pleased that we are incentivising preventive services; that is key. I am also pleased that there is a potential offer to target those in the most disadvantaged areas in terms of these GP contracts. That is a good move on the surface, but it needs to be evaluated properly.
On the other questions—I am sure that we will come on to this—when we make changes, we probably do not do a good enough job of robustly evaluating them. There is a multitude of reasons for that; much of it concerns planning and not having enough capacity in the system. There are exceedingly smart people in ICBs and public health systems, not just academic environments, who could be evaluating these changes.
Baroness Browning: Are there any training requirements attached to these increases in resources? Is it part of the GP contract that more money is going to this discipline, therefore it will have associated with it additional training to help GPs who have not been able to exercise it as others have?
Dr Ben Kasstan-Dabush: Again, it is payment for sustaining uptake. As you have heard from this panel and from Helen Donovan, training is a major question mark and has consistently been so since the 2012 reforms. How is it that there is no clear allocation of responsibility for consistent standards in training not just for vaccinators but for administrators, who are the gateway to the immunisation service? They are the first port of call—the first person you have a conversation with. How has this consistently been allowed to fall off the list of priorities?
Dr Dan Hungerford: My example ties in perfectly. A GP in Liverpool, Kate Taylor, said, “Families that require gelatine-free vaccinations were not being informed that this option existed. As a result, many parents believed that they had no choice but to decline the MMR vaccine entirely for their children. Through the Health Equity Liverpool Project in Liverpool, community insight work uncovered this barrier. Teams worked directly with healthcare providers to ensure both options were actively promoted and shared their findings with UKHSA to improve how this information is communicated to families during immunisation conversations”. That is a perfect example of how training and simplistic application can make a big difference, so training must come.
Baroness Freeman of Steventon: In your experience, how good an experience is the service for children who are not in school?
The Chair: May I add to that? Children in foster care, many of whom move around an awful lot, are another group who may well fall through cracks such as the ones you mentioned earlier.
Dr Ben Kasstan-Dabush: It will be different for the under-fives and those who are in school. School-age immunisation services are commissioned to deliver primarily through schools, because that is the route most kids are in, or to hold community outreach clinics. There are, again, engagement problems in making sure that the offer is delivered and accepted. If you have children learning outside mainstream school—that is, the state national curriculum or independent schools—and are educating your children at home, I suspect that a philosophy or ideology against vaccination might come with that. Yes, there is a worry that they will fall through the cracks. With regard to children in foster care, it is probably best that I follow up with written comments.
The Chair: Thank you; that would be good. If you know of any research or initiatives that work on reaching these groups of children, it would be very interesting to the committee to hear about them.
Q38 Baroness Neuberger: You have talked about this a bit. How effective are outreach services for under-vaccinated communities? You gave a specific example from Liverpool, but what are the main barriers to developing suitable and effective outreach services? You have said something about this already, but do you want to anything else quickly for the record?
Dr Dan Hungerford: Community outreach services are incredibly important. They supplement and support the overall universal offer, but the problems are often around sustainability and the cost that goes into them. You need that community trust built in to begin with, but widening inequalities feed mistrust. If we are not tackling the underlying inequalities, outreach services are going to have only a limited benefit in the end.
There are some great examples. The ReCITE project is building research by communities to address inequalities through expression. It is about arts organisations, health organisations and community leaders coming together to develop community-based innovation teams, to grow their own community insights and potential interventions, and to tackle a health equity-based problem. In many cases, it is childhood immunisations or, potentially, maternal immunisations. In the interests of time, I will send in some quotes I have here.
In essence, they are empowering communities to make health decisions. By doing that, you get more sustainability, rather than a community team being part of, but not necessarily leading, the outreach. What it needs is a partnership where you have community leaders leading and they are the right, trusted leaders. Ben probably has more experience in this area so I will hand over to him.
The Chair: Before you do, can you send those real-life examples to us?
Dr Dan Hungerford: Absolutely. I am happy to read one out now but, in the interests of time, I can send it in.
The Chair: We are getting a bit short on time. If you could send them, that would be lovely.
Dr Ben Kasstan-Dabush: Building on what Dan said, the issue with outreach is that there is no secure ring-fenced funding for it. Primary care teams and GP surgeries might have to bid for it; it is not an automatic entitlement. They might have to present a plan, which might get accepted or might not, and then they might have to spend the money in a short period of time. Sustainability just is not built into the outreach framework and processes; that is the biggest limitation.
One of the most interesting but, if I am being honest, frustrating examples comes from the World Health Organization’s Tailoring Immunization Programme. It was done in North London’s Orthodox Jewish Haredi community some years ago and worked to identify the drivers of non-vaccination, what might help to improve uptake and what recommendations should be made. However, there was never any assigning of responsibility or accountability to take that forward, and there was no set piggy bank to do it. What you see is a really great investment in learning, working with communities and community partners to fact-find but, if nothing follows up, why should they trust services? That is something I will never understand.
There are many other examples of this. Dr Chantler talked earlier about the London Jewish Health Partnership, which was funded for two years. We got to use this community expertise during the 2022 polio virus incident in London, but then the funding stopped, so that engagement work stopped with it and attrition started again. It is about the sustainability factor.
Baroness Neuberger: Would you say that one thing that would make a difference is that any coherent programme—supposing we are going to suggest that there should be a more coherent programme; from what we have heard, we probably will—should have sustained funding for community outreach work? Is that what you are really saying? At the moment, it does not make sense, because it keeps stopping.
Dr Ben Kasstan-Dabush: That is true, but there also needs to be effective monitoring and evaluation, possibly with the participation of the communities with which we are trying to engage.
Baroness Neuberger: Of course, it becomes a virtuous cycle.
Dr Ben Kasstan-Dabush: Stopping and starting and not knowing whether that funding will re-appear—
Baroness Neuberger: And never evaluating?
Dr Ben Kasstan-Dabush: Yes.
Dr Dan Hungerford: Part of the problem with evaluation is not necessarily that the data does not exist but that the sharing has been a barrier for outreach programmes. Sharing with the community organisations that are going to be delivering just is not possible due to governance and transfer between organisations. You are trying to empower communities but you are not giving them the ability to evaluate because they do not have access to the data on their own communities. That is a massive problem. We often have the data; it is the sharing that is being hindered. That is one thing that makes it sustainable. If communities can evaluate their own outreach, it is far easier for them to sustain it because they can prove its worth.
Dr Ben Kasstan-Dabush: Thank you for having a defined question on outreach. Outreach is more expensive but every dose delivered by an outreach process should be valued at so much more money because it is someone who possibly received a vaccine who would not have come through the primary care system. We cannot lose sight of that. It is an investment in a child’s health and lifelong health.
Baroness Neuberger: ICBs should be picking up on that.
Dr Dan Hungerford: One thing that ICBs could do, which is being started in certain ICBs, is collate the information on outreach services and make registers of what is going on. Often, there is a lot of good work going on in tandem. That makes it harder to evaluate, because what is making the impact? Being able to collate that information on what is actually going on from different partners is really valuable.
The Chair: They have the opportunity of finding out what works and perhaps disseminating that best practice within the ICB.
Dr Dan Hungerford: Exactly; it is reducing duplication.
Dr Ben Kasstan-Dabush: There might be a role for the NHS Race and Health Observatory in this space as well. It is not creating a new portal; it is using existing venues that are very much meant to be for this purpose.
Baroness Neuberger: We should also be using the public health facilities in local authorities.
Q39 Baroness Browning: When the committee completes its investigation and produces a report, we will make specific recommendations to the Government on what we think should happen to help reverse the decline in childhood vaccination and reduce disparities. If you were us, what would you prioritise? What can you think of now that we ought to focus on?
Dr Dan Hungerford: First, we have to recognise that vaccine uptake is embedded in these systemic barriers, including service accessibility, financial pressures and institutional trust. The priority must be significantly reducing child poverty. That has to be one of the absolute priorities; it is not just a vaccine problem. The removal of the unfair two-child benefit cap will potentially remove 350,000 children out of child poverty, but that still leaves 4 million. It cannot just be a vaccine problem. We have to make sure that any policies are integrating social determinants of health with vaccine policy. That is one of my key recommendations at the moment.
Secondly, the other aspect you have heard about throughout is that we have to use a data-driven approach in a better way. We have to make sure that we are evaluating whatever interventions we put in place, whether they are national-level GP contracts or health visitor programmes. We must have robust evaluations and should build the things that we use for randomised control trials into how we evaluate community interventions and things like that. That needs resource. We need an evidence-based model. Those would be my key things.
Dr Ben Kasstan-Dabush: I wholeheartedly agree with what Dan has just laid out about embedding vaccination in a bigger agenda to reverse the decline in child health and well-being that we have seen. I also wholeheartedly agree with bringing back immunisation co-ordinator roles, which you need in such a fragmented, complex system—someone to join the dots and make sure that as few kids as possible fall through the cracks.
Over the course of your conversations last week, with Helen Donovan, and today, I cannot help but feel that there is so much variation and fragmentation that we do not have a full grasp of the problem. We possibly need a system-wide audit of every step to really understand what is going on, how GP surgeries are doing this at a local level, what might help them engage with NICE guidance, what is happening with our school-age immunisation services, which schools just are not playing ball and how we can manage that. We need some fact-finding. I do not think that we have a full grasp of the extent of the issues underlying the drivers of disparity.
Q40 The Chair: Dr Hungerford, we have a little more time, so can you go back a question and tell us what real-life patients in real-life situations have been saying to you?
Dr Dan Hungerford: This is from a community organisation that has been part of an outreach programme. I will read it out verbatim.
Rebecca Ross-Williams, Liverpool Lighthouse’s creative director, said, “ReCITE”—it is building research by communities to address inequalities through expression; that is a bit of a mouthful—“is an incredible action research model with sound collaborative practice, giving ownership of the work to the community. Our community innovation team work on pertussis immunisation for women in the asylum system and women with English as an additional language. It was driven by women with lived experience of the asylum system, alongside health professionals representing two primary care networks, including Liverpool Women’s Hospital, and it was led by arts and community organisations, including Liverpool Lighthouse.
Rebecca went on to say, “The project team are very excited by the potential impact of this work, which rewrites national research on this issue. Not only do we expect to be able to evidence a significant increase in uptake of pertussis … vaccines, but every partner has also benefitted. ReCITE is about capacity building and the women with lived experience have developed skills and experience, resulting in every one of them having paid work in creative health. For Liverpool Lighthouse, this work supports the delivery of our vision and mission, and the impact demonstrated by the research will lever funding for more work. For health professionals, there will be an increase in uptake of pertussis and the learning from this project can inform the approach to address other health inequalities. And of course, this work is designed to prevent sickness and death in babies. Win-win for all involved! I couldn’t advocate more strongly for the ReCITE model!”
Our team is working with Liverpool Lighthouse to help evaluate this particular outreach project, but a number of others are using a similar model. Those findings should be out at the beginning of next year.
The Chair: That really demonstrates the value of developing outreach initiatives with the people to whom you are outreaching. They help you design it in a way that will work with a particular community. Is that right?
Dr Dan Hungerford: All of this starts with community insights. What is the problem that has been identified here? We identify a problem, but it might not be the right problem. It is about communities being the leaders of this, or at least equal leaders in these cases. If that is integrated with the fact that you are tackling systemic drivers, it is probably a sensible model moving forward. Many of the things you have heard about today work along those lines. It is not one size fits all or a magic silver bullet; it is a variety of factors.
The Chair: Thank you very much, Dr Hungerford and Dr Kasstan-Dabush, for all the information you have given us this afternoon; it has been extremely helpful. If you would like to add anything further, please send it to us. With that, I will end the second session of this afternoon, which is actually our third session of oral evidence. Thank you, everybody.
